'#<: 1 • , t ■.' '' • i ' ,*'f?;;«:;'""ti,:i; f'-i • :>« 3 ! *&!#•■■>■' £&> ^*^ v-8-V ^ ^ /\ \s ,-f y THE MEDICAL AND SURGICAL HISTORY OF THE WAR OF THE REBELLION. FART II. VOLUME II. SURGICAL HISTORY. Prepared, under the direction of JOSEPH K. BARNES, Sargeon General United States Army, By GEORGE A. OTIS, Assistant Surgeon United States Army. SEOOISTHD ISSUE. WASHINGTON: government printing office. l^L^l^LG^lJ^JSriDTJlS/L. A few words may be necessary to explain the relation of this volume to the large work, The Medical and Surgical History of the War of the Rebellion, of which it is a component part. In October, 1865, the Surgeon General published, under the title of Circular No. 6, "Reports on the Extent and Nature of the Materials availablo for the preparation of a Medical and Surgical History of the Rebellion," that had been accumulated in his Office. The circular comprised a report on the materials relating to military medicine, prepared by Assistant Surgeon J. J. WOODWAUD, U. S. A., and one on the surgical materials, prepared by the writer of this volume. Such elaboration wus given to these preliminary reports, that, while snbserving tbe purpose of the Surgeon General of calling the attention of Congress to the value of the data in his possession, the inconvenience arose that, in many quarters, they were regarded as an attempted digest of these materials, and were very frequently quoted as in fact the completed official medico-military report of the War. The recom- mendation of the Surgeon General, sustained by the Secretary of War, was so far complied with, that, in the " Act making Appropriations for Sundry Civil Expenses, etc.,'' approved July 28, 1S(!6, an item was inserted making provision for the preparation of plates and illustrations for a first part of a Medical and Surgical History; but it was not until March 3, 1869, that, by Public Resolution, No. 15, the Government Printing Office was authorized to print "five thousand copies of the First Part of the Medical and Surgical History of the Rebellion," to "be disposed of as Congress may hereafter direct." As the labor of designing the illustrations and digesting and arranging the data had long been "rosecuted, the work was rapidly pushed toward completion, and, in the winter of 1870, the First Part appeared, divided into a Medical Volume, a Surgical Volume, and an Appendix, the whole comprising eighteen hundred quarto pages, prefixed by a concise but comprehensive chapter by Surgeon General BARNES on the inception, progress, and scope of the work, and the probable requirements for its completion. The latter, it was thought, would demand two more parts of equal magnitude, each subdivided into medical and surgical volumes. On June 8, 1872, was approved "An Act for tlie Completion and Publication of the Medical and Surgical History of the War'' in two Parts of eighteen hundred pages each, in addition to the first Part already compiled. With the limited clerical force at the disposition of the Surgeon General, it was found utterly impracticable to complete this undertaking within the fiscal period of two years wherein the appropriation for the purpose was available, and accordingly, in the Act making Appropriations for Sundry Civil Expenses, etc., approved June 23, 1875, the unexpended balance of the appropriation of June 8, 1872, was continued, and, moreover, an additional appropriation was made for a second edition of the six volumes of the entire work. In the Surgical Volume of the First Part, after the Prefatory paper of the Surgeon General, the Introduction of the editor, and a Chronological Summary of Losses in Battles and Engagements, an exposition of the statistics and detailed reports of Special Wounds and Injuries of the Several Regions was commenced and continued through five Chapters, treating respectively of the Injuries of the Head, Face, Neck, Spine, and Chest. 1 he nature and results of forty-nine thousand and sixteen cases of injury by war-weapons were set forth. It was aimed to give concise details of as large a number as possible of individual facts bearing on the practice of military surgery. The space occupied by the detailed reports was so great, that discussion and comment on the material was to a great extent reserved for a later portion of tbe work. In the present, or Surgical Volume of the Second Part of the Medical and Surgical History, the presentation of the facts regarding the Special Wounds and Injuries is continued, according to regional classification, through frfur Chapters. In Chapter VI, eighty-five hundred and thirty-eight catcs of Wounds of the Abdomen are tabulated, and detailed abstracts of six hundred and seventeen of them recorded. In Chapter VII, thirty-one hun- dred cases of Wounds of the Pelvis are enumerated, six hundred and ten being detailed. In Chapter VIII, twelve thousand six hundred and eighty-ono cases of shot Flesh Wounds of the Back are tabulated, with abstracts of two examples. In Chapter IX, eighty-eight thousand seven hundred and forty-one cases of Wounds of the I'pper Extremities are considered—fifty-five thousand and eighty-six injuries of the soft parts, and thirty-three thousand six hundred and fifty-five cases of shot fractures. Detailed abstracts are given of eight hundred and seventeen cases; the principal facts concerning thirty-seven hundred and twelve excisions and eighty-two hundred and forty-five amputations are concisely recorded in tabular form ; the remainder of the cases are adverted to in numerical statements. The Record of the yet more numerous Injuries of the Lower Extremities constitute the subject-matter of Chapter X, with which the Surgical Volume of the Third Part of the History will begin. A chapter will succeed on Fractures and Luxations from other causes than gunshot injury reported during the War, to be followed by one on the reported instances of Jlurns, Scalds, and Frostbites. This will conclude the review of Special Wounds and Injuries, and will be followed by a chapter of generalities on shot wounds, their nature, frequency, and fatality, and principal complications, as pyaemia, secondary haemorrhage, gangrene, and tetanus. Generalities on amputations, excisions, and ligations will also be presented. Chapters on the Use of Anaesthetics in field and hospital, with details of the alleged deaths from chloroform, on the Materia Chirurgica, including Artificial Limbs and Prothetic Apparatus, and on the Transportation of the Wounded by Land and Water, will follow, and a copious Analytical Index of the three surgical Parts will conclude the Volume. GEORGE A. OTIS. III ADVERTISEMENT TO THE SECOND ISSUE. The first issue of this volume was made June 1, 1876. In accordance with a provision of An Act making appropriations for sundry civil expenses of the Government, etc., approved March 3, 1875, authorizing the Congressional Printer "to print and bind five thousand additional copies of the Medical and .Surgical History of the War of the Rebellion, one thousand of which shall be for the use of the Senate, three thousand for the use of the House of Representatives, and one thousand for distribution by the Surgeon General of the Army,"—this Second Issue of the Second Volume of the Second Part of the work has been prepared, corresponding as nearly as practicable with the First Issue. Numerous typographical corrections have been made, but sufficient time has not been allowed for undertaking a revision of the text. GEORGE A. OTIS, Assistant Surgeon, U. S. A. Surgeon Gexerai/s Office, December 1, 187C. IV TABLE OF CONTENTS OF VOLUME II OF PART II OF THE MEDICAL AND SURGICAL HISTORY OF THE REBELLION, HEING THE SECOND SUEGICAL VOLUME. MEMORANDUM p. III. CHAPTER VI. INJURIES OF THE ABDOMEN. Page. SECTION I. Contusions and Wounds of the Abdominal Parietes. 3 Punctured and IikjxiI wounds............. 3 Sabre and Bayonet wounds........................ 3 Other Punctured and Incised wounds.............. 4 Lacerated and Contused ivoiiikU........... 4 Rupture of Tl ii-.il<»........ ................... 5 Guunhot Fl«-»li v»ounds........................ 6 TABLE I. Partial numerical statement of shot wounds of the Abdomen....................................... 6 Tablb II. Cuses of injuries of the Abdominal Walls re- turned during the War.............................. 8 Compile;alion* of Parietal wound*......... 8 Haemorrhage..................................... 8 Foreign bodies.................................... 11 Gangrene........................................ 12 Hernia........................................... 13 Nervous disorders................................ 13 Tetanus.......................................... 14 SECTION II. Visceral Injuries without External Wounds.. 15 Ruptures of the I*iver......................... 16 RuptureH of the Spleen........................ 18 Ruptures of the Kidney....................... 20 Ruptures of the Stomach..................... 22 Ruptures of the Intestines................... 22 Plate I. Rupture of Jejunum, facing................ 23 Ruptures of the Omentum and IVIescntery Ruptures of the Rlood-vessels............... RuptureH of the. Diaphragm................. TABLE III. Numerical statement of Visceral Injuries without external wound............................. SECTION III. Penetrating Wounds of the Abdomen...... 29 Simple Penetrations and Perforations without Visceral injury................ Abstracts of Punctured and Incised wounds Abstracts of cases of Gunshot wounds...... Wounds of the Stomach.................. Punctured and Incised wounds...........____ Gunshot wounds.............................. Abstracts of cases of recovery................. 45 Fatal complicated cases....................... 48 Gastric fistula;.................................... 52 Page. SECTION III. Penetrating Wounus of Aisdomen—[Continued. WoiiimIn of the Small Intestines............ 60 Punctured and Incised wounds.................... 61 Gunshot wounds.................................. 64 Wounds of the Duodenum.................... C7 Wounds of the Jejunum...................... 68 Wounds of the Ileum......................... 70 Plate II. Enteroraphy of Ileum, facing.............. 72 Wouuds of the Large Intestines............ 75 Punctured and Incised wounds.................... 76 Gunshot wounds.................................. 76 Plate IV. Faecal Fistula of Colon, facing............ 77 Abstracts of fifty-nine cases of recovery........ 77 I 'late V. Shot perforation of Abdomen, facing........ 81 Balls voided at stool.......................... 98 Fatal cases................................... 102 Abnormal Anus............................ Suture....................................... Anaplasty................................ Enteroraphy............................. Plate HI. Suture of Ileum, facing.............. Palfyn's method.......................... Rcybard's method........................ Le Dran's method........................ Method of the Four Masters and Duverger. Method of Denans...................... Method of Ramdohr...................... Jobcrt's method.......................... Lembcrt's method........................ Gely's method............................ Views of Gross and Reybard.............. Enteroraphy in Shot wounds............... Wounds of the Wiiver.......................... Punctured and Incised wounds.................... Gunshot wounds.................................. Memoranda of fifly-nine uncomplicated cases... Memoranda of one hundred and fourteen compli- cated cases................................. PLATE VI. Metastatic Foci, facing................... Recoveries, abstracts of cases................. 109 111 111 112 113 114 115 115 116 116 117 118 119 119 123 125 129 129 131 131 132 133 1.39 V TABLE OF CONTENTS. CHAPTER VI. INJURIES OF THE Page. SECTION III. WOUNDS OF AUDOMEN—[Continued. Wound* of the Spleen......................... 149 Punctured and Incised wounds.................... 149 Gunshot wounds.................................. 150 Tubular statement of tbe recorded operations of Splen- otomy......................................... 152 Wounds of the Pancreas..................... 158 Wounds of the Kidney....................... 162 Gunshot wounds................................. 163 Memoranda of twenty-six alleged cases of re- covery ..................................... 163 Abstracts of fatal cases....................... 167 Wounds of the Suprarenal Capsules...... 173 Wounds of the Omentum, 3Iescntery, and It lood-vessels.................................. 174 Complications................................... 176 Haemorrhage.................................... 176 Foreign bodies.................................. 179 Visceral protrusions............................... 180 Plate X. Hernia of Jejunum, facing................. 184 Hernia........................................... 184 Herniotomy, abstracts of twelve cases......... 186 Abdominal effusions.............................. 188 Blood, abstracts of four cases.................. 189 ABDOME N—Continued. Page. SECTION III. Abdominal effusions—[Continued. 101 Paracentesis.................................. *""■ Bile.......................................... 192 Urine........................................ 193 Fjeces. etc.................................... I"4 Pa,.......................................... ly7 Air or gases.................................. *98 Traumatic peritonitis............................. 199 Frequency of Wounds of the Abdomen-- 201 mortality of Wounds and Injuries of the A bilomcn....................................... 202 Table IV. Statement of the cases of Penetrating wounds of the Abdomen returned during the War. 202 Table V. Number of Penetrating shot wounds of the Abdomen in other wars, with ratio of mortality. 203 Deadliness of shot wounds of Abdomen............ 204 Observations by Surg. J. J. B. Wright............. 204 Examples of Impalement......................... 204 Plate X I. Rupture of Ileum, facing................. 205 Concluding observations...................... 205 Laparotomy for traumatism....................... 206 Diagnosis........................................ 206 Treatment....................................... 207 Bibliography.................................... 208 CHAPTER VII. INJURIES OF THE PELVIS. Page. SECTION I. Shot Fractures of the Pelvic Bones......... 211 Shot fractures of the Ilium.................. 212 PLATE XXXVI. Shot fracture of Ilium, facing........ 212 Penetrations without visceral injury............... 213 Abstracts of cases........................... 214 Abstracts of fractures of both Ilia................. 215 Illustrated shot fractures.......................... 218 Table VI. Indicating the relative liability of the right and left Ilia to shot injury.................. 221 PLATE XXXIV. Carious shot fracture of Ilium, facing. 221 PLATE XXXV. Fracture of Os Innominatum, facing... 223 Caries and Necrosis............................... 225 PLATE XXXVII. Shot perforation of Ilium, facing--- 225 Pyaemia and Septicaemia.......................... 229 Excisions of portions of the Ilium.................. 230 Shot fractures of the Pubis.................. 237 Shot fractures of the Ischium............... 240 Excisions of portions of the Ischium and extraction of foreign bodies................................ 245 Shot fractures of the Sacrum................ 246 Excisions of portions of the Sacrum................ 250 Shot fractures of the Coccyx................. 252 Shot fractures of the Pelvic Bones in gen- era I.............................................. 254 TABLE VII. Numerical return of fourteen hundred and ninety cases of shot fracture of the Pelvis--- 255 Excisions of portions of the Pelvic bones.......... 255 PLATE XLT. Instruments for resection, facing......... 256 Injuries of the Pelvic Liiganicuts.......... 256 SECTION II. Injuries of the parts contained in the Pelvis.. 257 Shot penetrations or perforations without Visceral injury............................... 257 Injuries of the Bladder....................... 262 Ruptures of the Bladder.......................... 263 Punctured, Incised, and Lacerated wounds......... 263 Concussions of the Bladder........................ 264 Shot wounds of the Bladder................. 264 Foreign bodies in the Bladder............. 268 Vesical calculi formed about projectiles............ 269 PLATE VII. Vesical calculi, facing................... 272 Calculi having nuclei of bone or of encrusted bone splinters........................................ 276 Calculi consequent on shot wounds of Bladder...... 279 Plate VIII. Vesical calculi removed after shot wounds, facing.............................................. 280 Table VIII. Descriptive numerical statement of twenty-one cases of lithotomy................... 282 VI Page. SECTION II. Foreign bodies in the Bladder— [Continued. Lithotomy for ordinary vesical calculi.............. 282 Extraneous bodies escaping by the Urethra......... 283 Shot wounds of Bladder, other examples 283 Recovery, abstracts of twenty-eight cases.......... 286 Fatal shot wounds................................ 290 Urinary infiltration............................ 296 Remarks on shot wounds of the Bladder........... 297 Wounds ol the Prostate.............. ...... 303 Wounds of the Rectum...................... 305 Stercoral fistulas after shot wounds of the Rectum.. 308 Recovery after shot wounds of the Rectum......... 310 Fatal shot wounds of the Rectum.................. 315 Anal fistulas...................................... 321 Anal fissure...................................... 321 Haemorrhoides.................................... 322 Foreign bodies................................... 322 Wounds of the Blood-vessels and Nerves 323 Punctured and Incised wounds.................... 323 Gunshot wounds.................................. 324 Wounds of tbe Internal Pubic artery.......... 324 Wounds and ligations of the Sciatic artery..... 326 Wounds of the Ilio-lumbar artery.............. 327 Wounds and ligations of the Gluteal artery___ 327 Wounds and ligations of the Internal Iliac or Hypogastric artery......................... 330 Wounds and ligations of the Common Iliac artery 333 Wounds and ligations of the Spermatic artery.. 337 Wounds of the Veins.......................... 338 Wounds of the Nerves........................ 339 SECTION III On Injuries of the Genital Organs......... 343 Wounds of the Penis......................... 343 Incised wounds................................... 343 Gunshot wounds.................................. 345 Wounds of the Urethra...................... 349 Gunshot wounds.................................. 350 Recovery after gunshot wounds of the Urethra.. Traumatic strictures...................... 351 Urethral fistules.......................... 360 Deep Urethral fistules.................... 364 Urethro-rectal fistules..................... 369 Fatal shot wounds of the Urethra.............. 372 Urinary infiltration and free incision........ 373 Injuries not caused by shot........................ 374 Foreign bodies................................... 375 Treatment of wounds of the Urethra and of traumatic strictures, and fistules............................ 380 TABLE OF CONTENTS. CHAPTER VII. INJURIES OF THE PELVIS—[Continued. Page. SECTION III. Wounds op the Urethra—[Continued. Organio Strictures (three abstracts)............ 386, Dilatation and Divulsion...................... 388 Urethrotomy................................. 392 Internal Urethrotomy......................... 392 Plate XII. Urethral Instruments, facing.............. 395 External perineal Urethrotomy (seven abstracts) 396 Urethroraphy and Urethroplasty (four abstracts) 401 Injuries and diseases of the Testis......... 405 Shot injuries of the Testis......................... 405 Shot lacerations of the Testis (twenty abstracts) 406 Excisions of the Testis for shot injury.......... 409 Abstracts of thirty-two cases of recovery... 409 Fatal cases (seven abstracts).............. 413 Page. Prolegomena......................................... 433 TABLE XII. Collated return indicating the relative fre- quency of shot wounds of the upper extremity........ 434 SECTION I Flesh Wounds of the Upper Extremity...... 435 Punctured and Incised Wounds............ 435 Ligation of the Brachial artery.................... 436 Ligation of the Ulnar artery....................... 436 Ligation of the Radial artery...................... 436 Wounds of the Palmar arches..................... 437 Gunshot Wonnds.............................. 438 False Anchylosis................................. 438 Atrophy and Deformity after sloughing............ 439 Pyaemia.......................................... 440 Lesion of the large Blood-vessels.................. 440 Ligations of the Axillary artery............... 442 Abstracts of fifteen cases.................. 442 Ligations of the Brachial artery............... 446 TABLE XIII. Summary of seventy-six cases 448 Ligations of Ulnar artery...................... 451 Ligations of Radial artery..................... 452 Ligation of Interosseous, Superficial Palmar Arch, and other arteries..................... 454 Flesh wounds involving large Blood-vessels treated without operation............................... 454 Blood-vessels primarily involved, abstracts of nine cases.................................. 454 Sloughing involving the larger Blood-vessels... 456 Haemorrhage from the Subclavian or its branches............................... 456 Haemorrhage from the Axillary or its branches 456 Haemorrhage from the Brachial or its branches 457 Haemorrhage from the Ulnar or its branches 458 Haemorrhage from the Radial or its branches 458 Haemorrhage from the Interosseous artery.. 458 Flesh wounds involving the larger nerres.......... 461 Injuries of the Brachial plexus................ 463 Injuries of the Circumflex, Musculocutaneous, and Musculo-spiral nerves................... 463 Injuries of the Median nerve.................. 464 Neurotomy............................... 465 Injuries of the Ulnar nerve.................... 466 Injuries of the Radial nerve................... 467 Amputations consequent on Flesh wounds.......... 468 Amputations at the Shoulder Joint............. 4C8 TABLE XIV. Summary of fourteen cases.- 468 Amputations of the Upper Arm................... 469 Table XV. Summary of fifty-four cases...... 469 Page. SECTION III. Injuries, etc., of the Testis—[Continued. Excisions of both Testes (three abstracts).. 414 Atrophy of the Testes........................ 415 Injuries of the Spermatic Cord (five abstracts)...... 417 Contusions of the Testis (three abstracts)........... 418 Sarcocele (one abstract)........................... 418 Wounds of the Scrotum..................... 419 Hydrocele........................................ 420 Operations for Hydrocele...................... 421 Varicocele........................................ 422 Concluding observations.................... 423 TABLE IX. Statement of thirty-one hundred and seventy- four cases of injury to the Pelvis..................... 423 Page. SECTION I. Flesh Wounds—[Continued. Amputations of the Forearm....................... 471 TABLE XVI. Summary of fourteen cases...... 47] General observations on Flesh-wounds of the Upper Extremity........................ 471 SECTION II. Fractures of the Clavicle and Scapula___,. 473 Sabre and Bayonet wounds................. 473 Shot fractures of the Clavicle and Scapula 474 TABLE XVH. Statement of twenty-two hundred and eighty shot fractures of the Clavicle and Scapula.. 474 Shot fractures of the Clavicle............... 475 Excisions of the Clavicle.......................... 476 TABLE XVIII. Summary of twenty -two cases. 480 Shot fractures of tbe Scapula............... 481 Plate XLV. Shot fracture of Left Scapula, facing___ 488 Excisions of portions of the Scapula............... 492 TABLE XIX. Summary of forty examples___ 495 Partial excisions of Clavicle and Scapula........... 497 TABLE XXII. Summary of nine cases........ 497 SECTION III. Wounds of the Shoulder Joint............ 501 Wounds treated on the Expectant plan.. 502 Wounds unattended by Fracture................... 502 Wounds attended by Fracture of the bones composing the Shoulder Joint.............................. 503 Abstracts of thirteen cases of recovery......... 505 Abstracts of nine fatal cases................... 510 Excisions at the Shoulder.................... 519 TABLE XXI. Statementof eight hundred and eighty- five cases of excisions at the Shoulder............ 520 Excisions of the Head of the Humerus with portions of the Clavicle and Scapula..................... 520 Plate XIII. Results of excisions of the Head of the Humerus, facing.................................... 520 Table XXII. Tabular summary of forty-two cases....................................... 524 Partial excisions of the Head of the Humerus...... 526 Table XXIII. Tabular summary of fourteen cases....................................... 528 Decapitations of the Humerus.............. 529 Primary decapitations of the Head of the Humerus. 529 Successful operations, abstracts of six cases..... 529 PLATE XIV. Results of excisions of the Head of the Humerus, facing.................................... 529 TABLE XXIV. Summary of one hundred and nineteen cases...................... 531 Unsuccessful operations....................... 535 CHAPTER VIII. FLESH WOUNDS OF THE BACK. Page. Relative frequency of Shot wounds of the Back unat- tended by Fracture................................. 427 Table X. Statement of Wounds of the Back and Hips in the field or primary hospitals...................... 428 TABLE XL Statement of twelve thousand six hundred and eighty-one Gunshot Flesh wounds of the Back... 428 Page. Punctured and Incised wonnds of Back. 429 Gunshot wounds of the Back (abstracts of two cases)......................................... 429 Plate IX. Laceration of the Buttocks, facing......... 430 Skin Grafting................................... 431 Fatality of Shot wounds of Back...................... 432 CHAPTER IX. WOUNDS AND INJURIES OF THE UPPER EXTREMITIES. vu TABLE OF CONTENTS. CHAPTER IX. WOUNDS AND INJURIES Page. SKCTIOX III. Decapitations of tiie Hcmeucs—[Continued. Plate XVII. Results of excisions of the Head of the Humerus, facing.................................... 536 Table XXV. Tabular summary of fifty- six cases............................... 536 Intermediary decapitations of the Humerus......... 537 Successful cases (two abstracts)............... 537 Table XXVI. Tabular summary of twenty- one cases............................... 539 Unsuccessful cases (two abstracts)............. 540 Table XXVII. Tabularsummaryofthirty- four cases.............................. 541 Secondary decapitations of the Humerus........... 542 Successful cases (three abstracts).............. 543 Table XXVIII. Tabular summary of thir- teen cases.............................. 543 Plate XVII. Results of excisions of the Head of the Humerus, facing.................................... 544 Unsuccesful cases (two abstracts).............. 545 Table XIX. Tabular summary of thirteen cases..................................... 545 Decapitations of the Humerus of uncertain date (two abstracts)...................................... 547 Table XXX. Tabular statement of seventeen cases..................................... 547 Excisions of the Head and portions of the Shaft of the Humerus....................... 548 Primary excisions of the upper extremity of the Hu- merus .......................................... 548 Successful operations (abstracts of twenty-nine cases)...................................... 548 Table XXXI. Tabular summary of two hundred and thirteen cases..'............ 554 Unsuccessful operations (abstracts of nine cases) 569 Table XXXII. Tabular summary of eighty fatal cases.............................. 570 Intermediary excisions of the upper extremity of the Humerus....................................... 573 Successful operations (abstracts of fourteen cases) 573 Table XXXIII. Tabular summary of ninety one casus............................... 576 Unsuccessful operations (abstracts of seven cases) 584 Table XXXIV. Tabularsummaryofsixty- four cases........................-...... 585 Secondary excisions of the upper extremity of the Humerus....................................... 589 Successful operations (abstracts of eight cases).. 589 Table X XXV. Tabular summary of thirty- eight cases............................. 591 Unsuccessful operations (abstracts of two cases) 595 Table XXXVI. Tabularsummaryof twelve cases................................... 596 Excisions of the upper extremity of the Humerus of uncertain date.................................. 597 Table XXXVII. Tabular summary of nineteen cases....................................... 597 Excisions of the Shoulder, parts not defi- nitely determined............................. 597 Table XXXVIII. Tabular summary of thirty-nine cases........................................... 598 Concluding observations on Fxcisious at the Shoulder after shot injury............. 599 Table XXXIX. Numerical summary of the eight hundred and eighty-five excisions at the Shoulder. 599 Table XL. Tabular summary of two hundred and one cases practised in Confederate army.......... 601 TABLE XLI. Number of excisions of upper extrem- ity of the Humerus in other wars, with ratio of mortality....................................... 607 Amputations at the Shoulder................ 613 Scapulo-humeral amputations after shot fracture___ 613 Table XLII. Numerical statement of eight hun- dred and fifty-two amputations at the Shoulder Joint after fracture.......................... 614 Primary amputations at the Shoulder Joint......... 614 Successful operations (abstracts of thirteen cases) 615 OF THE UPPER EXTREMITIES-[Continued. Page. SECTION III. Amputations at the Shouldeu—[Continued. Table XL1II. Tabular summary of three hun- dred and sixty-eight cases................... 620 Unsuccessful operations (two abstracts)........ 630 Table XL1V. Tabular summary of one hun- dred and seventeen cases.................... 632 Operations with unknown results............... 636 Table XLV. Tabular summary of fourteen cases...................................... "36 Intermediary amputations at the Shoulder Joint--- 636 Successful operations (abstracts of three cases).. 637 Table XL VI. Tabular summary of eighty-five cases....................................... 638 - Plate XLVI. Shot comminutions of the Humerus, facing............................... .............. 640 Unsuccessful cases (abstracts of three cases)--- 641 Table XLVII. Tabular summary of seventy- two fatal cases.............................. 642 Secondary amputations at the Shoulder Joint....... 645 Successful operations (three abstracts)......... 4>45 TABLE XLVIII. Tabular summary of forty- seven cases................................. 647 Unsuccessful operations (abstract of one case).. 649 TABLE XLIX. Tabular summary of nineteen cases....................................... 650 Period unknown, amputations at the Shoulder Joint. 651 Successful operations.......................... 651 Table L. Condensed summary of ninety- one cases............................... 651 Unsuccessful operations....................... 653 Table LI. Condensed summary of twenty- eight cases............................. 653 Results of operation unknown................. 654 Table L1I. Condensed summary of eleven cases................................... 654 Recapitulation.................................... 655 Concluding observations on shot injuries of the Shoulder............................... 656 Treatment....................................... 657 Excision, Expectation, etc..................... 659 Table LIU. Mode of treatment and results of injuries of the Shoulder Joint in other wars__ 661 Table LIV. Statement of one hundred and fifty invalid pensioners treated either by expec- tation, excision, or amputation............... 662 SECTION IV. Injuries of the Shaft of the Humerus. Expectant conservative measures.......... 666 Shot contusions and partial fractures treated by ex- pectation (abstract of one case).................. 667 Partial shot fractures (abstracts of two cases)... 668 Complete shot fractures (abstracts of eleven cases) 669 Pseudarthrosis (abstracts of three cases)........ 673 Excision in the continuity of the Humerus for shot fracture.............................. 675 Primary excisions of the shaft of the Humerus..... 675 Successful cases (abstracts of four cases)....... 675 Table LVI. Condensed summary of three hundred and twenty-six cases............ 676 Fatal cases (abstracts of three cases).......... 682 Table LVH. Condensed summary of one hundred and forty-five cases............. 686 Result not ascertained......................... 686 TABLE LVIII. Condensed summary of six- teen cases.............................. 686 Intermediary excisions of the shaft of the Humerus. 686 Successful cases (one abstract)................. 686 TABLE LIX. Condensed summary of sixty- four cases.............................. 687 Fatal cases (one abstract)..................... 688 Table LX. Condensed summary of twenty- nine cases.............................. 688 Secondary excisions of the shaft of the Humerus___ 690 Successful cases (abstracts of four cases)....... 690 Table LXI. Condensed summary of thirty- six cases............................... 590 vni TABLE OF CONTENTS. CHAPTER IX. WOUNDS AND INJURIES OF THE UPPER EXTREMITIES—Continued. Page. SECTION IV. Excisions in the Humerus—[Continued. Fatal cases (abstract of one case).................... 693 TABLE LXII. Condensed summary of five cases. 693 Period unknown............................'___'........ 693 Successful cases.................................... 693 Table LXIII. Condensed summary of fifty-one cases......................................... 694 Fatal cases......................................... 695 TABLE LXIV. Condensed summary of twelve cases 695 Results unknown................................... 695 TABLE LXV. Condensed summary of twelve cases 695 Concluding observations on excisions in the continuity of the shaft of the Humerus for shot injuries.................. 695 Table LXVI. Numerical, of six hundred and ninety-six cases of excisions in the shaft of the Humerus for shot injury....................... 696 Amputations of the Arm for shot injury ...... 697 Table LXV'II. Summary of five thousand four hundred and fifty-six amputations of the Arm for shot injury................................... 697 Primary amputations in the Continuity.................. 697 Primary amputations in the upper third of the Arm... 698 Successful cases (abstracts of ten cases).......... 698 Table LXVHI. Summary of eleven hundred and fifty-five cases of recovery after primary amputations in the upper third of the shaft of the Humerus............................. 700 Fatal cases (abstracts of three cases)............. 717 Table LXIX. Summary of one hundred and eighty-three unsuccessful cases of primary amputations in the upper third of Humerus. 718 Primary amputations in the middle third of the Arm.. 721 Successful cases (four abstracts)................. 721 Table LXX. Summary of one thousand and nineteen cases of recovery after primary am- putations hi the middle third of the shaft of the Humerus ............................ 721 Fatal cases (two abstracts)...................... 736 Table LXXI. Summary of one hundred and forty-three unsuccessful cases of primary am- putations in the middle third of the shaft of the Humerus............................. 737 Primary amputations in the lower third of the Arm... 739 Successful cases (abstracts of six cases).......... 739 Table LXXII. Summary of four hundred and six cases of recovery after primary am- putations in the lower third of the shaft of the Humerus............................. 741 Fatal cases (abstracts of two cases).............. 746 Table LXXIH. Summary of one hundred and six unsuccessful cases of primary ampu- tations in the lower third of the shaft of the Humerus................................ 747 Primary amputations of the Arm without indication of the seat of incision................................ 748 Successful cases... ...............'............. 749 TABLE LXXIV. Summary of seventy-seven cases of recovery after primary amputations of the Arm, tbe point of ablation unspecified. 749 Fatal cases..................................... 750 TABLE LXXV. Summary of one hundred and seventy fatal primary amputations of the Arm, the point of ablation unspecified...... 750 Intermediary amputations in the Continuity............... 752 Intermediary amputations in the upper third of the Arm 753 Successful cases (abstracts of four cases)......... 753 Table LXXVI. Summary of two hundred and thirty-nine cases of recovery after inter mediary amputations in the upper third of the 6haft of the Humerus..................... 755 Fatal cases (abstracts of two cases).............. 7oS TABLE LXXVII. Summary of one hundred and eight fatal cases of intermediary ampu- tutations in the upper third of the shaft of the Humerus............................. 759 Page. SECTION IV. Amputations of the Arm—[Continued. Intermediary amputations in the middle third of the Arm 761 Successful cases (abstracts of six cases).......... 761 Table LXXVIII. Summary of two hundred and fifty-five cases of recovery after interme- diary amputations in the middle third of the shaft of the 11 umerus..................... 76 Fatal cases (abstracts of two cases).............. 766 Table LXXIX. Summary of ninety-three unsuccessful cases of intermediary amputa- tions in the middle third of the shaft of the Humerus................................. 768 Intermediary amputations at the lower third of the Arm 769 Successful cases (four abstracts)................. 769 Table LXXX. Summary of ninety-four cases of recovery after intermediary amputations in the lower third of the shaft of the Humerus. 771 Fatal cases (two abstracts)...................... 772 Table LXXXI. Summary of sixty-seven unsuccessful cases of intermediary amputa- tions in the lower third of the shaft of the Humerus................................. 773 Intermediary amputations of the Arm without indication of the seat of incision........,..................... 774 Successful cases................................ 774 Table LXXXII. Summary of twelve cases of recovery after intermediary amputations of the Arm, the point of ablation unspecified.. 774 Fatal cases..................................... 774 Table LXXXni. Summary of thirty-four un- successful cases of intermediary amputations of the Arm, the point of ablation unspecified 774 Secondary amputations in the Continuity................. 775 Secondary amputations in the upper third of the Arm. 775 Successful cases (two abstracts).................. 775 Table LXXXIV. Summary of one hundred and twenty-seven cases of recovery after sec- ondary amputations in the upper third of the Humerus................................. 777 Fatal cases (five abstracts)...................... 779 Table LXXXV. Summary of forty-six un- successful cases of secondary amputations in the upper third of tbe Humerus............ 781 Secondary amputations at the middle third of the Arm 782 Successful cases (five abstracts)................. 782 Table LXXXVI. Summary of one hundred and twenty-seven cases of recovery after sec- ondary amputations in the middle third of the shaft of the Humerus...................... 784 Fatal cases (three abstracts)..................... 786 TABLE LXXXVII. Summary of thirty-five unsuccessful cases of secondary amputations in the middle third of the Arm............ 787 Secondary amputations of the Arm at the lower third. 788 Successful cases (three abstracts)................ 788 TABLE LXXXVIII. Summary of thirty-seven cases of recovery after secondary amputations in the lower third of the Arm.............. 789 Fatal cases (two abstracts)...................... 790 TABLE LXXXIX. Summary of twenty-four unsuccessful cases of secondary amputations in the lower third of the Arm............... 791 Secondary amputations of the Arm without indication of the seat of incision (one abstract)................ 791 TABLE XC. Summary of fifteen cases of sec- ondary amputations of the Arm, the period of ablation unspecified....................... 792 Amputations in the continuity of the Arm of uncertain date 792 Amputations in the upper third of the Arm of uncertain date............................................. 792 Successful cases................................ 793 Table XCI. Summary of sixty-one successful cases of amputations in the upper third of the Humerus of uncertain date................ 793 Fatal cases..................................... 793 2* LX TABLE OF CONTENTS. OHAPTER IX. WOUNDS AND INJURIES OF THE UPPER EXTREMITIES-[Contim ed. Page. SECTION IV. Amputations of the Aum—[Continued. Table XCII. Summary of twenty-one fatal cases of amputations at the upper third of the Humerus of uncertain date................ 794 Undetermined cases............................. 794 Table XCIII. Summary of twelve cases of am- putations at the upper third of the Humerus of uncertain date and undetermined result.. 794 Amputations in the middle third of the Arm of uncer- tain date......................................... 794 Successful cases................................ 794 Table XCIV. Summary of forty-five cases of recovery after amputations in the middle third of the shaft of the Humerus of uncer- tain date................................. 795 Fatal cases..................................... 795 Table XCV. Summaryof thirteen casesof un- successful amputations in the middle third of the shaft of the Humerus of uncertain date. 795 I'ndetermined cases............................. 796 Table XCVI. Summary of nine cases of am- putations in the middle third of the shaft of the Humerus of uncertain date and uncertain result.................................... 796 Amputations in the lower third of the Arm of uncer- tain date........................................ 796 Taiile XCVII. Summaryof twenty-four cases of amputations in the lower third of the shaft of the Humerus of uncertain date.......... 796 Amputations in the coujinuity of the Arm of uncertain date, without indication of the seat of incision...... 797 Successful cases................................ T!>7 Table XCVIII. Summary of three hundred and forty-five cases of recovery after ampu- tations in the Arm of uncertain date, without indication of the seat of incision............ 797 Fatal cases...............................'...... 801 Table XCIX. Summary of one hundred and ninety-four fatal eases of amputations in the Arm of uncertain date and seat............ 801 Undetermined cases............................. 803 Table C. Summary of one hundred and sixty cases of amputations in the Arm in which the precise seat of operation and the result are unknown............................. 803 Recapitulation.......................................... 805 Table CI. Statement of the ages of three thousand and sixty-eight patients who submit- ted to amputation of the Arm for shot injury 806 Concluding observations on shot injuries of tbe Upper Arm...................................... 807 Simple shot fractures.................................... 815 Shot contusions of the Humerus (sixteen abstracts)....... 817 Excisions in the Continuity.............................. 819 Amputations in the Continuity........................... 822 Table CH. Statement showing the percentages of mortality of the various subdivisions of the fifty-four hundred and fifty-six amputations of the Arm for shot injury....................................... 824 Table CHI. Relative percentage of mortality of am- putations in the upper, middle, and lower thirds of the Upper Arm for shot injury..................... 824 TABLE CIV. Mcde of treatment and results of shot fractures involving the shaft of the Humerus on the occasions named and from the authorities quoted.... 826 SECTION V. Wounds and Injuries of the Elbow Joint... 827 Punctured and Incised wounds.......................... 827 Bayonet wounds of the Elbow (three abstracts)...... 827 Sabre wounds of the Elbow (six abstracts)........... 828 Shot wounds........................................... 829 Table CV. Tabular statement of two thou- sand six hundred and seventy-eight shot fractures of the bones of the Elbow Joint.. 829 Paoi wounds of the Elbow treated on the expectant plan.. 830 Cases of recovery (t'rmTy five abstracts) ............ 830 Page. SECTION V. WOUNDS OF THE ELBOW JOINT—[Continued. Fatal cases (eleven abstracts)....................... 841 PLATE XIX. Necrosis of the Humerus after shot injury, facing 842 Excisions at the Elbow Joint for shot injury. 845 Table CVI. Numerical statement of six hundred and twenty-six cases of complete or partial excisions of the bones of the Elbow Joint for shot injury....................... 845 Primary excisions at the Elbow......................... 845 Recoveries after primary excisions at the Elbow (twelve abstracts)........................................ 846 Plate LIII. Results of excisions of the Elbow for shot injury, facing.................................................... 850 Table CVII. Summary of two hundred and fifty cases of recovery after primary excisions at the Elbow Joint for shot injury......... 851 Fatal cases of primary excisions at the Elbow (four ab- stracts) ........................................... 861 Table CVIII. Summary of sixty-eight fatal cases after primary excisions of the Elbow Joint for shot injury...................... 863 Table CIX. Summary of four cases of pri- mary excisions of the bones of the Elbow Joint with undetermined result............ 864 Intermediary excisions at tbe Elbow..................... 865 Recoveries after intermediary excisions at the Elbow (fourteen abstracts)............................... 865 Plate LI. Bones of Elbow excised for shot injury, facing.. 872 Table CX. Summary of one hundred and twenty-seven cases of recovery after inter- mediary excisions of the bones at the Elbow for shot injury............................ 874 Fatal cases of intermediary excisions at the Elbow (seven abstracts)........................................ 879 Table CXI. Summary of sixty-nine unsuc- cessful cases of intermediary excisions of the Elbow Joint for shot injury................ 881 Excision with undetermined result (one abstract)..... 884 Secondary excisions at the Elbow....................... 884 Recoveries after secondary excisions at the Elbow (eleven abstracts)................................. 884 Table CXII. Summary of forty-nine cases of recovery after secondary excisions of the bones of the elbow for shot injury......... 889 Fatal secondary excisions at the Elbow (two abstracts) 890 Table CXIII. Summary of five fatal cases of secondary excisions at the Elbow for shot injury.................................... 891 Excisions at the Elbow of uncertain date (one abstract).. 892 TABLE CXIV. Summary, of fifty-three cases of excisions at the Elbow Joint, of uncertain date, for shot injury....................... 892 Recapitulation.......................................... 894 Table CXV. Statement of parts excised in six hundred and twenty-six instances of ex- cisions at the Elbow for shot injury ........ 894 Table CXVI. Period of the war at which the excisions at the Elbow were practised, with the results........................... 894 Table CXVII. Results of five hundred and seventy-three excisions at the Elbow accord- ing to the season at which the operations were practised............................ 595 Table CXV HI. Statement of the result of four hundred and ninety-five excisions at the elbow for shot injury, according to the ages of the patients............................ 895 Excisions at the Elbow in the Confederate service (abstracts of seven cases)............................... g^g Table CXIX. Summary of one hundred and thirty-eight cases of excisions at the Elbow after shot injury, practised in the Confeder- ate army............................. 898 Table CXX. Dates and results of one hun- dred and thirty-eight Confederate cases of excisions nt the Elbow for shot injury...... 900 TABLE OF CONTENTS. CHAPTER IX. WOUNDS AND INJURIES OF THE UPPER EXTREMITIES-[Continued. Page. SECTION V. Excisions at the Elbow—[Continued. Excisions at the Elbow in other campaigns............... 901 Table CXXI. Results of cases of shot frac- ture of the Elbow treated by excision on the occasions named and from the authorities quoted................................... 901 Concluding observations on Excisions at the Elbow................................................. 904 Plate LIV. Results of resections at the Elbow for shot in- jury, facing.............................................. 908 Amputations at the Elbow Joint................ 909 Primary disarticulations (abstracts of four cases).......... 910 Intermediary disarticulations (abstract of one case)....... 912 Secondary disarticulations (abstract of one case).......... 913 Disarticulations of uncertain date........................ 913 Table CXXII. Summary of forty cases of Amputations at the Elbow Joint for shot in- jury ..................................... 913 Concluding observations on Injuries of the Elbow................................................. 916 SECTION VI. Wonnds and Operations in the Foreann___ 917 Table CXXIII. Partial numerical statement of gunshot wounds of the Forearm in the field or primary hospitals in various cam- paigns during the last year of the Rebellion, 1864-65.................................. 917 Punctured and Incised wounds................... 918 Sabre wounds (abstracts of five cases)................... 918 Shot wounds.......................................... 919 Contusions and partial fractures.......................... 919 Shot contusions of the Radius and Ulna (abstracts of eight cases)...................................... 919 Partial shot fractures of the bones of the Forearm (ab- stracts of five cases).............................. 921 Shot Fractures of the Forearm................... 921 Table CXXIV. Numerical statement of the nature and treatment of five thousand one hundred and ninety-four shot fractures of the bones of the Forearm..................... 922 Shot Fractures of the Forearm treated by Ex- pectation .............................................. 922 Fractures involving both bones of the Forearm........... 922 Recoveries under expectant treatment after fractures of both bones of the Forearm (abstracts of four cases). 922 Fatal cases of shot fractures of the Ulna and Radius (one abstract)..................................... 924 Fractures of the Ulna treated by expectation............. 925 Successful cases (five abstracts)...................... 925 Fatal cases (two abstracts).......................... 827 Shot fractures of tbe Radius treated by expectation....... 927 Successful cases (eight abstracts)..................... 927 PLATE XVI. Hospital Gangrene, facing..................... 928 Fatal casesof shot fractures of the Radius (four abstracts) 930 Complications.......................................... 932 Treatment............................................. 932 Excisions in the Continuity of the bones of the Forearm for shot injury.......................... 933 Table CXXV. Numerical statement of nine hundred and eighty-six cases of excisions in the Forearm for shot injury................ 933 Primary excisions in the shaft of the Ulna, of the Radius, or of both bones...................................... 933 Recoveries after primary excisions in the Forearm..... 933 Recoveries after excisions in the shafts of both bones (two abstracts).......................... 934 Recoveries after excisions in the shaft of the Ulna (seven abstracts).............................. 934 Recoveries after excisions in the shaft of the Radius (four abstracts)............................... 937 Table CXXVI. Summary of five hundred and eighty-nine cases of recovery after pri- mary excisions of bones of the Forearm for shot injury............................... 939 Page. SECTION VI. Excisions in the Forearm— [Continued. Fatal cases after primary excisions in the Forearm (five abstracts)........................................ 950 TABLE CXXVII. Condensed summary of sev- enty-one fatal primary excisions of the bones of the Forearm........................... 951 Primary excisions in the bones of the Forearm with undetermined results (five abstracts)............... 953 Intermediary excisions in the bones of the Forearm....... 953 Recoveries after intermediary excisions (eight abstracts) 953 Table CX XVIII. Summary of one hundred and twenty cases of recovery after interme- diary excisions in the bones of the Forearm for shot injury............................ 957 Fatal intermediary excisions in the Forearm (seven abstracts)........................................ 959 Table CXXIX. Summary of twenty-nine fatal eases after intermediary excisions in the bones of the Forearm..................... 961 Secondary excisions in the bones of the Forearm......... 961 Recoveries after secondary excisions (two abstracts).. 961 Fatal secondaiy excisions (one abstract).............. 962 Table CXXX. Condensed summaryof forty secondary excisions of the bones of the Fore- arm ...................................... 963 Excisions in the Forearm of uncertain date............... 963 TABLE CXXXI. Summary of one hundred and thirty-two cases of excisions in the Fore- arm, the time between the injury and opera- tion being unknown....................... 9G4 Concluding observations on Excisions in the Shafts of the Rones of the Forearm.......... 966 Amputations in the Continuity of the Fore- arm for shot injury................................ 967 TABLE CXXXII. Numerical statement of sev- enteen hundred and forty-seven cases of am- putations in the Forearm for shot injury--- 967 Primary amputations in the Forearm for shot injury...... 967 Recoveries after primary amputations in the Forearm (one abstract).................................... 967 TABLE CXXXIII. Summary of nine hundred and ten cases of recovery after primary am- putations in the Forearm for shot injury--- 968 Fatal primary amputations in the Forearm (one ab- stract) ............................................ 978 TABLE CXXXIV. Condensed summary of ninety-seven fatal cases of primary amputa- tions in the Forearm...................... 978 Intermediary amputations in the Forearm for shot injury.. 980 Recoveries after intermediary amputations in the Fore- arm (one abstract)................................ 980 Table CXXXV. Condensed summary of three hundred and forty-four successful intermedi- ary amputations in the Forearm for shot in- jury..................................... 981 Fatal intermediary amputations in the Forearm (one abstract)......................................... 985 TABLE CXXXVI. Condensed summary of one hundred and six fatal intermediary amputa- tions in the Forearm for shot injury........ 986 Secondary amputations in the Forearm for shot injury--- 987 Recoveries after secondary amputations in the Foreann (one abstract)..................................... 987 TABLE CXXXVII. Summary of one hundred and fifty-five successful secondary amputa- tions in the Forearm for shot injury........ 988 Fatal secondary amputations in the Forearm (one ab- stract) ............................................ 990 TABLE CXXXVIII. Summary of twenty-nine fatal secondary amputations in the Forearm for shot injury............................ 990 Amputations in the Forearm of uncertain date........... 991 TABLE CXXXIX. Tabular statement of one hundred and six cases of amputations in the Forearm of uncertain date................. 991 XI TABLE OF CONTENTS. OHAPTER IX. WOUNDS AND INJURIES OF THE UPPER EXTREMITIES-[Continded. Page. SECTION VI. Woinds IN THE FOREARM—[Continued. Concluding observations on Shot Wounds of the Forearm......................................... 991 Table CXL. Mode of treatment and results of shot fractures involving the bones of the forearm on the occasions named and from the authorities quoted......................... 993 SECTION VII. Wounds and Operations at the Wrist..... 995 Table CXLI. Numerical statement of the treatment of fourteen hundred and ninety-six shot fractures of the bones of the Wrist..... 995 Shot fractures at the Wrist treated by Expec- tation .................................................. 996 Abstracts of five cases of shot fractures at the Wrist treated by expectation............................ 997 Excisions at the Wrist for shot injury.......... 999 Table CXLII. Numerical statement of the nature and results of ninety-six cases of ex- cisions at the Wrist for shot injury......... 999 Abstracts of ninety-six cases of excisions at the Wrist. 1000 Excisions at the Wrist in the Confederate ser- vice.................................................... 1012 Abstracts of thirteen cases.......................... 1012 Pngc. SECTION VII. EXCISIONS AT THE WlUST—[Continued. Concluding observations on Excisions at the Wrist for shot injury.............................. 1013 Amputations at the Wrist for shot injury.....1017 Table CXLII I. Summary of sixty-eight am- putations at the Wrist Joint for shot injury. 1017 SECTION VIII. Wounds and Operations in the Hand.....1019 Table CXLIV. Numerical statement of eleven thousand three hundred and sixty- nine fractures of the bones of the Hand for Bhot injury...............................1019 Shot wounds of the Hand treated by expectation......... 1020 Abstracts of two cases............................ 1020 PLATE LH. Effects of division of Ulnar Nerve and of shot perforation of the Hand, facing............................ I020 Shot wounds of the Hand treated by excision.............1021 Shot wounds of the Hand treated by amputation......... 1021 Shot wounds of the Palmer Arch.................... 1°2;J List of Reporters and Operators................. I List of Plates..........................................xvn Corrigenda. XII THE MEDICAL AND SURGICAL HISTORY OF THE WAR OF THE REBELLION (1861-65), PART II, VOLUME II. BEING THE SECOND SUIlGrlCAL VOLUME. ON SPECIAL WOUNDS AND INJURIES—CONTINUED CHAPTER VI. INJURIES OF THE ABDOMEN. Though the abdominal and pelvic cavities are contiguous and constitute, in reality, but one, yet their injuries will be described separately, and an arbitrary boundary must be established. The abdominal cavity properly so called, will then be limited, below, by a plane corresponding with the ileo-pectineal line or superior strait of the pelvis; above, by the diaphragm ; posteriorly, by the lumbar spine; laterally and anteriorly, by muscles. Injuries of the spine have been discussed in the third Chapter of the preceding volume. Wounds of the soft parts in the dorsal and lumbar regions will be enumerated with Wounds of the Back, except those which penetrate the abdominal cavity, which will be discussed in the third Section of this Chapter. The Chapter will contain a brief notice of the contusions and simple wounds of the anterior abdominal walls, that were reported during the War; a fuller account of the injuries of the abdominal viscera proper, unattended by external wounds; and an extended description of the penetrating wounds of the abdomen, within the limits above defined. Attention will be chiefly invited to the gunshot wounds of the stomach, small and large intestines, and of the liver, spleen, pancreas, and kidneys. 1 2 INJURIES OF THE ABDOMEN. [CHAP. VI. John Bell devoted the third and fourth of his admirable discourses1 to "wounds of the belly,1'1 and commenced the former with the following observations: "Every wound is a disease, and every disease is different according to the constitution of the parts affected, and according to the offices which the parts are destined to fulfil. In the abdomen, we find the principles which explain its diseases very simple and plain: we find the chief cause of danger to be the tendency of the peritoneum to inflame; we find every wound apt to excite this inflammation, and every inflammation, however slight, apt to spread, to extend itself over all the viscera, and terminate in gangrene and death. Upon these grounds, we cannot but pronounce a wound of the belly to be a mortal wound." The illustrious John Hunter said: "All wounds that enter the belly, which have injured some viscus, are to be treated according to the nature of the wounded part, with its compli- cations; which will be many, because the belly contains more parts of very dissimilar uses than any other cavity in the body; each of which will produce symptoms peculiar to itself, and the nature of the wound." The broad principles thus enunciated by these great writers,—that the main danger to be dreaded in wounds of the abdomen was inflammation of the peritoneum, and that the lesions of the several viscera should be revealed by distinctive disorders in their respective functions,—still guide us in dealing with this difficult subject. At the beginning of the War, the medical men who were summoned from their accustomed avocations to become military surgeons, possessed the general knowledge derived from their clinical experience in civil practice, and from the teachings of modern text-books, based mainly, as regards injuries of the abdomen, upon the teachings of Oallisen, Richter, Morgagni, Scarpa, Littre, Portal, Hevin, Cooper, Travers, and Gross,3 and were especially instructed in the application of this information to the treatment of the injuries, incident to war. by Guthrie's precepts,4 which were earnestly advocated by Dr. Tripler, the medical director of'the first large organized army, who epitomized them in a chapter of his excellent manual,5 and illustrated them by instances derived from his own extended experience, and from the writings of Dr. Macleod and others, on the surgery of the Crimean War. As the war progressed, however, and surgeons earned the right to rely upon their own observations, it was found expedient to modify the rules laid clown by these eminent authorities, in some essential particulars, as will appear in the subsequent pages of this Chapter. That the prognosis of wounds of the abdomen is very unfavorable, the diagnosis very obscure, and the results of treatment discouraging, are stubborn facts, that remain unchanged by the experience of the War. Yet it may be hoped that the observations accumulated will be found to afford a basis for more precise notions respecting the mortality, for some clues for the differential diagnosis, and hints, at least, as to what to do and leave undone, in the treatment of this class of injuries. For. to speak more definitely, we are placed in 'Bell, J., Discourses on the Nature and Cure of Wounds, Edinburgh, 1795, Part II, p. 50. 2 Hunter, A Treatise on the Blood, Inflammation, and Gunshot Wounds, London, 4to, 1794, p. 544. ' C ALUbE.v, Principia Systematis Chirurgise, Hodiernx, Hafniae, 1788, Vol. I, p. 597; Richter, Anfangsgrunde der Wundarzneykunst, Gottingen, 1801, B. V. S. 3; MOBGAGNI, De Vulneribus et Ictibus Ventris, in Epist. LIV, of the treatise De Sedibus et Causis Morborum, Op. Omnia, Patavii, 1765, Liber III, p. 176; SCARPA, Memorie Anatomico-Chirurgiche sull'Ernia, sec. ed., Pavia, 1819; Littre, Observations sur des Plaies de Ventre, in Mem. de I'Acad. des Sciences, 1705, p. 32; MARJOLIN, Article Plaies de VAbdomenin the Diet, de Mid. en XXX, T. I, p. 152; COOPER, The Anatomy ami Surgical Treatment of Inguinal and Congenital Hernia, folio, London, 1804 and 1807; TRAVERS, An Inquiry into the I'rocrss of Nature in L', pairing Injuries of the Intestines, London, 1812; GROSS, An Experimental and Critical Inquiry into the Nature and Treatment of Wounds of the Intestines. Louisville. 1843; Hevin. Mem. de VAcademic de Chirurgie. * Guthrie, On Wounds and Injuries of the Abdomen and I'eh-is, London, 1847, p. 7, and Commentaries, 6th ed., London, 1855, p. 535. 'TRIPLER, Handbook for the Military Surgeon, Cincinnati, 1861, p. 88. SF.CT. I.] PUNCTURED AND TNCTSET) WOUNDS. 8 possession of statistical data on the relative frequency and doath-rate of these injuries; we have clinical abstracts and post-mortem descriptions of the effects ot lesions of the several viscera, which, if they do not elucidate more fully the distinctive phenomena of such injuries, fail to do so because of the imperfection of our knowledge in regard to the normal functions of many of the organs involved; and, finally, we have a great mass of cases of traumatic peritonitis treated without venesection, and mainly by opium, with rest and starvation, and a certain number of cases in which the problem of the justifiable limits of operative interference is presented. After recording a series of instances of each of the three groups of abdominal lesions, these inquiries will be examined in detail. Section I. CONTUSIONS AND WOUNDS OF THE ABDOMINAL PARIETES. The superficial wounds of the abdomen implicating the walls only may be considered in two groups. First, the punctured, incised, and lacerated wounds and contusions inflicted by cutting weapons or miscellaneous causes; secondly, those produced by shot. Punctured and Incised Wounds.—Those that were narrow and oblique were frequently of difficult diagnosis, but extended cuts readily disclosed whether they were penetrating or otherwise. Simple punctured wounds were treated by the application of a dossil of moist lint, rest, and position to relax the muscles; incised wounds required, in addition, adhesive plasters, retentive bandages, and sutures. /Sabre and Bayonet Wounds.—Sword wounds in this region were infrequent. The few reported were inflicted by thrusts rather than cuts. Bayonet wounds were more common. But the more important wounds of this class were those penetrating the cavity, and will be noted in the Third Section. Among the few sword wounds of the parietes was one followed by extensive ventral hernia: Case 1.—Corporal Simeon A. Holden, Co. D, 1st Maine Cavalry. Wounded at the cavalry affair at Upperville, June "21, 1863, by a sabre cut in the lumbar region, extending nearly to the umbilicus. He recovered, and was discharged on November 25, 1864, and was a pensioner in 1872. Examining Surgeon P. H. Harding reported that, at the cicatrix, there was " a rupture and protrusion of intestines," and that the disability was three-fourths and permanent.1 Such protrusions require to be restrained by the application of a truss with a broad, somewhat concave, pad. They almost invariably follow extensive divisions of the mus- cular walls of the abdomen, unless the utmost pains is taken, in the primary dressings, to secure close coaptation. Few particulars of interest are recorded in connection with the other sabre and bayonet wounds of this region : Case 2.—Private C. D. Wheat, Co. B, 21st New York Cavalry, aged 18 years. New Market, May 16, 1864. Sabre wound of the abdomen. Treated in Harrisburg and New York hospitals. Furloughed, and, not returning, reported a deserter on December 30, 1864. Case 3.—Private James Wilkinson, Co. E, 11th New Jersey, aged 18 years. Bayonet flesh wound, right side of abdomen. Camp near Beverly Ford, August 18,1863. Sent to Fairfax Seminary Hospital. Furloughed on September 2d; readmitted on October 3d; sent to duty on January 12, 1864. Reported by Surgeon D. P. Smith, U. S. V. Cases 4-18.—On the occasions named, the thirteen following cases of bayonet flesh wounds occurred, without very grave consequences, and these men were ultimately returned to duty: Pt. W. B. Ensign, K, 130th New York, White House Landing, June 26,1863; Pt. W. Foster, H, 37th Kentucky, Glasgow, April, 1864 ; Corp. J. McCabe, E, 210th Pennsylvania, September 19, 1A subsequent report relates this case as a penetrating wound of the liver INJURIES OF THE ABDOMEN. It'HAP. VI. I - '4, duty November 23, 1814; Pt. F. Pierson, B, 115th New York, Mai vern Hill, August 14,1864 ; Pt. T. Toomy, G, 52(1 Kentucky, September 10, 1*61. duty September 16, 1*64; Pt. M. Riley, A, 26th Ohio, July, 1864, duty August 7, 1864; Pt. A. Berrish, L, 4th New York Cavalry. October 19, 1864; Pt. W. H. Campbell, K, 31st Maine, Petersburg, April 2, 1*55. duty June 10th; Pt. S. G. Swain. A. 60th Iowa, duty June 11, 1863; Pt. J. G. Norton, B, 17th New York, duty October 14, 1*63; Pt. J. II. Uarhan, I. 63d Ohio, Pocotaligo, January 21. 1855; Pt. S. Luddy, V. R. C, December 9, 1*63. duty January 11, 1854; Pt. T. Evans, 144th New York, June 9, 1864. The following received somewhat graver bayonet wounds of the walls of the belly: Sergt W. II. Simpson, K, 102d U. S. C. T., March 27, 1*54, at Detroit, a long seton wound in left umbilico-inguinal region, resulting in ventral hernia; discharged for disability, rated at three-fourths. Pt. M. Jennings, F, 7th Missouri, Vicksburg, December, 1863, extensive bayonet wound of abdominal walls; united by interrupted sutures, and healed by first intention; duty January 7, 1864. Other Punctured and Incised Womids— The reports specify twelve serious cases of punctured or incised wounds of the abdominal walls by knives or dirks, which eventually recovered, without complications of note, all of the patients being returned to duty : Casks 19-30.—Pt, J. Laughberry, C, 18th United States Infantry, October 9, 1884, duty November 24. 1864 ; Pt. Z. Wood, G, 37th Illinois, October 21, 1864, duty November 26, 1864; Pt. T. E. Grogan, M, 13th New York Heavy Artillery, August 6, 1*64 ; Pt. J. Reehart, 1,5th Missouri Cavalry, December, 1863, duty January 2, 1864; Pt. G. W. Adams, F, 64th Ohio, May 9, 1864 ; Corp. R. L. Gallatin, B, 8th Iowa, February 9, 1865. duty April 20, 1855 ; Pt. W. Jervis, K, 2d United States Infantry, March, 1865, duty March 8, 1865; Pt. J. F. Barrow, F, 7th Vermont, January 11, 1865, duty January 31, 1855; Corp. J. Benoit^ A, 7th Vermont, January 11, 1865, duty January 31, 1865; Pt. J. Wicker, A, 97th Illinois, November 25, 1864; Pt. S. Williams, 20th New York Battery, May 9, 1*35, duty May 17, 1855; Pt. D. Cushman, E, 2d Vermont, March, 1*54, duty April 5, 1864. Guthrie and Tripler taught that it was worse than useless to pass sutures through the muscular structures of the abdomen, and that incised wounds should be united by stitches including the integument only. It is unnecessary to review their familiar arguments, or the theories adduced on the other side.1 Later experience attests the utility of deep sutures, and it was generally observed during the War that ventral protrusions were only to be prevented, after extended division of the abdominal walls, by exact coaptation of the divided muscular tissues. Interrupted and twisted sutures were sometimes employed; but the quilled suture answered the best purpose, Jk reducing the extensible cellulo-fibrous cicatrix (\ ^/ /4KlS\ \s^C to the narrowest dimensions. Twice, by this //lMl\ 1 means, I secured firm cicatrices without pro- 1 ilFllffil .-*> trusion, in extensive incised wounds in the \ \mStm lr^~*> bellies of horses, where the difficulty of exact reunion is great. The drawings (Figs. 1 and 2) will refresh the reader's recollection of this form of suture, which recent improvements in plastic surgery and the treatment of ruptured Application of the quiiied perinseum have proved to be so useful. It is i irwMS^d wound. 1 -L well to tie the threads in a bow-knot, or to leave the ends long if wire is used, in order to loosen the stitches when inflammatorv swelling requires it. The sutures should be allowed to remain until the fourth or fifth day, and the loop of each double thread then being cut, the pieces should be withdrawn simultaneously in opposite directions. Lacerated and Contused Wounds.—Sixty-eight examples of non-penetrating injuries of this group were specified. It is unnecessary to enumerate them, as the cases Fig. 1.- suture to an incised wound. Via.'2.—Quilled suture completed. 1 The results of experience, however, may be referred to: JIattiikw (loc. cit.. p. 324), in discussing the flesh wounds of the abdomen in the Crimean War. says : " The uselessness and even the injurious tendency of sutures, when inserted into the substance of muscle, has been much insisted on. but it would appear needlessly so." LEGOUEST (cp. cit., p. 370) remarks: " Tons les auteurs tcnseillent do rendre la coaptaticn des bords de la p'.aie plus parfaite ulaide de baudelettes ag-^lutinatives; mais tons les chirirgiens savent aussi que ce moyen n'est qu' illusoire; * * si les muscles out 0,6 profondement divises, nous pensons qu il faut avoir recours .1 la suture enchevillS. * * * Cette suture ne doit pas se borner a la peau, mais clle doit comprendre les muscles eux memes. et les anses du fil doivent allcr jusqu'au fond de La plaie." sect. i.| LACERATED AND CONTUSED WOUNDS. 5 presented no features of especial interest, and this class is sufficiently illustrated by shot wounds. All of the sixty-eight patients recovered, save one (Sergeant II. Brandcnberg, I, 39th New York), who died of intercurrent typhoid fever. In these, as in all wounds of the abdomen, the necessity of absolute rest, was conspicuously illustrated, and the importance of maintaining muscular relaxation by elevating the head and shoulders and flexing the lower limbs. Fomentations and cataplasms were generally and advantageously used. In several lacerations with large flaps, sutures wore employed with benefit.1 It was noticed that lacerations above the umbilicus healed less readily than those lower down ; probably because of the greater mobility of the upper part of the abdominal parietes during respiration, and the strain of the arches of the lower ribs. There were sixteen graver lacerated and contused wounds from miscellaneous causes, complicated with internal mischief, differing from the visceral injuries, in the Second Section, by the existence of external lesions, and from the penetrating wounds, in the Third Section, in the absence of any primary opening of the cavity. Seven of the cases of this group were fatal. Rupture of Muscles.—Though enumerated among the physical lesions external to the peritoneum, yet, as Mr. Pollock observes, in his able account of Injuries of the Abdomen,2 ruptures of the abdominal muscles as a result of external violence are not often detected unless the accident prove fatal, and then they are usually associated with some visceral complication. Such ruptures may occur during tetanic spasms, or violent gymnastic efforts, or in coitu; but I find only one case on the records, of rupture of the rectus from violence: Case 31.—Private John Merkel, Co. A, 4th Pennsylvania Cavalry, aged 30 years, entered Satterlee Hospital, December 13, 1832. He had been thrown from his horse in September, and in falling came in contact with the stump of a tree, apparently producing laceration of the rectus muscle of the right side, and considerable protrusion of the umbilicus, according to his state- ment, about the size of a hens egg. He was rendered insensible and remained in that condition for three hours. Peritonitis followed, and, two days after the accident, a small quantity of blood was passed from the bowels. After the subsidence of the inflammation the abdomen was bandaged, a pad was applied over the umbilicus, and rest and quiet were enjoined. On admission to hospital he complained of no pain, except when the bowels were opened or he was shaken in any way. The umbilicus protruded to about the size of a plum, was quite mobile, and could be handled without giving pain—slight pressure reduced it a great deal. For about two inches above and below the umbilicus there was a tenderness of rectus of right side, with slight dulness on percussion, and a feeling of hardness. On January 11th, he had a cough, for which the compound licorice mixture was ordered, and his bowels being constipated, he was directed to take two compound cathartic pills and a draught of solution of citrate of potassa. A slight attack of ague followed, which was arrested by quinia. On February 7, 1863, Merkel was discharged from service. The case is reported by Dr. J. M. DaCosta.3 It is difficult to draw the line between such cases as this and those belonging; to the next section, as attended by serious visceral injury. The bloody stools and peritonitis on the second day indicate internal mischief, though, fortunately, of a mild character. There is no abrupt line of separation between the superficial injuries and those associated with grave internal trouble, and only the results determine how they shall be classed. Every abdominal injury must be treated as if it were serious, until time develops its true nature. Hospital records are usefully suggestive of the probabilities of prognosis. Thus, at Guy's Hospital,4 in eight years, of seventy-one cases of abdominal injuries admitted consec- utively, forty-four, or three-fifths, recovered without other definite symptoms than passing collapse and local tenderness; in ton cases, symptoms of peritonitis set in, yielding to treat- ment in seven, but terminating fatally in three; while in seventeen cases, or one-fourth, rup- ture of the viscera took place. This affords an idea of the average risks in such accidents. 1 NEUDOKFEIt (Handbuch der Kricgschirurgie, Leipzig, 1667, H. II, S. 706) dwells upon the utility of sutures in lacerations (Itisswunden) of the abdomen, in his experience in the Italian and Mexican wars. 2 POLLOCK, G., Injuries of the Abdomen, in HOLMES'S System of Surgery, 2d ed., 1870, Vol. II, p. 629; Lauuky, Clin. Chir., T. II, p. 488. 3M. LEGOUEST prints a similar case in the Gazette des Bopitaux, I860, No. 76, and refers to it in his Chirurgie d'Armec. p. 372. Mr. Pollock (op. cit.), p. C30, quotes it. VlDAL, Path. Ext., T. IV, p. 128, describes a rupture in coitu. A similar case occurred, during the War, at New Berne. 4 Bryant, A Practice of Surgery, London, 1872, p. 299. 6 INJURIES OF THE ABDOMEN. [chap. vi. Gunshot Flesh Wounds.—Of cases corning under surgical treatment of shot wounds of the head and chest, it has been seen1 that those involving the external soft parts predominate numerically. The proportion between the numbers of penetrating and non- penetrating shot wounds of the abdomen treated more nearly approaches an equality. This fact, which did not escape the authors of the Confederate Manual? is illustrated by the numerical casualty returns of the Union army for the last year of the War (Table I): Table I. Partial Numerical Statement of Shot Wounds of the Abdomen, in the Field or Primary Hospitals in various Campaigns, during the last Year of the Rebellion, 1864-65. ----------------------------- Wounds PENETRATING a Haitle, Action, or. Series of Engagements. OF ABDOMINAL WOUNDS OF THE MISSILE. H Parietes. Abdomen. -a p o < 2£ w -V 7. - o Names or Dates. Cases. Deaths. Cases. Deaths. Large projec-tiles, cannon shot, shell, and bomb frag- Small projec-tiles, musket, pistol ball*. ments, grape, and canister. si les from shrapnel and canister. o H "*< 762 4 634 257 102 1,285 38,944 3.58 Armies of the Cumberland, Tennessee, and Ohio during the Campaign to Atlanta, from May 4 to September 8, 1864.... 446 14 774 488 96 1,074 23,308 5.23 Armies of the Cumberland, Tennessee, and Ohio, and Cavalry, General Hood's invasion of Tennessee, from October 25 to December 31, 1864........................................ 70 39 73 58 20 42 14 3 129 94 3,610 1,533 3.96 G.32 General Sherman's Campaign in 1865 through the Carolinas... 1 Armies of the James and Ohio, etc., from Fort Fisher to Goldsboro'. N. C, 1805.................................... 7 o 35 7 3 38 1,075 3.90 Army of the West Mississippi during the siege of Mobile, from March 26 to April 9, 1865.................................. 26 3 27 14 8 45 2,111 2.50 Army of the James during General Grant's Campaign against 221 o 438 103 48 591 16,120 2,196 4.08 Engagements in the Shenandoah Valley, May 4 to Aug. 20,1864 Campaign in the Shenandoah Valley, Aug. 21 to Dec. 30,1864. Annv of the Potomac, from Sept. 1, 18,64. to April 9, 1865 43 74 27 4 98 5.32 165 174 51 39 221 7,542 4.49 217 3 294 136 27 483 10,407 4.91 1,996 29 2,581 1,145 344 4,058 106,846 4.28 Of the forty-five hundred and seventy-seven shot wounds included in this return, twenty-five hundred and eighty-one, or more than half, are recorded as penetrating wounds of the abdomen.3 The field returns include among penetrating wounds of the abdomen those in which the entrance is through the dorsal region, or diaphragm or pelvis, whereas only lesions limited to the anterior and lateral walls are commonly reported among the flesh wounds of the abdominal parietes. Therefore, to estimate aright the relative 1 First Surgical Volume, pages 308 and 599. 1 "It is in the regional cavity of the abdomen that the proportion of penetrating wounds is the greatest. The cranium, from its form, structure. and coverings, serves as a strong defence even against gunshot. The osseous, yet elastic and movable ribs, the sternum, and muscular parietes greatly protect the contents of the cavity which they enclose; but the extensively exposed surface of the abdomen, anteriorly and laterally, has no power of resistance to offer against a projectile directly impinging it; and when the important cavity is once penetrated by these means, death is the almost inevitable result. Even the chances of a favorable termination which may exist in wounds from other causes are generally wanting; and much of their treatment, such as the use of sutures, and other means to insure the apposition of cut edges, is inapplicable—from the parts to a certain distance toeing almost necessarily deprived of their vitality—to injuries from gunshot wounds."—^! Manual of Military Surgery, prepared for the use of the Confed- erate States Army, Richmond, 1863, p. 61. sIt is a commentary on the remark of Sir Charles Bell: "Although wounds of the belly are common enough immediately after a battle, bearing a fair relative proportion to other wounds, yet a few days suflBce to remove them, so that by the end of the first week there is scarcely one to be seen,'—that this number, derived from the returns of the Union army for one year, nearly equals the aggregate of penetrating wounds of the abdomen collected from the reports of the general hospitals and other sources, from both armies, throughout the war. SECT. I.] GUNSHOT FLESH wounds. 7 frequency of the several groups of injuries, it is necessary to analyze the gross aggregates, and to determine, for example, how many of the cases reported as "flesh wounds of the back," "side," or "hip," should be numbered with wounds of the abdominal parietes,— and how manv of the penetrating wounds should be separated as interesting the pelvic viscera. Many of the shot wounds have their entrance in one region and exit in another; many are at first regarded as superficial, and are subsequently found to have implicated or penetrated the peritoneum. The absence of standard rules of classification and inevitable imperfection of diagnosis are thus the two principal causes of the discrepancies in returns in which a certain uniformity should appear; for, undoubtedly, an exact regularity obtains, and becomes more discernible as the observations are weighed as well as counted. Of cases of shot wounds believed to involve the abdominal walls only, and situated in the epigastric, hypochondriac, umbilical, iliac, and hypogastric regions,1 four thousand four hundred and sixtv-nine were reported by name. Nearly one-fourth of these are unaccounted for,—a larger proportion of undetermined cases than usual, that might have been diminished by careful search, had it been practicable to find time for that labor. Of the three thousand one hundred and thirty-four determined cases, two hundred and fifty- three terminated fatallv, or a little over eight per cent.2 This is a large mortality rate when compared with that following gunshot scalp wounds or that resulting from gunshot flesh wounds of the thorax. The explanation is undoubtedly furnished by the frequency with which peritonitis complicates these non-penetrating wounds, and the facility with which the abdominal viscera may be injured without an opening being made in the peritoneal cavity. Gunshot flesh wounds of the abdomen varied greatly in their form and extent, accord- ing to the size, shape, velocity, and direction of the projectiles that inflicted them. Small missiles sometimes lodged, sometimes pocketed the clothing and were withdrawn with it from the cul-de-sac thus formed,—often produced long furrowed wounds and often seton 1 Flesh wounds of the dorsal and gluteal regions and some of those of the lumbar region will be discussed in the Eighth Chapter, and some ci those of the lumbar, inguinal, and perineal regions, in the Seventh Chapter. 2 This, though a larger proportion than that given in the preliminary report, in Circular No. 6, S. G. O., 1865, p. 24 (2,164 flesh wounds of the abdomen, 114 deaths, or a mortality rate of 5.2). does not compare, as Professor Longmore has pointed out (On the Classification and Tabulation of Injuries and Surgical Operations in Time of War, in Med. Chir. Trans., Vol. LIV, p. 238). with the fatality of the corresponding series of cases in the British and French Crimean returns. It is not probable that the mortality rate of the American returns would be materially modified if the terminations of the 1,335 unfinished cases were ascertained. The 3,134 determined cases afford a fair average of the death-rate. This rate is slightly augmented by the addition of the fatal visceral shot injuries without external wounds, recorded in the next section. In these two groups all of the cases of non- penetrating gunshot injuries reported byname are included. The cases in which the abdominal viscera were injured or supposed to be injured, although the cavity was not opened, are not excluded, and "the indiscriminate mixing together of these latter cases with the penetrating wounds," to which Dr. Longmore courteously objects, has been sedulously avoided. It seems more probable that the lack of discrimination may be found in the British and French Crimean returns, in which the mortality rates of gunshot flesh wounds of the abdomen are inordinate and the aggregates too small to afford fair averages. The British returns give, as Dr. Longmore correctly observes, " 115 gunshot injuries of the abdomen in which the peritoneal cavity was not penetrated;" but not "22 deaths," as inorrectly stated by M. Cheuu and by Dr. Longmore, but 17 deaths. (See MATTHEW, op. cit., Vol II, p. 327.) Misled probably by the entry of five invalided officers, M. Chenu (op. cit., p. 197) and Dr. Longmore (I. c, p. 237) record the mortality rate of the British cases as 19.1 per cent, instead of 14.7 per cent, as recorded by the official annalist. Dr. Longmore proceeds to say that in the French statistics of the Crimean War 'the percentage of mortality of these son-penetrating wounds is shown to be nearly the same ' as in the English statistics. The French historian, M. Chenu, gives 148 cases in the Crimea of non-penetrating gunshot wounds of the abdomen, with 28 deaths, or a mortality rate of 18.91. I shall have further occasion to examine the validity of Professor Longmore's criticisms, reluctantly descending to details, which the unjust animadversions upon the American returns compel ino t) notice. It will be admitted that Professor Longmore's illustration of the difficulty of comparing the American with the French and British returns is, in this instance, at least, sufficiently unfortunate. But this is a minor consideration. A more important object is to arrive at some approximation to the ordinary fatality of this group of wounds. This is probably presented by the American returns. It has been noted that the British and French Crimean statistics are too limited to afford fair averages. In M. Chenu's Surgical History of the Italian War (T. II, p. 493) he gives 380 cases of contused gunshot wounds of the abdomen without penetration, with 11 deaths, or a mortality rate of 2.8.), a difference, as compared with his Crimean return, of 16.0J. In the British returns from the New Zealand War (Stat. San. and Med. Rep., 18f>5, Vol. VII, p. 473) the cases of gunshot wounds of the muscles and parietes of the abdomen were only eight in number, and all recovered. Six cases are noted in the account of the wounded in the Indian Mutiny (WILLIAMSON, Med. Surg., p. 102), none of them proving fatal. GUTHRIE and IlENWEN refer to a number of cases of gunshot wounds of the parietes of the abdomen ; but adduce no fatal cases, except such as were complicated by visceral injuries. Larrey, Bauden'8, and Sckive are silent on the subject. So far as the British and French authorities adduce information they do not corroborate the high rate of mortality Professor LONGMORE ascribes to this group of injuries. Demme (Studien, B. II, S. 121) cites 185 cases with 15 deaths, a percentage of 8.1. Dr. Stromeyer (Erf. iibcr Schussw., 18'j'6, S. 6) gives 13 cases with no deaths. Generalarzt BECK. (Chir der Schussw., S. 519—Werdei's Corps at Metz) gives 33 cases, of which only one, a shell contusion with visceral rupture, was fatal. Dr. H. FISCHER (Kriegschir. Erf., Vor Metz, S. 128) gives 18 cases with no deaths. INJUR!MS OF THE A15DOMEX. ICHAP. VI wounds. Instances w>re common in which such missiles wounded the hands or forearms on striking or emerging from the abdominal walls. The larger projectiles produced extended lacerations and contusions. A good illustration of a cicatrix after a laceration of the abdominal walls by a shell fragment, is furnished by Plate V, opposite page 162, in the First Surgical Volume. Contusions from spent grape and canister shot were numerous. There is a series of two hundred and thirty-eight such cases, of which five had a fatal result in consequence of peritonitis being lighted up. In a few instances belonging to this group, the ecchymoses resulted in superficial abscesses or in peculiar indolent ulcers, with a sanious discharge, the vitality of the tissues being lessened, but not abso- lutely destroyed. These ulcers were benefited by camphorated lotions or other mildly stimulating dressings, while saturnine, lotions, or emollients, on the one hand, and tere- binthinate, or strongly stimulating topical applications, on the other, were disadvantageous. The seton wounds were sometimes quite long. It is an error to suppose that the cylindro- conical musket balls are rareiy deflected. They often pursue long subcutaneous or inter- muscular tracks, and occasionally make nearly the circuit of the trunk.1 Illustrations of these different forms of injury will be cited in describing the complications. The compli- cations observed in a few cases of this group of injuries were: haemorrhage, foreign bodies, gangrene, hernia, nervous disorders, tetanus. As many of these are common to the miscellaneous and shot wounds, it will be best, to avoid repetitions, to tabulate all the cases belonging to this section, and to consider their complications together: Table II. Numerical Statement of the Cases of Injuries of the Abdominal Parietes returned during the War. NATURE OF INJURY. Sabre ami Bayonet Wounds ............ Other Punctured and Incised Wounds___ Lacerated and Contused Wounds (slight). Lacerated and Contused Wounds (severe) (iunshot Flesh Wounds................. Gunshot Contusions.................... Aggregates............................................... 4, 821 18 12 68 16 4,469 238 1 7 253 262 9 532 22 574 Duty. 15 U 59 Unknown. 2,341 9S 1,335 113 2,533 1,418 Complications of Parietal Wounds.—It will be unnecessary to cite more than a few instances, inasmuch as the subject must be adverted to in the Third Section, where it will be desirable to adduce numerous illustrative cases. Hccmorrhage.—Punctured and lacerated wounds are commonly followed by only a few drops of blood, and incised, contused, and shot wounds are rarely attended by serious hemorrhage; but, occasionally, the epigastric, internal mammary, and circumflex iliac may be wounded, and require torsion, or compression, on the ligature. Sometimes these vessels when divided retract in the muscles, and it is requisite to enlarge the wound in order to tie them. This happens particularly when the epigastric is divided near where it enters the ' Similar observations have been made, in the Franco-German War, regarding the action of the chassepot missile in striking the abdominal walls. Dr. B. BECK (Chirurgie der S:hussverletzungen, Freiburg, i. B., 1872, 8. 5W) mentions having notice! scton wounds of the abdominal walls "seven and eleven inches in length; but the healing process progressed without serious inc9avenicnce." He regards furrowed and seton wonnds as compar atively unimportant unless they pass deeply, in proximity with the peritoneum, when they may be very serious. sect, l.l COMPLICATIONS OF PAK1KTAL WOUNDS. 9 rectus. M. Legouest1 has twice had occasion to use the ligature in profuse bleeding from superficial wounds of the abdomen. Sometimes, from punctured wounds, the bleeding is interstitial, the blood escaping in the cellular tissue and forming a tumor, or else dissecting up the aponeurotic planes. It may be absorbed, or may give rise to a sanguineous abscess, which ought to be evacuated by a timely incision, lest there should be inflammatory trouble lighted up in the contiguous peritoneum, or infiltration of the muscular bundles. It must be confessed that the histories of the examples of haemorrhage, in wounds of the abdominal walls, that appear upon the reports, do not impress the investigator with a favorable estimate of the manner in which this complication appears to have been dealt with by our army surgeons. Here, as in the management of bleeding from the wounded internal mammary and intercostal arteries, timid, inefficient, temporizing treatment appears to have been followed by lamentable loss of life. The instances to be cited teach emphatically that wounds of the epigastric, circumflex, mammary, and lumbar arteries are not to be regarded as trivial, but demand the rigorous application of the rules fcr the management of wounded arteries, the exposure of the bleeding point, and a proximal and a distal ligature.2 Schindler and Hesselbach have invented compressors for the epigastric artery, and the practitioner will find propositions in the books for compression by bougies intro- duced in the wound, or by raising a fold of the soft parts, and recommendations of the ever ready styptics; but all such means should be rejected by those who would practice sound surgery. The rule of Chelius in regard to astringent styptics ("their use, therefore, is confined to bleeding from small vessels, from mucous membranes, and to so-called parenchvmatous bleedings") must be strictly observed, and the arteries under consideration must not be regarded as small vessels, in the sense in which the term is here employed. In two cases compression was resorted to with impunity: Case 32.—Corporal W. D. Ashford, Co. C, 11th Iowa, aged 24 years, was wounded at Yazoo City, March 5, 1854, by a conoidal ball, which entered in the groin and emerged at the epigastric region. Secondary haemorrhage occurred, eight days afterward, from the epigastric artery. The haemorrhage was controlled by a plaster of Paris compress. Tincture of myrrh was given internally, and eggnog and porter. He recovered, and was returned to duty on November Id, 1864. Case 33.—Private A. Marske, Co. I, 7th Illinois, aged 30 years, was wounded at Fort Blakeley, April 9, 1865, by a conoidal ball, which entered a little to the right of and above the umbilicus and emerged from the right lumbar region. On April 13th, he entered Sedgwick Hospital at Greenville, Louisiana. On'the 17th, haemorrhage, to the amount of twenty-five ounces, occurred, from the anastomosing branches of the internal mammary and deep epigastric arteries. The bleeding was arrested and controlled by styptics, aided by compression. Haemorrhage did not recur. The patient recovered, and returned to duty on July 1, 18G5. Assistant Surgeon A. Hartsuff, U. S. A., reports the case. But in a larger number of instances, a reliance on compression and styptics resulted lamentably: 1 LEGOUEST, Chirurgie d' Armie, 26nie cd., p. 371. Once on the epigastric, and once on the circumflex iliac. 2 Professor CHISOLM (A Manual of Military Surgery, for the Use of Surgeons of the Confederate States Army, 3d ed., Columbia, 18U4, p. 337) dismisses non-penetrating wounds of the abdomen with the remark : " When the abdominal walls are not perforated, but the entire track of the ball lies in the thickness of the muscles, the wound is simply a flesh wound of a comparatively trivial character, and should be treated accordingly." Professor F. H. Hamilton (A Treatise on Military Surgery and Hygiene, pp. 318, 373) is silent in regard to haemorrhage as a complication of punctured, incised, and gunshot superficial wounds of the abdomen, but treats of it under 'wounds penetrating the abdominal parietes " (p. 374). A comment suggested by his practice is therefore reserved for the Third Section, when it will be necessary to revert to this subject. Professor GROSS (A System of Surgery, 5th ed., Vol. II, p. G58) dwells with emphasis on the occasional profuseness and obstinacy of bleeding from the epigastric, mammary, circumflex, and lumbar arteries, on the accumulation of blood beneath the muscles, and adds: " However the bleeding may be induced, or from whatever source it may emanate, the only way to arrest it is to ligate the affected vessel, unless, as may occasionally happen, it is situated favorably for acupressure." BOYr.n (Traitc des Maladies Chirurgicales, aeme 6d., T. VI, p. 8) speaks forcibly on the importance of the ligature, and gives details of an interesting fatal case of wound of the epigastric, in which this measure was neglected. But Mr. POLLOCK (Holmes's System of Surgery. 2d ed.. Vol. II, p. C58) has. perhaps with greater earnestness than any other author, insisted on the danger of trifling with haemorrhage in this region: "Perhaps we shall be excused,''he says, "if we trespass out of our province on this one occasion, and speak an extra word or two of caution to the practitioner who may have to deal with hemorrhage in a wound of the abdomen. If there be severe haemorrhage, and the wound not sufficient to allow the bleeding mouth of the vessel to bo seen, no hesitation need be felt regarding treatment. The wound should bo enlarged—enlarged until the wounded vessel canxbe seen and can be secured. We need not fear haemoiThage so long as such a wound is open and we can place a finger on the bleeding point. When the surgeon trusts to external pressure and closes the wound without securing the wounded artery, then there is abundant cause for anxiety. If these principles be of importance in hoemorrhage of ordinary character, they are tenfold important when applied to the treatment of wounds in the region of the groin, or the neighborhood of the crest of the ilium." ■1 10 INJURIES OF THE ABDOMINAL WALLS. [CHAP. VI. Case 34.__Private A. Neuman, Co. A, 49th New York, aged 38 years, received a lacerated wound of the abdominal walls in the hypogastric and left iliac regions, from a fragment of shell, at Spottsylvania, May 18, 1864. He was treated at the field hospital and at Washington till May 27th. He was then transferred to the Summit House Hospital, at Philadelphia. A few days after admission, recurring hamiorrhages from the wound took place, and were treated by cold applications, styptics, and compresses confined by a bandage. The patient finally sank from loss of blood, and died on June 23, 18G4. Cask 3:>.—Private P. McXabb, Co. E, 16th Missouri, was wounded while on picket, May 24, 1862. A conoidal ball, after producing a flesh wound of the right forearm, entered the right inguinal region, passed inward toward the median line, and lodged somewhere without wounding any of the viscera. No peritonitis or other indication of penetration of the cavity ensued. From the regimental hospital the patient was transferred, on June 4th, to the general hospital at Monterey. A few days after admission hemorrhage came on, but was readily checked by compression and styptics. It recurred, however, more copiously, and apparently proceeded from the epigastric artery. Compression was again resorted to, with temporary success. The patient sank, and died on June 15, 1862. The notes of the case are derived from the reports of the regimental surgeon, G. S. Walker, and that of Surgeon N. K. Derby, U. S. V. Case 36.—Corporal W. Blair, Co. F, 63d Pennsylvania, aged 26 years, received a flesh wound of the parietes of the right inguinal region, from a conoidal ball, at Spottsylvania, May 12, 1864. The wound presented no serious complication, and the patient was soon conveyed to Washington and placed in Lincoln Hospital, and was allowed full diet and a supporting treatment. The wound became inflamed and irritable, and haemorrhage supervened. This was arrested by compression, but recurred, when applications of the solution of persulphate of iron were used in addition to pressure. Repeated bleedings took place, with a fatal result. The patient sank, in spite of free stimulation, and died on June 30, 1864. Case 37.—Sergeant W. Blunt, Co. D, 3d Massachusetts, aged 23 years, received, at Gettysburg, July 3,1863, a gunshot flesh wound in the left groin, and was sent to the Twelfth Corps Hospital. Gangrene supervened. On July 18th, intermediary haemorrhage occurred, and thirty ounces of blood were lost from the epigastric artery. The vessel was not tied, and the patient died on July 18, 1863. Case 38.—Private J. Lowe, Co. B, 29th U. S. Colored Troops, received a furrowed wound through the muscles of the left side of the hypogastric region, from a conoidal ball, at Petersburg, July 30, 1864. He was carried to the field hospital of the JSinth Corps, where water dressings were applied. On August 18th, he was transferred to the Summit House Hospital, Philadelphia. A few days after haemorrhage took place, and was controlled by compression. Repeated bleedings recurred, however, and the patient died on August 27, 1864, from secondary haemorrhage of the epigastric artery. Yet a sixth case proved fatal, after the extreme measure of ligating the external iliac artery had been resorted to, thus converting the lesion into a penetrating wound: Case 39.—Lieutenant John Ridge, Co. G, 13th Iowa, aged 30 years, was wounded, July 20, 1864, at Atlanta, by a musket ball, which passed through the abdominal parietes, making a seton wound from a little above the pubes to the point of emergence in the left iliac region. Brief details are given in five different reports from the field, Nashville, and Louisville hospitals, by the regimental surgeon, Dr. M. W. Thomas, and by Surgeons Herbst and McDermont, U. S. V. There had been no serious primary bleeding, and the patient's condition was encouraging when he entered the Officers' Hospital at Louisville, on August (ith. He was ordered light nourishing diet, with tonics and simple dressings. On the 8th, there was bleeding from the lower orifice of the wound, which was checked by the application of solution of persulphate of iron. The haemorrhage recurred profusely on the 9th, and less copiously on the 10th and 11th, and was treated by styptics and pressure. On the 12th, there was free, healthy suppuration. On the 26th, a slight haemorrhage occurred, and Monsel's salt and pressure were again resorted to, and again on the 27th, 28th, and 29th. On the 29th, the blood lost was estimated at thirty-two ounces. On the 30th, on the ninth recurrence of the haemorrhage, Surgeon C. McDermont, U. S. V., tied the external iliac artery. The patient rested well that night, and the bleeding did not recur. On the following day, he was ordered a draught, thrice daily, of sulphate of quinia with the tincture of the sesquichloride of iron. The date of separation of the ligature is not recorded. On September 10th, there was a severe chill. Quinine was then prescribed in full doses. This treatment was pursued until September 30th, without benefit. A more generous diet was then ordered, with milk punch, and "as much wine as could be borne." Death ''from pyaemia" is recorded on October 4, 1864. No autopsy. There were a number of other instances of ligations of arteries; but they were in cases of penetrating wounds. It is probable that if the detailed histories could be had, it would be learned that in the cases cited the compression entailed extravasation in the deeper tissues, followed, perhaps, b}^ suppuration or sloughing,—while the application of Monsel's salt rendered the relations of parts indistinguishable, and attempts at ligation difficult and uninviting. This series affords an impressive lesson of the necessity of adhering to standard surgical rules even in what may be regarded as minor accidents.1 1 DUPUYTREN (Lecons Orales de Clinique Chirurgicale, 2eme ed , par PAILLAKD et Marx, 1839, T. VI, p. 407) says: "Le repos, la diete, les refrigerants et la compression suffisent presque toujours pour arreter cette h6morragie." The master has here fallen into a common error of didactic authors in generalizing, without facts on which to base an average. A few lines above he has stated that copious haemorrhage from wounds of the abdominal walls is very rare. The statistics of the War of the Rebellion indicate its rarity as less than one per cent. Therefore a military surgeon of large experience may never meet a case. It is highly improbable that he should encounter a series, and be enabled to test the advantages of different modes of treatment. He should, therefore, act promptly, in accordance with general principles and the lessons derived from the experience of others. Enough facts have been presented to demonstrate the danger of neglecting to secure the artery in all serious bleedings from wounds of the abdominal walls, and to indicate the culpability of hereafter omitting this simple precaution. sect. i.| COMPLICATIONS OF PARI FT AL WOUNDS. 11 Foreign Bodies.—Instances of the lodgement of balls and other foreign bodies, such as portions of clothing and equipments, coins, fragments of various articles carried in the pockets, were common in this region. The following is a curious example: Cask 41).—Private R. B. Soybert, Co. H. 11th Pennsylvania, Second Bull Run, August 30, 1862, converted his tin-cup into a pail by putting a hoop of sixteenth of an inch iron wire to it and slinging it to the right side of his belt. A conoidal musket ball struck tbe wire, twisting it, and entered the abdonfinal walls two inches in front of the right anterior superior process. The short end of the wire protruded an inch to the left and a little below the umbilicus. With some difficulty, and a slight enlargement of the wound, the foreign body (Flo. 3) was extracted. The man recovered without the occurrence of peritoneal inflammation, and was returned to duty January, 1803, from Tnii-fax Seminary Hospital. Surgeon H. W. Ducacbet, U. S. V., contributed the speci- men and notes. August 16, 1871, the Pension Examining Hoard, at Philadelphia, reports this pensioner as complaining of pain and loss of rest from muscular contraction, and expresses the opinion that the tenth rib was fractured at the entrance cicatrix. There was no aggravation of • , FIG. 3.—Bullet and wire extracted the disability, which was last rated at three-fourths. His age is given as 26 years, and weight from abdominal walls. .s>;c. 4417. 12.H pounds avoirdupois. He was last paid on March 2, 1872. (Reduced to one-third.) A fragment of shell, which entered the thoracic parietes, lodged, and was cut out from the abdominal wall near the umbilicus, is figured in the First Surgical Volume, page 590 (case of Private Julius Wilt). The following is an instance of a musket ball making a partial superficial circuit, a circumstance more common than Guthrie1 admitted: Cask 41.—Private Theodore Lozar, Co. H, 15th New Jersey, shot at the battle of Chancel- lorsville, May 3, 1863. A conoidal musket ball entered at the cartilage opposite the left external rib and lodged. The man was conveyed to Washington, and entered'Douglas Hospital on May 7th. On May 11th, Assistant Surgeon W. Thomson, U. S. A., discovered the projectile (Fig. 4) in the right transverse muscle, opposite the wound of entrance, and removed it through a counter-incision. The patient contracted variola, and was transferred to Kalorama Hospital on June 7, 1863, where he died Fig. 4.—Conoidal musket r . . ball removed iroin the ab- July 19, 1863, with pyaemic complications. dominal walls. Spec.4622- There were forty-nine other cases of extraction of balls or other foreign bodies from the abdominal parietes. In twenty-two cases, the patients returned to duty; in twenty- two, they recovered and were discharged, and five died: Cases 42-90.—The following recovered and were returned to duty: Pt. J. L. Hayes, 17th Connecticut, Gettysburg, July, 1863; Corp. P. Kelly, 53d Illinois, duty January 26, 1864; Pt, B. Hayes, 90th Pennsylvania, July, 1863, duty February 15, 1S'>4 ; Pt, J. B. Edgar, 36th Illinois, December 31,1864; Brig. Gen. Barlow, Second Corps, September 17, 1862, duty November, 1852; Serg't F. Lorens, 2d New York Cavalry, duty October 29,1863; Corp. G. W. Smith, 51st Indiana, April 29, 1863; Capt. Daniel, May 27, 1862, healed by first intention; Pt. T. A. Shelton, 57th Virginia, July, 1863, duty September 25, 1863; Pt. C. Daily, 8th New Jersey Cavalry, April, 1865; Pt. R. Mulberger, 7th New York, April 5, 1865; Pt. J. Gavin, 38th Illinois, Feb- ruary 15, 1863, duty November 25, 1864; Pt. W. B. Donkersly, 2d New York, May 2, 1863, duty September 21, 1863; Pt, C. J. Mahoney, 48th New York, February 20, 1864, duty June 20, 1864; Corp. N. J. Wheeler, 12th Massachusetts, May 6, 1864, duty May 12, 1864; Pt, J. McNulty, 137th Illinois, July 14, 1864, duty; Pt. W. Graham, 12th New York, July 18, 1831, duty; Serg't M. Mullins, 2d New York Cavalry, transferred October 31, 1863, duty; Pt. W. Evans, 80th Ohio, May 14, 1863, duty; Pt. C. Scott, 58th Pennsylvania, Gettysburg, July 3, 1863, duty December 8, 1863; Pt. J. Meanes, 31st New Jersey, May 3, 1864; Pt, J. Stick, 4th Connecticut, June 15, 1864. In the case of Private Scott, the projectile, represented in the adjacent wood-cut (Fig. 5), is preserved in the Museum. It entered above the crest of the right ilium, and was extracted, a fortnight after the reception of the iniury, by Acting Assistant Surgeon W. G. Smuli, 1 J J ' J o ^ o Fir,. 5.-Laterally compressed from beneath the integument near the median line. c.moidai ban. removed from the o abdominal walls. Spec. 2669. The following recovered and were discharged the service: Pt. J. Carter, 57th New York, December 13, 1832, discharged July 16, 1863; Pt. J. O'Brady, 6th New York Artillery, September 17, 1862; Pt. J. W. Meyers, 13th Illinois, Vicksburg, May, 1863, discharged March 25, 1884; Pt. T. Gleason, 47th New York, February 29, 1864, discharged August 25, 1864; Pt. W. W. Newton, 8;ith Illinois, August 7, 1864, discharged June 14, 1835; Pt. P. West, 25th Illinois, September 29, 1863, discharged July 3, 1864; Pt. J. Wilson, 1st U. S. Colored Troops, October 27, 1864, discharged March 13, 1865; Pt. J. Lopeman, 127th U. S. Colored Troops, April 2. 1865, discharged September 8, 1865; Pt. R. Stevenson, 198th Pennsylvania, March 29, 1865, discharged June 16, 1865; Pt. W. Kich, 64th New York, March 25, 1855, discharged September 6, 1865; Pt, M. D. Cavanaugh, 'GUTHRIE, Commentaries, London, 18.1 12 INJURIES OF THE ABDOMINAL WALLS. |cn.\i\ VI 10th Vermont, April 2, 1865, discharged September 9, 1865; Pt. J. Sonthwick, 88th Pennsylvania, September 17. 1862, dis- charged September 27. 1S63; Capt. J. W. Hague, 134th Pennsylvania, December 13. 1862. discharged May 26, 1863; Corp. G. Hatch. 1st New York Sharpshooters. March 31, 1865, discharged May 31, 1865; Serg't R. Anderson, 51st New York, September 16. H62. discharged June 30, 1866; I>t. P. W. Waggoner, 89th Indiana, May 18, 1864, discharged September 16, 1864; Pt. Charles O'Brvan, 88,h New York, September 4, 1863, discharged; Pt. O. W. Canfield, 80th Indiana, May 14, 1864; Pt. ('. Granger, 2d New York M R., March 31, 1865; Pt. B. Jones, 141st Pennsylvania, May 3, 1833; Pt. A. Hunsecker, 29th Ohio, Mav 1, 1863; Pt. W. Cubbon, E. 5th Michigan, May 31, 1882, discharged January 13, 1833. The following cases terminated in death: Pt. S. B. Plummer,10th Kansas, April 9, 1865, died May 4, 1865, from pyaemia; Pt. W. L. McMiehael, 13th Tennessee Cavalry, April 12, 1834, died June 27, 1864; Pt. J. J. Smoat, 1st Kentucky Cavalry, died October 9, 1863, from peritonitis; Lieut. J. D. Priest, 56th Massachusetts, June 22, 1864; Pt. T. Fenton, 69th New York, December 13, 1862. The fatal cases were instances in which the extraction of the foreign body was delayed, and its irritation induced abscesses, or extended sloughing or peritonitis. Guthrie's suggestion, that when a ball is deeply situated in the walls of the abdomen "it is often better left alone unless it prove troublesome" (Comm., p. 538), is unsound.1 There are no other exceptions to the general rule of-extracting foreign bodies than the instances in which they are so situated in vital organs that their extraction may immediately jeopardize life. It is especially important to extract them from the abdominal walls; for they rarely become encysted there; the action of the muscles and disposition of the sheaths facilitating their movement; the liability to abscess-formation in propinquity to the peritoneum presenting a constant source of danger while they remain. The course of balls, making a long track, was indicated by a red or reddish-blue line, when they passed beneath the skin or first layer of muscles. It was sometimes necessary to make an incision for the evacuation of pus and sloughs at the middle of the track; but it was considered injudicious to lay open the canal, the seton wounds healing sooner, as a general rule, than the furrowed wounds. Gangrene.—Sloughing wras an infrequent but dangerous complication, supervening oftenest in shot lacerations produced either by shell fragments, or by elongated balls striking sideways. These sloughing wounds, by leading to secondary haemorrhages, septicaemia, exhaustive suppuration, and consecutive peritonitis, contributed largely to the mortality list of gunshot flesh wounds of the abdomen, though many of the fatal cases are returned under headings representing what was regarded as the immediate cause of death. It is not impossible that a few cases properly referable to this category may be included in the Third Section, having been returned as penetrating wounds, although the involve- ment of the peritoneal cavity was secondary and through extension by contiguity. Howrever, it has been sought, in revising the registers, to amend the diagnoses, and to transfer the cases to their proper positions, as far as the reported details warranted, and thus a number of examples, in which the injuries primarily affected only the parietes, have been restored to the group of flesh wounds: Cask 91.—Private Adolph Voshage, Co. L, 9th New York State Militia, aged 29 years, was wounded at Fredericksburg, December 13, 1862. admitted to Harewood Hospital December 23, 1862. A musket ball had entered near the left anterior superior spinous process, and emerged near Poupart's ligament. On January 14, 1863. sloughing appeared, and was treated by free cauterization with nitric acid. Pus had burrowed deeply, and the sinuses were laid open, and tents were introduced. There was recurrent gangrene on the 27th, and great destruction of tissue. Frequent haemorrhages took place, which were arrested by tampons. In the middle of March, the immense sore was granulating kindly, but pus continued to burrow in the muscular interstices. By May 1st, the wound had cicatrized. The destruction of tissue was so great that the thigh was flexed on the abdomen, and the patient moved about by resting alternately on the nates and palms of his hands. He was discharged July 7, 1-33, "for spurious anchylosis of left hip joint." The limb remained contracted and useless, unfitting him lor manual labor, according to the Pension Board, April, 1870. He died July 28, 1871, "of uraemia," according to the report of the attending physician, M. H. S. huler, M. D. 'BECK (Chir. der S:lui.*sverl.. S. 523) advises delay in extracting deep-seated balls, until the danger of peritonitis is passed. Consult also DKMMB, Studien, B. II, p. 127: N'ELIx'JRlF.n, Handb. der Kriegschir., II. II, S. 710; LEGOUEST, Chir. d'Armec, p. 373. SECT. I.] COMPLICATIONS OF PARIETAL WOUNDS. 13 Hernia.—Ventral rupture was, of course, a frequent result1 of incised, lacerated, and shot wounds of the abdominal walls, and an occasional consequence of contusions followed by muscular atrophy. The production of true inguinal hernia was also often ascribed to these causes, as in the following cases: Cases 92-94.—1. Reported from DoCamp Hospital,—Pt. C. Stark, Co. K, 87th Pennsylvania, aged 25 years; shell wound of left side of abdominal walls, left inguinal hernia; discharged.—2. Reported from Finley Hospital,—Corp. H. Crandall, Co. H, 112th New York, aged 11 years; shell wound of abdominal parieties, "causing inguinal hernia."—3. Reported from Davenport Hospital,—Pt. (i. F. Marion, Co. K, 29th Iowa, aged 32 years, Spoonville, Arkansas, April 2, 1861, "shot wound of abdominal walls, resulting in inguinal hernia." The list might be largely augmented. Eleven other instances are noted, in which the production of inguinal, femoral, or umbilical ruptures is ascribed to shot wounds. An examination of the details of these cases fails to discover any other relation than coincidence between the shot wounds and inguinal, crural, and umbilical ruptures. Great liability of men of the military age and stature to hernia is observed, even in classes of recruits selected after the most rigorous physical examination ;2 naturally the proportion of ruptured men was greatly augmented, when, during the war, the recruiting regulations were either relaxed or systematically disregarded. And soldiers, laboring under this infirmity, rarely failed to recall some blow or muscular strain which connected their infirmity with the incidents of service, and a wound of the abdominal walls was adduced by a ruptured applicant for discharge as an unquestionable cause of, perhaps, a scrotal hernia. On the other hand, direct ventral hernia was an almost uniform and necessary consequence of extensive injury of the muscular walls. Much ingenuity was demanded, in some cases, in the adjustment of suitable retentive bandages or apparatus.3 This important subject will be reverted to in the Third Volume. Case 95.—Private B. W. Hall, Co. H, 92d New York, received a lacerated wound of the abdomen, by a fragment of shell, at Fair Oaks, May 31, 1832. The wound was dressed at the field hospital. On June 7th, the patient was transferred to Knight Hospital, New Haven, whence he was discharged from service on April 23, 1833, on account of " hernia from wound." Pension Examiner S. C. Wait, in a report dated February, 1863, states: " The missile struck the abdomen just inside of Poupart's ligament, at the upper or inner iuguinal ring, causing the loss of a portion of the muscular and ligameutous covering of the abdomen, letting the bowels out, and producing traumatic hernia. The tumor under the skin is very large. He wears a truss and a wide strap around him all the time to keep the bowels, etc., in. While walking, he rotates the left thigh inwardly and has to keep the left leg forward of the other. Locomotion is very difficult and embarrassing. His disability is greater than the loss of a leg, and is permanent in its present degree." Nervous Disorders.—Profound shock was the occasional consequence of simple contusions of the parietes, and also of shot contusions and flesh wounds; but it was not common in the absence of visceral lesion. There were cases, too, of tympanitis and constipation following contusions and wounds of the parietes, in which the temporary paralysis of the muscular coat of the bowel was ascribed to concussion of the nerve centres. Persistency of collapse appears to have been indicative of internal lesion ; but the intensity of the symptoms was not a standard by which the nature of the case could be determined. At the military hospital for nervous affections, at Christian street, Philadelphia, Dr. Mitchell and his associates, Drs. Morehouse and Keen, had opportunities of observing few, if any, cases of abdominal wounds. Otherwise the records would probably have been 1 There are on the rolls of the Pension Office not less than five thousand seven hundred and thirty-five pensioners for " wounds and injuries of the abdomen," of whom (See Report of the Commissioner of Pensions to the Secretary of the Interior for the year ended June 30, 1871, p. 7, and AlTENDIX, Table A, p. 20) three thousand two hundred and eighty-three are reported as having hernia (2,740 single, 543 double). To determine in what propor- tion the hernial protrusions in these thirty-two hundred and eighty-three cases were really due to external lesions or to the incidents of military service, would be an inquiry worth}' of the attention of the supervising officers of the Pension Bureau. "For estimates of the proportion of adult males in the population subject to rupture, according to age aud stature and avocation, consult a lecture by MALGAIGNE, in the Gazette, and Moniteur des Hopitaux, and V Union Midicale. for 18M. I printed an English version of it in the Virginia Medical and Surgical Journal, Vol. Ill, p. 229. 3 Consult, in regard to trusses for ventral hernia. GrAUJOT, Arsenal de la Chirurgie Contemporaine, Paris, 1872, T. II, p. G13 ; BIGG, Othopraxy: T,ie Mechanical Treatment of Deformities, Debilities, and Deficiencies of the Human Frame, London, 1833, p. 370; EMMEUT, Pralctische Verbandlehre, Bern, 1871, S. 316; and, in regard to abdominal bandages, GOPFKES, Precis Iconographique de Bandages, Pansements et Appareils, Paris, 1866, p. 114. It INJURIES OF THE ABDOMINAL WALLS. |CHAP. VI. enriched by careful studies of the obscure nervous affections sometimes consequent upon them. Twenty cases appear on the reports, in which partial paralysis in one or both of the lower extremities was attributed to shot wounds of the parietes: Casks 96-99.—1. Pt, J. T. Reese, Co. C, 184th Pennsylvania, shot flesh wound in right inguinal region, "partial paralysis of lower extremities," Cold Harbor, June 3, 1864; discharged February 15, 1885.—2. Corp. II. B. Smith, Co. K, 5th Vermont, aged 40 years, wound of right inguinal region by conoidal ball, Winchester, September 19, 1864, "numbness of right thigh;" discharged January 13, 18G5.—3. Pt. J. Murphy, Co. B, 63d New York, shot wound of left inguinal region, Antietu.ni, September 17. 1862. "paraplegia;" discharged.—4. Pt. W. G. Thornton, Co. H, 141st Pennsylvania, aged 24 years, flesh wound of abdomen, Chancellorsville, May 3,1863, " paralysis of left leg;'' discharged March 11, 1834. There were sixteen other cases of this nature. An examination of the imperfect details of these cases from the hospital and pension reports indicates that the loss of motor power was due, in most instances, to contracted cicatrices, or to muscular atrophy, and that only those in which some injury to the spine might be suspected were examples of true paralysis. Among the punctured wounds, there were no instances of that local irritation of the nerve filaments to which Boyer has especially called attention.1 Tetanus.—So instances are recorded of the apparition of tetanus in the punctured and miscellaneous wounds of the abdominal walls ; but eleven cases are recorded among the gunshot flesh wounds of this region. Ten well-developed cases terminated fatally. The eleventh, which is described as an example of " slight trismus, with tetanic symp- toms," had a favorable issue. When these cases are added to those in which tetanus complicated penetrating wounds of the abdomen, and superficial and deep wounds of the pelvis, the greater frequency of this complication in injuries of the abdomen as compared with injuries of the chest, adverted to on page 635 of the First Surgical Volume, will become apparent. Case 100.—Private E. Gorman, 11th Connecticut, was wounded at New Berne, March 14,1862, by a large shell fragment, A rectangular portion of the integument and subjacent connective and adipose tissue, six by eight inches, was torn from the anterior part of the abdomen, from the xiphoid appendage above to the umbilicus below, and three or four inches on either side of the median line. The huge wound resembled, at the first glance, the exposed raw surface made by a blister plaster, such was its regularity; but on closer examination, save some slight laceration at the edges, its appearance was as if cleanly dissected by a cutting instrument, the fibres of the external oblique and rectus being as neatly exposed as could have been done by a careful anatomist. The large wound was covered by a cerate cloth. There was not much pain; but an unnatural vivacity and nervous exaltation, which awakened solicitude. The patient was treated at the field station on the right wing. The apparent absence of the usual symptoms of grave shock was remarked. On the 19th, the patient was removed to Academy Green Hospital, at New Berne. The nervous irritability that had excited alarm became aggravated on transportation, the distance being five or six miles. Anodynes were administered, but on the following day well-pronounced symptoms of tetanus appeared, and, rapidly augmenting in intensity, ended fatally in less than thirty-six hours. Chloroform and opium were the remedial agents unavail- ingly employed. [The name and dates appear oil the report of Surgeon G. Derby, 23d Massachusetts, and I have described the case from recollection, and a memorandum in the Boston Medical and Surgical Journal, Vol. LXVI, p. 240.] The ten other cases will be tabulated in the special Chapter on tetanus. The survey of this large group of cases of injuries of the abdominal walls indicates the proportion of instances in which troublesome complications arise ; the necessity of enlarging wounds to control haemorrhage, to remove foreign bodies, or to prevent the confinement of pus ;2 the necessity of promoting cicatrization by position, bandaging, and sometimes by sutures ; and of averting peritonitis by quietude and the use of opium. 1 Boyer, Traite des Maladies Chirurgicaks et des Opirations qui leur conviennent. Cinquieme 6d. publi6e par le baron Philippe Boyer, Paris, )84i>. T. VI, p. 4. BOYER states that this local nervous irritation can be best relieved by introducing a caustic troche into the wound. * Dr. G. B. MACLEOD (Notes on the Surgery of the War in the Crimea, London, 1858, p. 263) indulges in an uncalled-for denunciation of debride- ment in wounds of the abdomen ; but does not reiterate his strictures in his recent articles on " Wounds," which replaces the sound teachings of the original compiler, in the eighth edition of Cooper's Dictionary of Practical Surgery, London, 1872, p. 1019. Hunter's rebuke (On the Blood, Inflam- mation, and Gunshot Wounds, p. 532) of the abuse of debridement by the continental surgeons of his day was opportune, salutary, and effective; but the parrot-like iteration of his censures by modern British writers, when tbe practice that evoked them has long been obsolete, is superfluous and tire- some, and especially ill-timed in treating of wounds of the abdomen, where the importance of enlarging wounds to tie bleeding vessels or to remove foreign bodies, and of early intervention in threatened suppuration, is almost universally conceded. SECT, n.] INJURIES OF THE CONTAINED PARTS. 15 Section II. VISCERAL INJURIES WITHOUT EXTERNAL WOUNDS. The effect of contusions of the abdomen is often not limited to the walls; but extends sometimes to the whole visceral mass, but more commonly to the large solid and fixed viscera, the liver, spleen, and kidneys; and, less- frequently, to the hollow viscera, the stomach, intestines, and gall-bladder. Probably all the organs contained in the abdo- men, even the blood-vessels,1 may be torn or ruptured, without the existence of external wounds.3 These injuries are classified on the registers according to the causes producing them; those due to blows, falls, kicks from men and horses, the buffer accidents on rail- ways, the contusions inflicted by the wheels of wagons, cannon, and caissons, being placed in one group, and those caused by the impact of nearly-spent large projectiles being placed in a second group. But it will be more convenient to consider them here according to the part injured. It is an open question, whether a blow on the abdomen may produce sudden death without any organic lesion. The affirmative and popular opinion has been handed down' among surgeons, and appears to rest on Sir Astley Cooper's authority3 and upon very little evidence, and Mr. Pollock and Mr. Bryant are justified in their skepticism reo;ardin<>- it. It need not be further discussed here; for no instance in which a fatal result was ascribed to such a cause was reported during the war. There were cases, however, in which very severe symptoms were induced by comparatively trifling blows, or by injuries attended with slight apparent physical lesions. The diagnosis of visceral complications without external sign of injury is very difficult; for, as will be fully illustrated in the next section, the distinctive signs of direct wounds of the several organs contained in the abdomen are by no means clear or constant. Little dependence is to be placed on pain or shock as signs of visceral lesion; for, as has been seen in the Section on parietal wounds and contusions, these effects accompany injuries limited to the walls. When the pain is persistent, and radiating from one spot, it may be significant of internal trouble; and if the collapse returns a few days after the injury, it is supposed to mean internal haemorrhage or extravasation. The collapse from bleeding, however, resembles syncope as distinguished from shock. The nature and position of the injury afford some clue. Vomiting, tympanitis, blood in the stools or urine, jaundice, and glucosuria, pain in the shoulder, and general itching, may be so conjoined with other circumstances as to become characteristic. The differential diagnosis has been well discussed by Mr. LeGros Clark.4 1 M. LEGOUE8T (Chirurgie d'Armie, 2eme 6d., p. 372) saw a case of transverse laceration of the left side of the aorta, one-quarter of an inch in length, three-fingers breadth above the promontory <>f the sacrum, in a farrier, who received, at the line of the umbilicus, a kick from a horse. The haemorrhage was rapidly fatal. 2 Though I have not met with any recorded instances of such lacerations of the suprarenal capsules, and but one of the pancreas. 'Poland, in his MS. Prize Essay On Wounds and Injuries of the Abdomen, quoted by Mr. POLLOCK (Holmes's System, Vol. II, p. 623) and by Mr. Bryant (Ihe Practice of Surgery, 1872, p. 299), cites three cases in support of the popular view. BRAN'SBY COOPER (Lectures on the Principles and Practice of Surgery, Am. ed., Phila., 1852, p. 564) says that "it is authentically recorded that a slight blow upon the epigastrium has caused immediate death, without any apparent cause being discovered on post-mortem examinations," but gives no instances. TAYLOR (Medical Jurisprudence 1858, p. 299) gives a supposed case from M. WOOD (Med. Gaz., Vol. XLIV, p. 213). 'Clark, Lectures on the Principles of Surgical Diagnosis. London, 1870, Lectures X and XI. in TX.TrUTKS OF THL ABDOMKN. [chap. vi. It is only when resulting from contusions by spent projectiles, that injuries of this class are especially incident to warfare;1 the majority of the cases are due to the same causes that are observed to produce such lesions in civil practice. Assistant Surgeon S. S. Melchcr, 5th Missouri Volunteers, states2 that he saw two men killed at the engagement at Wilson's Creek "by spent solid shot striking the abdomen. One was in great agony, with excessive tumefaction, for five hours. The other lived twenty hours, in great pain. There was no abrasion of the skin in these cases." Ruptured viscera would probably have been discovered had autopsies been made. Sudden tympanitis, ballonnement subit, is pronounced by Jobert to be the most characteristic sign of rupture of the intestines. The cases cannot be identified in the battle-field reports. Puptures of the Liver.—Five cases were reported. Four were due to a buffer accident, the passage of carriage-wheels, and a blow from the tongue of a wagon, and proved speedily fatal from haemorrhage or peritonitis: Cases 101-104.—The Museum contains no illustrations of this form of injury. Few details are given of the cases reported: 1. Reported by Surgeon F. Meacham, U. S. V.: Private G. P. Leipard, Co. I, 2d Ohio Heavy Artillery. Contusion in, right liypochondriuni by collision of cars, January 29, 1865; rupture of liver; death in a few hours.—2. Reported by Surgeon D. W. Bliss, IT. S. V.: Private H. H. Thayer, Co. H, 4th New York Heavy Artillery. Contusion, without external injury, of right side of abdomen, by the tongue of a wagon. Admitted into Armory Square Hospital January 5, 18.54. Liver injured. Died, in three days, from peritonitis.—3. Reported by Assistant Surgeon V. H. B. Lang, 49th Ohio: Pt. D. Mezmer, Co. C, 49th Ohio, Murfreesboro', December 31, lH(5t>. Contusion of abdomen; death tbe same day.—4. Reported by Assistant Surgeon J. H. Frantz, V. S. A.: Jackson Miller, Portsmouth, Va., May 1, 185."), crushed by cart-wheel, liver ruptured. Death from internal haemorrhage the same day. The fifth is more interesting, the patient having survived for forty-eight days: Cask 105.—Private W. Howard, Co. G, 30th U. S. Colored Troops, was struck in the right side, July 30, 1864, at Peters- burg, by a large spent fragment of shell, and was conveyed to the hospital for colored troops. There was extensive ecchymosis on the outer side of the right hypochoiulrium, but no abrasion of the skin. The patient was faint, and there was pain and great tenderness in the injured region, with moderate collapse, unattended by indications of internal haemorrhage. Rest in bed and warm fomentations constituted the treatment. The patient was sent, after a few days, on a hospital transport steamer to Philadelphia, and entered Satterlee Hospital; but was soon after transferred to Summit House Hospital, undercharge of Surgeon J. II. Taylor, IT. S. V., who reports the case. Except the pain in the hepatic region, there were no symptoms of injury of the liver—no jaundice, nor deficiency of bile in the stools, nor gastric irritability. Active counter-irritation by epispastics was employed unavailingly to remove the local pain. The general treatment was supporting, tonics and stimulants being prescribed. The patient steadily lost ground, and died September 16, 1864. At the autopsy, old pleuritic adhesions were found in the left pleura. In the abdominal cavity there were slight traces of peritonitis. But " the superior posterior portion of the right lobe of the liver was very much lacerated, the substance of this portion of the organ being reduced to a pulp, breaking down under pressure, and showing a complete line of demarcation between the injured and healthy parts." Pain, collapse, haemorrhage, dulness on percussion, bilious vomitings, followed by peri- tonitis, white stools, jaundice, and saccharine diabetes, are the symptoms usually ascribed to ruptures of the liver. Only the three latter are characteristic. There is no question that patients may recover from this form of injury, when the rent in the liver is not so great as to cause haemorrhage to a hopeless extent.3 This organ is more readily lacerated when diseased. It is most commonly fissured on its convex surface.4 Sometimes, the 1 In the British Army in the Crimea: " Four fatal cases occurred from rupture of viscera, without external wound. Two of these were rupture of the liver, one of the spleen, and one of the intestines." MATTHEW, Surgical History of the British Army which served in Turkey and the Crimea during the War against Russia, in the years 1854-55-56, London, 1858, Vol. II, p. 332. BECK (Chirurgieder Schussverletzungen, Freiburg, i. B., 1872 Zweite Halfte, S. 520) remarks: "At the seiges of Malghara and Venice, and lately before Strasbourg and Belfort, I have seen wounded, with no out ward sign of injury, who suffered from contusion and rupture of the intestines, rupture of the stomach, the liver, the spleen ; rarely of the kidney and large blood-vessels; in a few cases the patients reached the hospital, but died shortly afterward. At Kehl we had a fatal case of this kind, Captain v. F----. an artillery officer, who lived only a very short time after the reception of the injury." 2 Melcheu, Appendix to Part I, Med. and Surg. Hist, of the Rebellion, p. 18. »Mr. Erichsex (The Science and Art of Surgery, 1869, Vol. I. p. 444) gives a case of rupture of the liver, fatal on the sixteenth day, in which the laceration was beginning to cicatrize, and a well-marked case of recovery. In Guy's Hospital Museum there are several preparations illustrating the repair of these injuries. See Prep. 194^-1951-5, in Pathological Catalogue of the Museum of Guy's Hospital, London, 1857, Vol. II, p. 102. For a remarkable instance of recovery, see FRYER, Medico-Chirurgical Transactions, 1813, Vol. IV, p. 330. * Mr. Clark says (Lectures, etc., p. 293): '• In superficial lacerations I have found, almost invariably, that it is the under surface of the liver that is torn." My observations accord rather with those of Mr. Bryant (The Practice of Surgery, 1872, p. 301), who says: "Fissures of the liver are usually met with on its upper surface." This opinion is corroborated by the specimens preserved at Netley (see Specs. 1504, 1500, Catalogue of the Preparations SECT. II.] RUPTURES OF THE LIVER. 17 capsule of Glisson remains intact, while the gland substance is crushed, and such cases are likely to result in abscesses, and eventually in recover}^.1 In the majority of cases death occurs within a few hours, in some within a few days. In a series of nine cases noted by Mr. Bryant (op. cit., p. 300), "five died rapidly, three survived three, seven, and nine days, respectively."2 It is believed that a sudden action of the abdominal muscles may produce this lesion.3 Unless the laceration extends far backward and involves the vena cava, the amount of extravasated blood is commonly not considerable. It is generally found partly coagulated and partly fluid.4 General peritonitis is not an inevitable nor even a general consequence of rupture of the liver. The differential diagnosis is not easy. The attendant collapse and vomiting and modification of percussion sounds are not peculiar; the seat, direction, and persistence of the pain may, or may not be significant; icterus is not uniformly present; glucosuria, though demonstrated experimentally in lower animals, has rarely been observed clinically. A perceptible depression at the fissure has, according to Emmert (Lehrbuch der Chir., B. Ill, S. 244), been observed by Steffens. This, which could only be readily detected in lacerations of the under surface, and trau- matic diabetes, would be conclusive, while the other signs in conjunction, would be strong presumptive evidence. In the minor lacerations of the liver in which alone there is ' the prospect of the formation of adhesions and the question of treatment arises, absolute rest, the patient not being allowed to raise himself or be raised in bed, is the accepted essential condition. Opium must be given, and, after the danger of bleeding is past, hot fomentations and poultices afford great comfort. The remaining treatment must be guided by symptoms. contained in the Museum of the Army Medical Department, edited by GEORGE Williamson", M. D., Assistant Surgeon to the Forces, London, 1845, p. 199); Spec. 1400 in Descriptive Catalogue of the Pathological Museum of the Pennsylvania Hospital, by William Pepper, Philadelphia. 1869, p. 72; the case detailed by Mr. Athol Johxsox (Med. Chir. Trans., 1851, Vol. XXXIV, p. 55), and quoted in Holmes's System, Vol. II, p. 648, and by many others. For other illustrations of ruptures of the liver, see Spec. 2368 (plaster cast), in A Descriptive Catalogue of the Warren Anatomical Museum, by J. B. S. JACKSOX, M. D., Boston, 1870, p. 498; Spec. 545 (plaster cast), in A Descriptive Catalogue of the Boston Society for Medical Improvement, Boston, 1847, p. 162; Specs. 1815, 181G, Class V, Div. II, in Catalogue of the Museum of the Royal College of Surgeons of Edinburgh, 183G, p. 225; Spec. 1, Series XVIII, in A Descriptive Catalogue of the Anatomical Museum of St. Bartholomew's Hospital (Mr. Paget's revision of Stanley's Catalogue), London, 1846, Vol. I, p. 338; GROSS, System, 5th ed., Vol. II, p. 68 J; KlRK'.SRlDE, Clinical Reports, Case XII, in Am. Jour. Med. Sci., 1834, Vol. XV, p. 359; Gheex, Cases of Fracture of the Liver, in Am. Jour. Med, Sci., 1830, Vol. VI, p. 539; Bulletin de la Societe Anatomique, T. XXIII, p. 193, T. XXVI, p. 100, T. XXVIII, p. 260; MOHRENHEIM, Wienerische Beitrage, B. I; Thedex, Med. Chir. Xachrichtcn, Jahrg. HI, St. 43, S. 341; Rust's Magazin, B. XXII, Hft. I, S. 196; Hunter, Rupture of Liver, death on the tenth day, from haemorrnage, in Proceedings of the Pathological Society of Philadelphia, in Am. Jour. Med. Sci., N. S., 1870, Vol. LIX, p. 405. 'I find that DuruvTREN 'Lecons Orales de Clinique Chirurgicale, T. VI, p. 443) had observed this cause of abscesses of the liver. RiCHERAND'S experiment of precipitating a cadaver from a gallery to the floor of his lecturing amphitheatre, and thus producing ruptures of the liver, will also be remembered. He sought thus to explain the association of hepatic abscesses with cranial fractures, the etiology of what we now term metastatic foci in the liver. Consult Louis, Memoire sur les Abels du Foie, in Rixherches Anat. Path., Paris, 1825; Richerand, Nosograph. Chir., T. V, p. 244. Dr. Liuell, in his excellent article on rupture of the abdominal viscera (Am. Jour. Med. Sci., N. S., Vol. LIII, p. 340), gives the case of extensive hepatic laceration with unbroken peritoneum, and quotes another from Mr. POLLOCK (Holmes's System, Vol. II, p. 416). For an interesting case of recovery from hepatic abscess, due to a fall from a horse, see Dr. Haklky's paper, read before the Clinical Society of London (Lancet, 1870, Vol. II, p. 569). Compare, also, cases by Heaton, Brit. Med. Jour., 1869, Vol. II, p. 8, and MOOBE, Ibid., 1870, Vol. II, p. 693. 2 Preparation 1391, of the Hunterian Museum, shows a laceration of the liver extending through the whole thickness of the organ. The patient, who was crushed, survived two days. Descriptive Cat. of the Path. Specimens contained in the Museum of the Royal College of Surgeons of England, Vol. Ill, p. 152. Assistant Surgeon G. F. Guxx, U. S. A., has reported (Circular 3, S. G. O., 1871) a fatal case of rupture of the liver by the passing wheel of a carriage. The diagnosis was verified after death. An attendant laceration of the spleen was not detected until the autopsy. For a case, in which death was almost immediate, see PEARSON, Transactions of the College of Physicians, London, Vol. III. For an interesting case in which a laceration was found nearly cicatrized and a large effusion of blood partially absorbed, when the patient died from a cause foreign to the accident, see Peli.etax, Clinique Chirurgicale, Paris, 1810, T. II, p. 112; Velpeau (TraiU Complet d'Antomic Chirurgicale, T. II, p. 159), among other instances, cites two unpublished cases by M. Forget. In the discussion on Mr. ATHOL Johnson's paper above cited, LLOYD and Solly (Lancet, 1851, Vol. I, p. 94) called in question the cicatrization of lacerations of the liver; hut COPELAND considered the fact demonstrated. 3 Taylor, Medical Jurisprudence, Am. ed. of Griffith, 1845, p. 320. For a case in which this accident happened to an individual attempting to avoid a fall from his horse, see Male's Epitome of Juridical or Forensic Medicine, London, 1816, p. 119. « Devergie, Medecine legale, theorique et pratique, 2eme ed., 1840, T. II, p. 45. From several of the following dissertations de hepatitide vel de Jecinor is inflammatione, particulars of cases of traumatic hepatitis and of the post-mortem appearances after rupture, may be gleaned: Gerhard, C A., Halae, 1721; Bianchi, Genevae, 1725; l[^:;i';i\i;a, J. C, Halae, 1726; Smith (Marx), Edinburgh, 1766; Willax, Edinburgh, 1780; Uossum, Louvain, 1782; Vpkrex, Leyden, 1782; Mv.w, Edinburgh, 1785; Causland, Edinburgh, 1787; Maclean, Edinburgh, 1790; Miller, Edinburgh! 1795, AcilEL, Upsala. 1797; HORXE, J., Edinburgh, 179;); Aixslie, Edinburgh, 1801; Beech, FYFE, MAXWELL, Edinburgh, 1801; STOCK, Keating^ Edinburgh, 1802; B:tOADFOOT, O'Beirx, Edinburgh, 1803; Mellville, Edinburgh, 1803; White, Baltimore, 1808; Huggins, Edinburgh, 1809; ZlMMERMANN, Leyden, 1815; KOWAN, Baltimore, 1815; Facee, Leyden, 1816; RAGUENET, Strasbourg, 1820. 3 18 INJURIES OF THE ABDOMEN. [CHAP. VI Fig. 6.—Spleen torn com- pletely through by a blow from the fist. Spec. 5600, [Reduced to one-fourth.] Puptures of the Spleen.—Notwithstanding the looseness of its attachments, and its consequent mobility, the delicacy and friability of the texture of the spleen exposes it to injury from external violence. Next to the liver, this viscus is probably the most frequently lacerated of the abdominal organs.1 Its extended rupture commonly gives rise to fatal haemorrhage.2 Yet, that recoveries occur in such cases, is indicated by observation and demonstrated by post-mortem investigations.3 Very extended lacerations are followed by profuse internal haemorrhage, and the consequent symptoms and result. The patient, from whom the preparation represented in the wood-cut (Fig. ()) was taken, survived a rupture of the spleen from a blow with the fist less than fifteen minutes. The case is related by Surgeon J. F. Weeds, U. S. A., in Circular No. 3, S. G. 0., 1871, page 107. Fissures and lacerations of the spleen are generally most conspicuous on the convex surface, though often extending through the entire substance of the organ,4 as in Dr. Weeds's case. Another instance, a laceration by a rail- road accident, is recorded on page 38 of the First Surgical Volume. Two other cases are reported, both represented by preparations in the Museum, and it is not improbable that among the fatal cases that will be referred to hereafter, returned as deaths from con- tusions of the abdomen, or among the cases of recovery after grave contusions in the left hypochondrium, there may have been examples of rupture of the spleen. Professor Gunther5 relates a case of recovery in which he regarded the signs of rupture of the spleen and intra-abdominal extravasation as indisputable. Case 103.—Private Charles G------, Co. B, 23th Illinois, was struck in the left side of the abdomen, November 26, IS,;:?, at the battle of Mission Bidge, by a spent cannon ball, or, more strictly, by an unexploded shell, which rolled against his side, as he was lying down, and was stopped by the impact. The blow produced great distress in the abdomen, and nausea, yet there was no visible ecchymosis or other injury of the integument, and, after taking a restorative draught, the wounded man felt able to walk several miles to Chattanooga, where he was received in ona of the hospitals. He was confined to his bed until December 20, 1S'3:S, when he was transferred to the general field hospital, under the care of Acting Assistant Surgeon E. A. Ball, 1 The literature of ruptures of the spleen is copious. Morgagni (Di Sidibus et Cansis Morb., Patavii, 17G5, Vol. II, p. 279, Ep. LIV. 15) adduces many cases from the old authors: Thus three examples, caused b}' blows from canes, are recorded by Tulpius (Obs. Mr.d., Amstelodami, 1641. Lib. II, Obs. 29); FOXTEVN (Epitome, VESALII ad HORSTII, p. 22); CRASSIUS (Miscellaneorum Cariosorum, Dec. Ill, Ann. II). Other examples, the results of kicks from horses, of blows from the fist, of falls and other forms of violence, are noted by BOHN (De Renuntiatione Vulnerum, Lipsue, 1G89). Albreciit (Lien afortipercussione ruptus, in the Acta Eruditorum, Venet., 1740, An. X, Dec. Ill, Obs. 0) and others, enumerated by Heisteu, in his Institutiones Chirurgicx, Amstelodami, 1739. EYSEL, De Rupturd Lienis, Erford, 1693; SCHEID, Historise Lienum lluptorum, Argent., 1725; HUNAULD, Mem. de I'Acad. de St. Petersburg, 1726, Vol. I; Hautesierk, Recueil d'Observat. de Med. des Hopitaux Mil., Paris, 1776; BlETT and Aussandox are quoted by Breschet, Diet, des Sci. Med., T. VIII. p. 149. Among the American cases recorded are those of Buist, Rupture of the Spleen from a Fall, in Am. Jour. Med. Sci., N. S. Vol. LX, p. 575. and Waring, Three cases of Ruptured Spleen, in Am. Jour. Med. Sci., N. S., 1856, Vol. XXXII, p. 354. Ingalls, Boston Med. and Surg. Journal, 1829, Vol. I, p. 296; Lopez, N. Am. Med. Chir. Rev., Vol. IV, p. 286; Adams, Dublin Med. Press, March 21, 1860. 2 As in Hennex's Case, LXXVI (Princ. of Mil. Surg., 3d ed., p. 445). Guthrie (Comm., 5th ed., p. 590, and Lectures, p. 56) adverts to ruptures of this organ, •' which I have several times seen occur in consequence of falls, or from blows from cannon shot, which have not opened into the cavity," fatal "from haemorrhage filling the general cavity of the abdomen." C. J. Langexbeck (Nosologic und Therapie der Chirurgischen Krankheiten, Gottingen, 1830, S. 554) records a case fatal in fourteen hours, and cites several others. " Yet, copious bleeding is not a necessary consequence of this Lesion; for. in a patient recently under my care, who sustained this and other injuries and survived for some hours, there was not more than two ounces of blood in the abdomen, though there was an extensive rent in the spleen. In one of my cases, a deep linear cicatrix on the convex surface of the spleen seemed to indicate the position of a former wound, but the patient died of a more recent injury."—Clark, op. cit., p. 298. 3 Preparation 201810, of Guy's Museum, illustrates the repair of the spleen after injury (Path. Cat., Vol. II, Addenda, p. 65). Mr. Clark (Lectures on Surg. Diagnosis, p. 293) does not think that the spleen can be placed in the same category with the liver and kidney, as to frequency of recovery, because of its peculiar texture and vascularity. The subject will be more fully discussed under the head of penetrating wounds. 4 For other illustrations, see Spec. 37, Series X, Catalogue of tlie Patlwlogical Museum of St. George's Hospital, by Dr. Ogle and Mr. Holmes, London, 1856, p. 520; JACKSOX, J. B. S., Boston S'>c. Cat., I. c, Spec. 587; Portal, Cours d Anatomic Medicale, T. V, p. 345; St. Bartholomew Hasp. Cat.. Series V, Prep. 22, p. 352; Netley Collection Cat., Prep. 1586, p. 208; Edinburgh Cat., R. C. S., Spec. 1939, XXXI, D; AssOLAXT, Recherches sur la Rate, pp. 101, 102; Pigxe, Bull, de la S»c. Anat., 1837, p. 125. 5.MOEHRS. Deutsche Klinik, No. 20, May 18, 1850, B. II, S. 222. The case was that of a man of 27 years, who fell from a height of thirty feet, the left side striking a carpenter's trestle. An audible souffle jugulaire attended the effusion of blood. For descriptions of ruptured spleens, consult FOURXIER, in LlEUTAUD's Historia Anatomico-mcdica, L. I, Ltesiones abdominis, Obs. 977, 978, Paris, 1767; Diret, Jour. Gen. de Med. Chir. et Phar., T. XCIX, p. 136; MuXTFALCOX. Histoire Med. de Marais, p. 305; ZOPF, Eph. Acad. Nat. Cur., Norimberg, 1740, Obs. 123, "mors subita ex ruptc liene;" DIXCAX, Med. Chir. Rec, 1830, Vol. XVII, p. 227; A scull. London Lancet, 1839, Vol. II, p. 894; NfECKEL, in Med. Zeit.. May, 1839, quoted in Arch. Gen. de Med., S. in, T. VI, p. 97; COOPER, Lancet, 1840, Vol. I. p. 486. Thesis in Arch. Gen. de Med., 1854, 3eme s6rie, T. IV. p. 85; Barth, Ibid., 1855. T. V, p. 285; CHARCOT, Gaz. des Hop., 1858; Love, Lancet, 1859, Vol. I, p. 329; Erichsen, Lancet, 1839, Vol. II, p. 9; Heddle, Med. Chir. Rev., 183:". p. 391. SECT. 11.1 RUPTURES OF THE SPLEEN. 19 Fig. 7.—Kiaifinents of spleen ruptured by the contusion of an unex- ploded shell, and broken down by suppuration. Spec. 2113. [Reduced to one-fourth.] who took notes of the case, and contributed the specimen represented in the wood-cut (Fig. 7). At this date the patient was emaci:ited, his pulse frequent and feeble; he had slight cough without expectoration; the abdomen was tympanitic and slightly painful on pressure; anorexia, micturition, and defecation regular; legs cedematous; complained of excessive lassitude and weakness. The swelling of the abdomen subsided considerably until ten days before his death; but the pain and soreness persisted. He was able to walk about the tent every day before his death, which took place on January 8, 1SG4, a month and thirteen days from the reception of the injury. At the autopsy, a discoloration of the integument in the left hypochondriac region was noted, a suggillation resembling incipient post-mortem decomposition. On opening the thoracic and abdominal cavities, the lungs were found to be normal; the pleura of the base of the left lung was adherent to the diaphragm. From the under surface of the diaphragm, in this region, extended a huge abscess as far down as the left and right iliac regions. Its boundaries were noticed in detail by the reporter; but it may be said to have occupied the entire lesser peritoneal cavity. Its walls were lined by an abundant dark gray, shaggy exudation, and it contained fetid, cheesy pus. It communicated with the left pleural cavity through an opening in the diaphragm, and the lung in its immediate vicinity, though crepitant and well filled with air, was brown-colored and more friable than elsewhere. The spleen was ruptured, and divided along the hilus into two portions; the larger weighed three and one-half ounces, the smaller, two ounces. The proper substance of the spleen is much broken down. On microscopical examination of the specimen at the Museum, it is found, in a transverse section in glycerine, that the polygonal arrangement of the trabecular enclosing the proper substance of the spleen has everywhere disappeared. The capillaries are much shrunken, which may be due to long immersion in alcohol without previous injection. No Malpighian corpuscles are visible. There are melanotic or pigment deposits infiltrated at frequent intervals throughout the tissue. The peritoneal.investment is thickened, and coated with lymph in some places. Case 107.—John S------, aged 45 years, weighing about 170 pounds, an epileptic, fell from a stable-loft during the night of October 24, 1871, and his body was found lifeless on the pavement in the morning. There was a slight cut on the scalp, but no other external evidence of injury. At the autopsy, six hours after death, the brain and its membranes were found to be much congested; hut there was no intracranial effusion of blood or serum. There were old pleuritic adhesions on the left side; but the lungs were normal. The heart was flabby, and contained no coagula. The liver was cicatrized; the stomach and intestines showed no abnormal alteration. The spleen was much enlarged, weighing twenty and one-half ounces avoirdupois, and was ruptured, radiating fissures extending completely through its substance. Profuse haemorrhage into the peritoneal cavity had resulted from this laceration. The speci- men, represented in the accompanying wood-cut (Fig. 8), and the memorandum of the case, were contributed to the Army Medical Museum by Dr. J. F. Hartigan. A thin microscopical section hi the vicinity of the rupture exhibits increased vascularity and abnormal enlargement of the Malpighian corpuscles, and numerous small deposits of pigment cells. The first of these cases is very interesting on account of the protracted duration of life after the accident. If there was any primary laceration and extravasation, the former must have been slight and the latter circumscribed. The case should be described, perhaps, as an example of traumatic splenitis terminating in abscess. M. Vigla1 and M. Collin2 have published exhaustive papers on ruptures of the spleen, occurring in diseased subjects, from muscular contraction or very slight external violence. The former believes in the possibility of recovery, though all the cases he has collected proved fatal. Peritonitis did not occur in any case, and on the absence of its signs M. Vigla founds a distinction between the symptoms of splenic rupture and those of rupture of the intestinal tube, which they closely resemble. M. Collin adds a number of cases observed in Africa. 'Vigla, Recherches sur la Rupture Spontanee de la Rate, in Arch. Gen. de Med., 4" Serie, T. III. p. 377, 1843, T. IV, 17, 1844. The author analyzes seventeen cases, all of which were fatal—fourteen within forty-eight hours, one on the sixth day, two early, but date not specified. The exact diagnosis was made out in very few instances. Diaphragmatic pleurisy, internal bleeding from rupture of an aneurism or large vessel, were among the lesions suspected. M. Vigla holds that the absence of the signs of peritonitis distinguishes these cases from rupture of the intestinal tube. Absolute rest, opium, and haemostatics constituted the treatment. 2 COLLIN, Des Ruptures Spontane.es de la Rate, in Mimoires de Chirurgie de Medccine et de Pharmacie Militaires, 2'' Serie, T. XV, p. 1, 1855. The author regards splenic ruptures in subjects with malarial cachexy as more common than has heretofore been admitted. He describes capsular ruptures unattended by haemorrhage. In examining and palpating cacheetics with enlarged spleeus, practitioners should exercise great caution, and such patients should bo warned to be always on their guard. The diagnosis was equivocal in all the cases collected by Mr. Collin. No pathognomonic sign can be suggested. FIG. 8.—Enlarged spleen, ruptured by a fall. Spec. 5948. [Reduced to one-fourth.] 20 INJURIES OF THE ABDOMEN. [Ciiap. vi He inclines to the opinion that the prognosis is uniformly unfavorable, although he demon- strates in several instances the existence of cicatrization. He mentions three examples of generalized peritonitis following the accident. Ruptures of the Kidney.—Notwithstanding its protected position in the loins, well padded with adipose tissue, rupture of the kidney is not an infrequent accident. But few fatal cases, however, appear on the reports during the War. An interesting case, fatal from haemorrhage, a complete longitudinal laceration of the right kidney, caused by the passage of a wagon-wheel, is recorded by Assistant Surgeon Gunn, U. S. A., in Circular No. 3, S. G. 0., 1871, page 106. The morbid specimen was not preserved, and the Museum is still without a preparation illustrating this form of injury.1 One fatal case, in the War, was from a buffer accident, another from a shell contusion: Case 108.—Private Gerald Tiffany, 27th New York Battery, aged 44 years, falling between the platforms of two railway cars, February 6, 1854, was caught and squeezed between the buffers. The compression was anteroposterior and over a space to the left of the umbilicus in front, and between the crest of the ilium and the ribs behind. There was ecchymosis in the lumbar region, but the integuments were intact. The patient was conveyed to Kalorama Hospital. There was profound collapse, from which he slowly rallied. The abdomen was tender and swollen, the urine bloody. Emollient fomentations were applied and opiates were administered, and diluents and a light diet were prescribed. There were symptoms of peritonitis during the first week, but not of an aggravated character. The hsematuria persisted for three weeks, clots being passed occasionally molded of the form of the ureter. There was dulness of percussion over the left flank. The symptoms seemed to indicate rupture of the left kidney, with limited and probably extra-peritoneal urinary extravasation. Balsamic remedies were employed, and the bloody appearance of the urine at last disappeared, an albuminous condition of the secretion persisting. CEdema of the lower extremities supervened. With occasional amendments, the evidence of uraemic infection became more confirmed. The patient had several severe attacks of diarrhoea, and sank and died from the effects of his injuries on April 6, 1834. No autopsy. Case 109.—Private Nathaniel J. Loveland, Co. D, 19th Massachusetts, received, June 25, 1832, a severe contusion of the left side of the abdomen, from a fragment of shell, at Oak Grove, in the advanced trenches near Eichmond, of General Dana's brigade of the First Corps. The shock was great and of long continuance; there was a bruise on the left flank, and excessive tenderness, anuria, and pain and retraction of the left testicle. Surgeon J. Franklin Dyer, 19th Massachusetts, notes, at the regimental hospital, "serious danger apprehended." The patient was placed on a hospital car and sent to Savage's Station, and thence to Yorktown, where he died on June 27, 1862. Very probably other instances may be included among the fatal abdominal contusions reported without distinct specification of the symptoms. There were also a number of cases of recovery in which there was reason to suspect the existence of laceration of the kidney, or at least of severe contusion of its substance. Unfortunately they are not reported with fulness or'precision of detail. That recoveries take place2 after very consid- erable laceration of the kidney, with extravasation of both blood and urine, has long since been demonstrated by clinical observation and the investigations of pathologists: Case 110.—Private J. H. Dulepohn, Co. K, 142d Pennsylvania, aged 20 years, was struck in the left lumbar region, July 2,1863, at Gettysburg, by a large fragment of shell, which caused a grave contusion with ecchymosis, but without abrasion of the skin. There was shock, and much pain and tenderness at the injured part, and the urine was scanty and bloody. The 1 "When not very severe, and uncomplicated with other injuries, such cases usually do well. It is generally known by an attack of haematuria following a blow in the lumbar region, local pain as a rule co-existing. This hsematuria may be only passing, and cease after the lapse of two or three days, when it is probable that only a contusion of the kidney had taken place; for in severer injuries the bleeding lasts fifteen days or more. At times clots will be passed, assuming the shape of the ureter. I have before me the notes of some half a dozen cases in which these symptoms were present, and from which recovery took place."—Bryant, The Practice of Surgery, London, 1872, p. 304. 2 Preparation 1728, Class VI, Division II, Section IX, of the Museum of the British Army Medical Department, represents a rupture of the right kidney (Catalogue, p. 225). At the Museum of St. George's Hospital, London, specimens 1, 2, 3, and 4 of Series XI illustrate ruptures of the kidney. The first is the right kidney of a boy of fifteen years, run over by a cart. There was extensive haemorrhage into the sub-peritoneal cellular tissue; the kidney was the only organ injured. The patient did not rally from collapse. Prep. 2 shows rupture of the left kidney of a man of sixty-seven years. Prep. 3 shows a rupture of the left kidney from a fall; there was copious haemorrhage into the peritoneal cavity. Prep. 4, of two granular kidneys, shows a cicatrix in the right, from a rupture that occurred eighteen months before death.—(Catalogue, p. 530.) At St. Bartholomew's Museum, Prep. 14, of Series XXVI, is the specimen from a case of rupture of the ureter described by STANLEY in the Medico-Chirurgical Transactions, Vol.'XXVII, p. 8. The kidney itself appears healthy. In the Pathological Cabinet of the New York Hospital, Sect. VII, Prep. 747, is a kidney raptured by violence; 748 shows the repair of a rupture that almost completely divided the organ horizontally near the centre; "lymph is copiously effused between the separated surfaces and upon the exterior."—(Kay's Cat., 297.) Prep. 2363, of Guy's Hospital Musenm, is a "kidney showing slight laceration on its surface, produced by injury."— (WlLKS's Cat., 1859, Vol. II, Pt. 2, p. 30.) Prep. 2451, of the Warren Anatomical Museum, is a kidney with a horizontal laceration, one-eighth to one-third of an inch in depth; there was a largv effusion of blood about it, but none in the bladder. The patient, who jumped from a railroad car in motion, survived the accident forty-eight hours.—Bui. de la Soc. Anat., T. XVIII, p. 186, T. XV, p. 106, T. XXVII, p. 112. SECT. II.] RUPTURES OF THE KIDNEY. 21 pain extended along the course of the ureter, and there was retraction of the testicle and smarting at the orifice of the urethra. There was much difficulty in micturition, and occasionally tubular clots of blood were passed, after which the urine flowed in a stream, with great relief. The patient was suffering with diarrhoea, lie was treated with hot fomentations to the injured part, and with chalk mixture and spirits of nitric ether, until the 11th, when he had sufficiently rallied to be transferred to the Satterloe Hospital, at Philadelphia, under the care of Surgeon I. I. Hayes, U. S. V., who reports the case. He was ordered infusion of buchu, and counter-irritation over the loins, and, as soon as the irritability of the bowels permitted, he was placed on nourishing diet, with ferruginous medicines and bitter tonics. The hairaaturia disappeared after the third week from the reception of the injury, and the patient gradually convalesced, and was transferred to the Invalid Corps, December 31, 18(53. Case 111.—Lieutenant H. T. Burrows, Co. C, 7th Maryland, was struck, May 5, 1H34, by a fragment of shell, in the left lumbar region. He was treated by Surgeon C. J. Nordquist, 83d New York, at the 2d division hospital of the Fifth Corps. Severe pain and difficult micturition, with hsematuria, led to the belief that a laceration of the kidney had been induced. On May 12th, this officer was sent to Washington, and was treated in quarters by Surgeon Antisell, U. S. V. He recovered, and on June 8, 1864, was placed on Court-Martial duty. No instances are specified in the reports of ruptures of the gall-bladder,1 or of the hepatic or common duct,2 or ureter,3 nor are instances given of rupture of the pancreas,4 or suprarenal capsules, yet a number of fatal cases were recorded in which visceral ruptures were diagnosticated, when opportunity to ascertain the extent and nature of the lesion were either not afforded or not improved. Some of these, of which it is mentioned that "all the viscera were pulpified," might have included illustrations of some of the rarer forms of abdominal lesions; but the descriptions are too vague to be instructive. Thus, Assistant Surgeon V. H. B. Lang, 49th Ohio, reports two instances of men killed, by contusions from spent shells, at the battle of Murfreesboro': Cases 112-113.—Pt. John Bolles, Co. A, 49th Ohio, shell contusion of abdomen, December 31, 1832, death on the same day; Pt, Joseph Stanch, Co. C, 49th Ohio, rupture of abdominal viscera by shell contusion, Murfreesboro', December 31, 1862. In other cases, the fatal result was delayed: Case 114.—Captain D. M. Myers, Co. G, 144th New York, was struck in the abdomen, at the engagement at Honey Hill, South Carolina, November 30, 1834, by a spent cannon ball. There was no external injury; but collapse, followed by nausea and vomiting, tenderness and tension of the abdomen, and bloody stools, indicated serious internal mischief. This officer was conveyed to the hospital at Hilton Head. Symptoms of traumatic peritonitis were combated by opium and emollient fomentations. He died on December 17, 1834. No autopsy. Case 115.—Private J. Bobbins, Co. G, 119th Pennsylvania, received, at the Wilderness, May 14,1834, a severe contusion of the abdomen from a fragment of shell. Extreme depression followed, from which he slowly rallied. Opiates were admin- istered. There was extreme tenderness in the region of the liver, and jaundice. The patient was treated on a hospital transport steamer and conveyed to Alexandria, where he died on May 28, 1864. Case 116.—Private J. Crooks, Co. I, 2d Massachusetts Artillery, aged 46 years, was struck, March 8, 1835, at Kinston, North Carolina, on the right side of the abdomen, by a large fragment of an exploded shell. There was intense nervous depression, followed by symptoms of traumatic peritonitis, and indications of injury of the liver or spleen. The patient survived to be transported to the Dale Hospital, in Massachusetts, where he died on April 25, 1835. 'BRESCHET, in his excellent article Dcchirement (Diet, des Sci. Med., T. VIII, p. 148), cites cases of rupture of the gall-bladder from Bonetus, Salmuthius, Bertinus, Hoffman, Portal, and the contributors to the Ephemerides Cur. Nat. Salmuth (Obs. med. posth., Brunsvio, cent. I, obs. 3, 1G48) relates the case of a boy of twelve years, who survived four days the rupture of the gall-bladder by a blow. Bertlxus (Medicina absoluta, Basil, 1587) records an early instance. Fergus (Med. Chir. Trans., Vol. XXXI, 1848, p. 47) reports a case in a boy of seventeen years, crushed bj- a cart- wheel : he died on the ninth day, after appearing to be fairly convalescent. LESUEUR (Sur les ruptures et les perforations de la visicule biliaire, Paris, 1824) records a case, fatal in four days. HOring (Diss, sistens experim. de mutationibus quas materiae in cavum peritonei ingestse subeunt, Tubings, 1817) proves, experimentally, that extravasation of bile in the peritoneal cavity is not necessarily fatal in the lower animals. I have met with no instances of recovery in the human subject. At St, Bartholomew's Museum, Prep. 14, of Series XIX, shows a rupture of the gall-bladder, three-fourths of an inch long. The specimen is from a man 53 years old, who was kicked near the region of the liver while stooping. He died in fifteen hours. 2 Poland (MS. Fothergillian Prize Essay) reports a case, quoted by Mr. Pollock, in Holmes's System, Vol. II, p. 649, of rupture of the common eholedoch duct, in a boy of seventeen years, from a blow on the abdomen, followed by great pain and speedy death. Mr. BRYANT (The Pract. of Surgery, p. 305) relates another case from Dr. Sutton's practice, in which a man survived a rupture of the hepatic duct thirty-eight days. CampaigxaC (Gazette Hebdomadaire, J829, T. II, p. 204) gives yet another example, a rupture of the left branch of the hepatic duct, near the lobule of Spigelius, from the passage of a cart-wheel. The patient died from peritonitis on the eighteenth day. Another case is quoted in the Lancet, 18~'9, Vol. II, p. 45i, from Grsefe and Waltlier's Journal. Clark (op. cit., p. 295) gives a complicated case. Ellis (Boston Med. and Surg. Jour., 1860, Vol. LXII, p. 22) reports a fatal case of rupture cf the common duct, in a woman of 22 years, crushed by a sleigh. T. M. Drysdale (Am. Jour, of Med. Sci., N. S., Vol. XLI, 1861, p. 399) records a case of rupture of the common duct of the liver, in a boy of 13 years; death on the fifty-third day. 3 STANLEY (Med. Chir. Trans., Vol. XXVII, p. 1) relates two cases; and POLAND (Guy's Hosp. Rep. for 1869) a third case. In all, the ureter was ruptured by stretching, and near the renal end. MORGAGXI (De Sed. et Causis, Ep. LIV), VATER (in IIaller'S Disp. Chir.. T. IV, p. 5, Diss, de Generat. Calc), Heuermann (Abhandl. der vornehurst. Chirurg. Operationen, Kopenhagen, 1778), and DESAULT have also recorded cases. 4 COOPER (London Lancet, Dec. 31, 1839, Vol. I, p. 480) reports the case of J. C., aged 33 years, run over by a light cart moving with great speed. No marks of external injury were visible; but the lower left ribs were fractured, and "the pancreas was literally smashed, and embedded in semi- coagulated blood." The spleen and left kidney were also ruptured. He died a few hours after the accident. Clark (op. cit, p. 298) says: ''I have on record but one instance of laceration of the pancreas, which occurred in a.lad, who was the subject of other severe injuries, that speedily proved fatal." Devergie (Med. Legale, Seme 6d., T. II, p. 94) cites a case, an unknown woman, crushed by a carriage on a road in Flanders. • 99 INJURIES OF THE ABDOMEN. |('HAP. VI. Ruptures of the Stomach.—Some of the fatal cases of contusions by spent cannon shot, when the injury is stated to have been in the epigastric region and attended by vomiting of blood, were probably examples of rupture of the stomach; but no details of these cases were recorded.1 Commonly, the shock or profound collapse that attends rupture of this organ is speedily fatal. If life is prolonged, there is pain radiating from the seat of injury, of indescribable acut.en.ess and intensity. Haamatemesis is a constant symptom. The extent of laceration and the degree of repletion of the organ at the time of rupture influence the result. It is believed, but not demonstrated, that a small lacera- tion of an empty stomach may be followed by recovery. Ruptures of the Intestines.—Five cases were reported; four were accompanied by the usual symptoms in such cases. These symptoms are described in Poland's paper2 with his accustomed graphic accuracy and precision. In the third case, the agonizing pain that commonly attends such injuries was absent, probably because of the absence of faecal extravasation. The lesion of the bowel is depicted in the print opposite page 23 (Plate I), a photographic print by the Woodbury process. The perforation of the gut, and the infil- tration of blood into its coats, are represented as perfectly as in the wet preparation in the Museum.3 Sudden and excessive meteorism, produced by the escape of intestinal flatus into the peritoneal cavity, is, as has been remarked, regarded by Jobert4 as the most characteristic sign of rupture of the intestines, and he gives, in support of his opinion, a case remarkable not only for the accuracy of the diagnosis, but as an illustration of the reparative efforts of nature in such accidents. The significance of sudden typanitis is probably not exag- gerated by Jobert; yet it is a sign by no means uniformly present in intestinal rupture. Case 117.—Private F. Landenslager, Co. H, 22d Veteran Reserve Corps, aged 23 years, received a kick in the abdomen, in an affray, on the night of September 30, 1864, at Albany, New York. There was no external ecchymosis; but the blow was followed by faintness, nervous depression, and, soon after, by excruciating abdominal pain and tenderness, with tympanitis, and vomiting. He died on October 2, 1834, from acute traumatic peritonitis with faecal extravasation. At the autopsy, two small perforations were found near the middle of the ileum, through which a part of the contents of the bowel had passed out into the cavity of the peritoneum. Assistant Surgeon M. F. Cogswell, U. S. V., reports the case. Case 118.—Teamster W. H. Wood was kicked in the umbilical region, by a mule, at Cape Girardeau, Missouri, September 22, 1864. He was conveyed to hospital, suffering intense pain, with collapse and vomiting. The abdomen was distended and exquisitely tender on pressure. Opiates and hot fomentations afforded but slight mitigation of the distressing symptoms, which terminated fatally, in about forty-eight hours, September 24, 18(54. At the autopsy, the jejunum was found to be ruptured, and blood and focal matter effused in the peritoneal cavity. The case is reported by Acting Assistant Surgeon W. A. Wilcox. 'Examples of rupture of the stomach have been collected by MOHGACXI (op. cit., Ep. LIV, Art. 15), BitESCIIET (Diet, des Sci. Med., T. VIII, p. 150), and VELPEAU (Diet, de Med., T. I, p. 177). The cases of Lieutaxd, Anduy, Portal, Sandifort, BOSQUES, and Dupuytricn have been often cited. IIEXRICI (t'eber die Wunden des Magens, Leipzig, 18C4, S. 11, C8, 69) enumerates twenty-two ruptures of the stomach from various causes. STROMEYER (Maximen, u. s. w., S. 633) cites a case of abdominal contusion, at Idstedt, in which haematemesis recurred on the fourteenth day. At the autopsy a rupture of the stomach was found. 2 Poland. A Collection of Several Cases of Contusions of the Abdomen, accompanied with Injury to the Stomach and Intestines, in Guy's Hospital Reports, 1858, Third Series, Vol. IV, p. 123. He gives abstracts of sixty-four cases of ruptured stomach and bowels. Of fifty-six, in which the time of death is stated, ten were fatal in the first five hours; eighteen, in from five to twenty-four hours; nineteen, in from twenty-four to forty-eight hours; nine between the third and sixteenth days, during the period of reparative attempts. 1 The rupture was in the jejunum, which, from its fixed position, is more frequently torn than any other portion of the intestinal canal, especially by crushing weights. In fourteen examples adduced by POLAND, in half the laceration was at the upper part of the jejunum. All of these perished from collapse and peritonitis. For other instances, consult Drake ( Western Med. and Phys. Journal, Vol. I, p. 550); HART, (Dub. Hosp. Rep., Vol. V, p. 297); Bakaduc (Bull, de la Soc. Anat., T. XIII, p. 309). See Taylor (Med. Jour., p. 321), WATSON (On Homicide, p, 159), and IlENKS (Zcil.ich. der S. A., 1830, XXII) for interesting' medico-legal cases. For pathological specimens, compare Prep. 404 (N. Y. Hosp.), 351 (Pennsylvania IIosp.), 485 (Boston Soc. Med. Improv.); Preps. 93, 110, 111, 112, at St. George's Hosp., London; Prep. 1164, at Netley. The ileum is also frequently ruptured: LlDELL (Am. Jour. Med. S'.i., N. S., Vol. LIII, p. 351) records a fatal instance in a man of 50 years, kicked by a woman with her bare foot; ANNAN (Ibid., O. S.. Vol. XXI, p. 530) gives a case, fatal in sixteen hours, from the kick of a horse. For specimens, see Prep. 105, at St. George's, und 1165, 1166, at Xetley. HOGUKins. according to Mokoagxi, recorded a case of rupture of the duodenum. Collier (London Med. Gaz., 1838, Vol. XII, p. 766) records another example in a boy of 13 years, struck by a churn handle. The pathological specimen cf a third case is Prep. 103, at St. George's Hctp. (Cat., p. 431), from a man of 40 years, run over by a cab. Sr-EER (Dub. Ho?p. Hep., Vol. IV, p. 359) records a case of rupture of the caxHim. MORINEAU (Gaz. Mild., 185}. p. 788) gives an instance of rupture of the ascending colon. Pathological specimens of these lesions are desiderata. 'JOBERT (de Lamballe), Iraiti theorique et pratique des Maladies chirurgicales du canal intestinal, Paris, 1829, T. II. M«d and Surj Hist of the "War of the Rebellion Parti. Vol.I. ijipof 11. page 2.3 Ward, pkot. J Bien, Litk. PLATE I. RUPTURE OF THE JEJUNUM BY THE KICK OF A HORSE No. 6188. SURGICAL SECTION. ......."■■'".! Jl."".t ■'I r' ■:•• ■ :*"i • HI- ■-'. I •■.!-' •,.!": \ I: ' ■t I: N .' '•. ■ v '.4. A :» 'ii.- p 4 :JHV!V' ' '•:'.'■*'"".<■ .•..■••.>•.•...•■ .-;♦/•■ •• .v-WMfciLV .•.*/■ 4 ■-/$■ ■'■.'! JU I. ,•• " W- V yi>:: ':• ;:*'•'•• ■**■ ■■■//.'v ' H Khk ■ & '.•■■*•./:■:;"•■ • «*VHP;?w ■•■■ ^lii *E OF THE JEJUNI■ ■+ P 6138. SURG;C.'; SKivr. n.1 RUPTURES OF TIIK INTESTINAL CANAL. 23 Cask 110.—Frank R------, aged 11 years, a servant of Mr. Smoot, • Inhianee Corps, was kicked by a horse in the lower umbilical region, while assisting a child to mount, O.i receiving the blow, he ran to the house and examined the injured part, and then walked a short distance to his mother's quarters, crying, lie was put to bed, and was presently attended by Dr. J. S. Kennedy, who found him, half an hour after the reception of the injury, vomiting blood, complaining of great nausea, and great tenderness over the umbilical region, but of no acute pain. The pulse was accelerated and the heat of surface augmented. There was no abrasion or visible contusion of the surface. An anodyne was prescribed, and absolute rest in the easiest posture. At the Doctor's second visit, in the evening, the stomach was less irritable!, but the abdominal tenderness was extreme, and extended to the hepatic region, and was attended with much pain, referred chiefly to the right hypochondrium. During the night the febrile disturbance augmented; there was excessive restlessness and anxiety, with occasional retching. In the morning, Dr. Kennedy found the little patient almost moribund ; a clammy sweat covered the surface; the pulse was rapid and thready ; the patient was conscious and free from pain. He never rallied from this condition, and expired twenty-four hours after the reception of the injury. The remains wore sent to Washington, where a post-mortem examination was made by Dr. J. F. llaitigan. Careful inspection could not reveal the slightest contusion or ecchymosis externally, nor extravasation in the abdominal muscles. About half a pint of clear serum was contained in the cavity of the abdomen ; the peritoneum was agglu- tinated in various parts, and bands of lymph covered the intestines. About the middle of the jejenum there was found a small rupture of about half an inch, irregular in shape, surrounded with coagula. The other organs were healthy. The notes of the case, and the specimen, No. 6133, represented in Plate I, were contributed to the Museum by Dr. J. F. Hartigan. Cask U;).—Private I. Bishop, 50th New York Engineers, was struck in the abdomen, on June 4, 1864, at the battle of Cold Harbor, by a large fragment of shell. Collapse was immediate and intense, and reaction was slowly brought about by the administration of diffusible stimulants, the application of external warmth, with friction of the surface of the extremities. Surgeon C. N. Hewitt, 50th New York, reports that there was excessive tenderness, with meteorism, as soon as reaction was established. Opium was freely administered, and warm cataplasms were applied over the abdomen. The patient, suffering acutely, lingered for nearly forty-eight hours, and died on June 6, lri;>4. A large rent, with gangrenous edges, appeared in the jejunum. Faeces and a small amount of semi-fluid blood were found in the peritoneal cavity. Case 121.—Private J. Bence, Co. B, 93th Pennsylvania, was struck in the belly, at Hatcher's Run, March 25, 1885, by a spent cannon shot. There was no ecchymosis in the umbilical region, where the missile struck; but the patient was prostrated, an I tlure was much pain and anxiety. When admitted to the 2d division hospital of the Sixth Corps, Surgeon »S. F. Cliapin, 139th Pennsylvania, inferred, from the tension and tenderness of the abdomen and bloody stools, that the small intestines were greatly contused or ruptured. Symptoms of traumatic peritonitis were more aggravated. Opiates did not control the pain or nausea. Symptoms of iuternal gangrene supervened, and the case terminated fatally on April 2, 1835. There is no record of an autopsy. Ruptures of the membranous viscera are more fatal than wounds of the same part, or than wounds or ruptures of the solid organs. Larrey,1 in his Memoir on the Austrian Campaign, describes several cases of abdominal contusion by shot, in which many of the viscera were injured, though, perhaps, none actually lacerated. Among the cases reported during the War, in whiclj the character of the lesion cannot be precisely determined, were the following: Cases 122-124.—1. Pt T. Brown, Co. I, 58th Massachusetts, aged 44 years, contusion in hypogastrium, with injury of small intestines; Petersburg, March, 1855 ; died on April 24, 1865.—2. Pt. J. Rand, Co. C, 79th Ohio; shell contusion of the bowels: Kenesaw, June 26, 1864; died on August. 21, 1864.—3. Pt. W. Bowditch, Co. B, 158th New York, aged 30 years; shell contusion of abdomen, with injury of viscera; Chapin's Farm, September 23, 18J4; died on October 13, 18o4. Assistant Surgeon E. Bentley,2 U. S. A., has reported, since the War, two cases of rupture of the intestines, with judicious remarks on their medico-legal relations.3 Ruptures of the Omentum and Mesentery.—In proof that such lacerations, unaccom- panied by any outward marks of injury, sometimes cause death, Professor Gross (System, Vol. II, p. 679) adduces a case reported by Dr. Derner, of a huzzar, in whom a violent leap of his horse caused a rent in the omentum an inch and a half long, which led to the extravasation of five ounces of blood in the peritoneal cavity, and death the next morning. No parallel instance was reported during the War. But an interesting example of rupture 1 IiARUEY, D. J., Memoires de Chirurgie Militaire et Campagnes, T. Ill, p. 334. 2BENTLKY, Path. Deductions from Conditions found in the Study of Morbid Anatomy, in Pacific Med. and Surg. Jour., 1872, Vol. VI, p. 127. 3 Mr. Thomas Bryant (A Practice of Surgery, a Manual, London, 1872, p. 302) gives the following list of the preparations illustrating ruptures of the intestines, in the museum of Guy's Hospital: " In Guy's Museum there is a specimen (Prep. 185186) of perforation of the small intestines of a man who had received a kick from a horse; he died thirteen days after the accident, with extensive peritonitis following faecal effusion. Prep. 185186 consists of a portion of jejunum, taken from a man who had been kicked in the abdomen ; the injury was quickly followed by symptoms of extrava- sation, and death in forty-eight hours. Prep. 185088 was taken from a case of perforation of small intestines from the kick of a horse, terminating in death in twenty-four hours. No. 185180 is a portion of jejunum presenting two openings, in which the mucous membrane is inverted, following the blow from a kick in the abdomen. No. 185191 is an example of laceration of the jejunum; the bowel is seen to be completely divided; this was taken from a man aet. 37, who was run over by a cart, and lived twenty-four hours ; and lastly, the specimen marked 18518' is from a case that occurred in the practice of my father, the late Mr. T. E. Bryant, of Kensington ; it is a portion of ileum having a small perforation, produced by a blow in running against a post; a state of collapse came on, the patient did not rally, but died on the third day." 24 INJURIES OF THE ABDOMEN. [CHAP. VI. of the mesentery was communicated, which was followed by the intrusion and strangula- tion of the intestines in the abnormal aperture. The preparation from this case is No. 50o of the M'-Hcal Section of the Museum.1 The following, if not a rupture, must have been a contusion of the mesentery, followed by abscess and, possibly, by faecal fistula: Cask 125.—Private William Williams, Co. K, 9th Pennsylvania, received a shell contusion of the abdomen, three inches below the umbilicus, at Fredericksburg, December 13, 1862. He was carried to the field hospital, whence he was transferred, on the S.\t\, to Washington and admitted to Lincoln Hospital. Two days after admission, an abscess, which had formed at the point of injury, opened and discharged pus which was apparently mixed with fecal matter; this discharge continued from day to day, and the abdominal walls sloughed about the opening until it was three inches long by two inches wide. No inflammation of the bowels or peritoneum, except this abscess, appeared until January 11,1863; nor was there swelling or meteorism, nor any prostration or disturbance of the system. The patient appeared to he free from the influence of shock; he suffered no pain, ate well what was allowed him, chiefly bread and milk, without nausea, and was able to get out of bed without assistance; pulse normal, bowels regular. On January 11th, he began to be restless, had some fever, much thirst, and considerable nausea; the bowels became swollen, inflamed, and painful. Fomentations and poultices were applied, and calomel and Dover's powders given, without relief. The nausea increased, faecal matter apparently being constantly thrown up. The pulse was rapid, small' and easily compressed. He died on January 16,1863. The autopsy was made nineteen hours after death. The lungs exhibited intense hypostatic congestion. On the left side posteriorly was a circumscribed pleuritis with a thick deposit of fibrinous lymph. Throughout the lung substance were numerous black spots averaging one line in diameter. The lungs weighed thirty-five and one-half ounces. The auricles of the heart were distended with black clots; a white fibrinous clot appeared in the right ventricle, attached by its base to the tricuspid valve. The left ventricle was empty and firmly contracted. The heart weighed nine and one-half ounces. The liver weighed fifty-seven ounces. Fibrinous lymph was found upon the peritoneal coating; it was irregularly mottled—blue and dark; its substance was decidedly hard. One fluid ounce of pale yellow serum was found in the cavity of the pericardium. The spleen weighed five ounces and was of a pale reddish color. Pus, in considerable quantity, was found in the peritoneal sac. The kidneys weighed five ounces. Upon opening the abdomen and raising the injured portion of its wall, dark yellow pus came through an opening opposite to the injury; there was thickening and injection of the intes- tinal walls, especially those of the large intestine. The lower part of the ileum had apparently lost both its mucous and muscular coats, and was contracted so as to resemble a cord. The mesentery was enormously thickened, its glands inflamed, and large collections of black fetid pus were found in it, which communicated with the sac of the peritoneum nearly opposite the opening through the mesentery and abdominal Avails. Abscesses were found on the outside of the peritoneum, in the left iliac region, which communicated with abscesses in the course of the lymphatic glands following the course of the great vessels. Peritonitis was found connecting the omentum by adhesions to the anterior wall of the abdomen. The subject was five feet eight inches high, and emaciated. There are cases of intestinal obstruction following contusions of the abdomen, that are ascribed to injury covering the affected portion of the bowel,2 as in the following instance, reported by Assistant Surgeon Warren Webster, U. S. A.: Cask 126.—Private J. 0. Wilson, Co. F, 1st Ohio Artillery, aged 30 years, was admitted into Douglas Hospital, having received on January 22, 1862, a kick from a horse in the right hypochondriac region. There was no abrasion of the skin, and but a slight redm-ss of the part struck, with extreme tenderness, especially in the region of the liver. The patient was dull, listless, and at times unconscious; pulse full and slow, tongue furred, eyes suffused, skin hot and dry. Diaphoretics and purgatives were given. He remained in the same condition two days. No evacuation of the bowels having occurred, the purgative was repeated, which produced copious evacuations and an amelioration of all the symptoms. He slowly improved, recovered, and returned to duty on August 20, 1862. The safety of a resort to purgatives in such cases admits of question. It is more prudent to trust to rest and emollients. Ruptures of the Plood-vessels.—If examples of lesions of the larger arteries or veins, without the parenchyma of viscera, were included among the fatal cases of abdominal contusions without external wounds, they were not specified with sufficient precision to be recognized. A few such examples are found in the annals of surgery. M. Legouest's observation of a rupture of the aorta has been noted (p. 15). Velpeau3 refers to three cases of rupture of the ascending cava. Professor Gross4 cites a fatal instance of laceration of the splenic vein, recorded by Dr. Miling. 1 WOODWARD, Catalogue of the Medical Section of the United States Army Medical Museum, 4to, Washington, 1867, p. 50. 2 Asiihuiist, The Principles and Practice of Surgery, Philadelphia, 1871, p. 3o'6. 'VELPEAU, Diet, de Med., T. 1 ; one by Gkaaf, in Eph. Nat. Cur., Dec. Ill, Am. 2, p. 8G; another by BRF.SCHET (Diet, des Sci. Med., T. VIII, p. 137); a third by RiCHEKAXD (Nosographie et Therap. Chir., T. IV). VELl'EAU makes one of his rare errors by stating that ruptures of the blood- vessels are observed only in cases of crushing, and not as the result of blows. Bourguigxox cites another case of rupture of the vena cava (Bull, de la Soc. Anal., T. XIII. p. 507). A specimen of rupture of the vena cava by a blow is preserved in Guy's Hospital Museum, No. 1521", Catalogue I, p. 91. 1 GBO*-s, A System of Surgery, 5th ed., Vol. II, p. 6S7. SECT. II.1 VISCERAL INJURIES WITHOUT EXTERNAL WOUNDS. 25 There is an interesting preparation in the Museum of an aneurism of the superior mesenteric artery,1 in which the lesion of the inner and middle coats of the vessel may have been due to violence, as there is no visible atheromatous alteration. The tumor represented in the wood-cut (Fig. {)) is of the size of a small orange. It was recognized by its position and pulsation during the life of the patient, who died of another disease; but the antecedent history is, unfortunately, unrecorded. Ruptures of the Diaphragm.—Xo well-defined example of this lesion was reported, though, from the descriptions of some of the cases of crushing of the upper part of the abdomen by carriages, the probability of its existence might be surmised. There were also imperfect accounts of anomalous spasmodic affections following blows on the epigas- trium, and referred to the diaphragm, that seemed analogous to the phenomena described by Generalarzt Stromeyer, on page (329 of his JIaximen. Wounds of the diaphragm, as will be seen in the next Section, were not uncom- mon. A preparation of strangulated phrenic hernia, in which the stomach and part of the great omentum have intruded into the thoracic cavity through the oesophageal opening, is preserved in the Museum.2 It must be regretted that the facts concerning the majority of the instances of this small and obscure group of injuries of the abdominal organs without external wounds were so imperfectly re- corded. It is one of the disadvantages of collect- ing data on official forms, that the particulars of rare and anomalous cases are often omitted, while the details of familiar injuries and operations are related with laudable, yet fatiguing minuteness. Lists are appended of the severe and sometimes fatal shot contusions of the abdomen that were barely noted on the reports during the War, and these, with the brief memoranda on the preceding pages, may revive the recollections of surgeons in regard to some of these doubtful cases, and enable them to contribute toward perfecting the history of . . . „ , . FIG. 9.—Aneurism of the superior mesenteric artery. Spec injuries ot this group. 503, sect, n, a. m. m. Casks 127-13-.—The following were returned as examples of "shell contusions of the abdomen, with internal injury." They recovered from symptoms of more or less gravity, and were sent to duty at periods varying from a few weeks to several months. Their names do not appear on the Pension List: 1. Pt. D. Conklin, Co. G, 29th Connecticut, aged21 years; Chapin's Bi iff, September 29, 1864; duty December 2, 1834.—2. Pt. J. N. Burk, Co. G, 14th New York Heavy Artillery; Petersburg, July 30, 1864; duty January 23, 1835.—3. Pt. J. Bolls, Co. D, 19th Illinois, Murfreesboro', December 29, 1862, "contusion of bowels from piece of shell; haemorrhage from bowels; peritonitis;" duty March 15, 1863.—4. Pt. J. C. Reamer, Co. F, 7th Wisconsin, aged 24 years, "shot contusion of abdomen, injuring stomach; much inflammation;" Gettysburg, July 3, 18J3; duty August 3, 1863.—5. Pt. J. Miller, Co. C, 1st Maryland, aged 22 years; Petersburg, June 18, 1864; duty October 25, 1864.— 6. Ass't Surg. J. Gardiner, 24th Kentucky, "shot contusion over spleen;" Atlanta, August 6; duty September 6, 1864.—7. Pt. J. Thompson, Co. G, 148th Pennsylvania, aged 19 years; Gettysburg, July 3; duty August 11, 1863.—8. Capt. J. H. Lyons, Co. 1 Catalogue of the Medi'.al Section, Chap. If. Sec. 2, No. 503, p. 22. The specimen was contributed by Surgeon 51. Goldsmith, V. S. V. No. 228, of the Musee Dupuytren, is an aneurism of the inferior mesenteric (BliOCA, Des Anevrysmes et de leur Traitement, Paris, IS'i1), p. 44); and Mr. Cuise (A Treatise on the Structure, Diseases, and Injuries of the Blood-vessels, 1857, p. 113) found two aneurisms of the mesenteric, whether superior or inferior is not stated, among three hundred and sixty-four preparations of aneurism in the London Museums. From the catalogues, I find that Prepara- tions 114 and 219 at .St. George's, and 150445 at Guy's, are specimens of aneurisms of the superior mesenteric artery, from disease. 2 Catalogue of the Medical Section, Cbap. IV, Sec. 3, No. 522, p. 50. Case of Sergeant L. McB., 14th Veteran Reserves. 4 26 INJURIES OF THE ABDOMEN. [eiiAP. vi. A. 57th Pennsylvania, aged 36 years; Spottsylvania, May 12; duty May. 24. 1864.—9. Pt. J. Wood, Co. D. 5th V. S. Colored Troops, aged 22 years; Chapin's Farm, September 30, 1864: duty November 2, 1854.—10. Surgeon J. M. Rice, 25th Massa- chusetts, aged 34 years; Roanoke Island, February 7, 1862; duty February 21, 1*62.—11. Pt. T. Tull, Co. A, 15th West Virginia, aged 44 years; Snicker's Gap, July 18, 1864; contusion ascribed to "wind of shell in epigastrium, grave symptoms of internal injury;" reported by Surgeon Jerningham Boone, 1st Maryland P. H. B.; duty September 8, 1854.—12. Pt. II. Kimball, Co. H, 6th Pennsylvania; Fredericksburg, December 13, 1852; duty December 24, 1862. Casks 139-145.—The following, reported as injured by shot contusions of the abdomen " with injury of the internal organs." recovered, with various degrees of disability, for which they were discharged from service: 1. Pt. B. Shoop, Co. I, 1st Michigan, "contusion of liver;" Fredericksburg, December 13th; discharged December 23, 1862; not a pensioner.—2. Corp. W. F. Smith, Co. H, 26th Illinois, "contusion in epigastrium by solid spent cannon shot;" Farmington, Mississippi, May 9, 1862: discharged October 2, 1852.—3. Corp. E. Ivers, Co. E, 81st Pennsylvania, aged 35 years; Petersburg, March 31, 1865; discharged July 10, 1865.—4. Pt. T. Riley, Co. H, 143d Pennsylvania, aged 23 years; Spottsylvania, May 10th; discharged October 4, 1854.—5. Sergeant D. Payborne, Co. C, 77th New York; Wilderness, May 6th; discharged November 30, 1864.— 6. Pt. A. Hendrickson, Co. D, 29th Ohio; Chancellorsville, May 3d; discharged September 16, 1853.—7. Pt. H. Thomas, Co. K, 6th Connecticut, aged 34 years; North Anna River, May 25, 1864; discharged September 23, 1864. The following were among the instances of fatal contusions of the abdomen, reported without precise specification of the nature of the internal lesions: Cases 145-149.—1. Reported by Surgeon S. Marks, 10th Wisconsin: Sergeant H. 1). Price, Co. D, 104th Illinois, Peach Tree Creek, July 20, 1864; contusion of abdomen by cannon ball; death the same day.—2. Reported by Surgeon H. B. Fowler, 12th New Hampshire: Pt. J. E. Reese, Co. C, 10th New York Artillery, Petersburg, April 2, 1855; shell contusion of right side of abdomen; died April 3, 1865.—3. Reported by Surgeon W. 0. McDonald, U. S. V.: Pt. A. D. Snook, Co. F, 205th Penn'a, Petersburg, April 2, 1865; shell contusion in flank, tympanitis; terrible shock; died April 3, 1865.—4. Reported by Surgeon M. M. Manly, 2d U. S. Colored Cavalry: Pt, G. Nixon, Co. H, 2d U. S. Colored Cavalry, Petersburg, July 5, 1864; shell con- tusion on right umbilical region, great tension and pain in abdomen; great shock; died the same day. There are many other fatal cases reported as "shell contusions of the abdomen," in which the absence of external lesions is not especially noted. Table III. Return of Visceral Injuries without External Wounds, reported during the War. O Result. RUPTURES. ^, c E s o > § o o 3 w W M a PS ^ 41 11 1 4 1 2 3 1 5 4 31 21 1 20 10 Total..................................................................... 52 5 3 4 9 31 22 30 The most careful records of the attendant circumstances would probably not have afforded elements for the solution of the problems presented in this group of cases. It would still be difficult to trace the relations between the symptoms and the apparent alterations of texture, with any uniformity. The cases that have been adduced sufficiently exemplify the complexity of the lesions and the ambiguity of the symptoms to be con- sidered in framing a diagnosis in injuries of this group. There may be profound and persistent shock, unattended by organic injury; acute local pain or general tenderness are not conclusive proof of the existence or otherwise of visceral lesion; tympanitis and constipation cannot be accepted as evidence of textural alteration, for they may depend on concussion of the ganglionic centres; vomiting and retention of urine are common in abdominal contusions without reference to the parts struck; haemorrhage rarely occurs except from a ruptured viscus, yet, when intra-peritoneal, the syncope it induces is with difficulty distinguished from shock in the early stage, and, when discharged from the digestive or urinary canals, it is not necessarily indicative of fatal injury. But if the diagnosis and prognosis are doubtful, the treatment of these cases is comparatively plain. Absolute rest, the patient not being moved or allowed to move [sr.cr. n. VISCERAL INJURIES WITHOUT EXTERNAL WOUNDS. 27 himself, caution in the employment of restoratives and stimulants, warmth to the surface, evacuation of the bladder with a catheter if requisite, and the administration of opium, if there be much pain, are the sate expectant measures that constitute the early treatment applicable to nearly all cases. The complications must be met as they arise. Tight bandages, ice poultices,1 with internal haemostatic remedies, or general and local depletion during the hsemorrhagic period, have been employed. The utility of leeches over the seat of pain, and of subsequent counter-irritation by blisters, has been strongly advocated. In ruptures of the stomach,2 as the rule prohibiting food or drink or medication by the mouth is absolute, opium has commonly been administered by enema. Assistant Surgeon E. Bentley, U. S. A., has called attention to the utility and convenience of the hypo- dermic introduction of morphia., under such circumstances. In ruptures of any portion of -the digestive tube, the premature administration of food or drink, or purgative medicine, is extremely hazardous. For several days the patient must be literally, and, for a fortnight, nearly starved. Only toward the close of this period is it safe to venture 'upon aperients, and then only in the shape of the mildest laxative enemata. After the first few days, as much of iced milk by the mouth, and of beef-tea enemata, as may be requisite to sustain life, may be cautiously administered. A review of the records of the treatment of this class of cases suggests this repetition (which may appear superfluous to most readers) of well-known rules. Watchfulness of the state of the bladder is another golden rule applicable to all of these cases. Some operative expedients, recommended for promoting the elimination of effusions of bile, urine, feces, blood, and pus, or in the treat- ment of fistulous outlets resulting from such extravasations, will be more conveniently considered in connection with wounds of the several viscera. But little information has been acquired relative to the morbid alterations of texture that result from contusions producing visceral injury short of actual laceration. Prepara- tion 363, of the Medical Series of the Museum, exhibits a portion of the "greater curva- ture of stomach, thickened with conspicuous rugae, and coated with pseudo-membrane," from an artilleryman, who received, at Beaufort, an injury from the limber of a gun, in 1 The value of this therapeutical resource is, perhaps, inadequately appreciated. Vidal (Traite de Path. Ext., T. V, p. 83) regards it as, with the exception of phlebotomy, almost the sole available effective means at our disposition, in the parenchymatous bleedings from ruptures of the abdominal viscera. Prof. Guoss (System, I. c, Vol. II, p. 6G1) emphatically commends the application of ice under such circumstances. Mr. Bryant (Practice, already ciled, p. 403, note) adds his favorable estimate of the utility of ice poultices, and gives the following directions for making them: "Ice poultices, as suggested by Maisonneuve, appear excellent things for the local application of cold; they are made as follows: Take of linseed meal a sufficient quantity to form a layer from three-quarters to an inch thick, spread on a cloth of proper size; upon this, at iutervals of an inch or more, place lumps of ice of convenient size—of a big marble—then sprinkle them over lightly with the meal, cover with another cloth, folding in the edges to prevent the escape of the mass, and apply the thick side to the surface or wound. The exclusion of air retards the melting of the ice, and the thick layer intervening between it and the surface prevents painful or injurious contact; for injuries to the abdomen this expedient seems very applicable." 2 After the remarks on ruptures of the stomach on page 22, I inadvertently omitted the following reference to recent American cases, and to the rarity of pathological preparations of this lesion, a memorandum which may be of interest to pathologists. The following cases are reported in American periodicals: AVEIU, American Medical Times, 1860, Vol. I, p. 45: Rupture of stomach, in a boy of 14 years, by striking a clothes-line in falling from a housetop; death in eleven hours; no other viscera injured. COLLINS, Boston Medical and Surgical Journal, 866, Vol. LXXIII, p. 202: rupture of the stomach, by a fall from a tree, in a lad of 13 years ; death in less than nine hours. BUIST, -4mer. Journal of Medical Sciences, 1870, Vol. LX, N. S., p. 575: rupture of the stomach from a fall; I know of no specimen of rupture of the stomach, preserved as a pathological preparation, except No. 181726 at Guy's Hospital Museum (Cat., Vol. II, p. 27). In the Medico-Chirurgical Transactions, Vol. V, p. 93. Vol. V, p. 374, Vol. VIII, p. 228. Vol. XIII, p. 226, Vol. XIV, p. 247, and Vol. XLI, p. 11, will be found some very interesting papers by Mukciiison, CitAMi'TON, Chevalier, Wheelwright, Tkavers, Elliotson, and Weekks, on ruptures of the stomach, with many references to analogous cases. In the proceedings of the Pathological Society of London, reported in the British Medical Journal, December 3, 1870, Vol. II, p. 617, "Mr. Davy exhibited the ruptured stomach of a dog, which had been run over in the streets. There was no external injury, yet the stomach was traversed by a large rent. Mr. Arnott had no idea that these cases were rare or he would have brought some before the Society. In one case, a little boy fell from a ladder; there was no external mark, yet there was a large rupture of the stomach. At University College Hospital, a man came complaining of colicky pains. He had already been supplied with diarrhoea medicine; while there he was taken very ill and speedily died. The day before he had had a fall and hurt his side, but lie walked home and partook of a meal as well as of the physic. There was a large rent in the wall of his stomach, and its contents were lying in the peritoneal cavity. Dr. Murchison had seen as many as three in one day, the result of a railway accident, the passengers stomachs being full. Mr. Hulko had seen a case where the stomach formed part of the contents of an umbilical hernia, and in forcible attempts at reduction, a rent, four or five inches long, was made in its wall. Dr. Moxon had seen the stomach of a boy, run over by a carriage, where the vertebral column seemed to have cut the stomach like a knife." 28 INJURIES OF THE ABDOMEN. [CHAP. VI. the autumn of 1863, and suffered afterward from pain in the epigastric region, and nausea and vomiting, and died from chronic diarrhoea in the summer of 1864. Larrey, in his Memoirs and Clinique, gives a number of detached observations of adhesions, indurations, and various exudations, consequent upon visceral contusions. Dr. C. Handheld Jones (Med. Chir. Trans., Second Ser., 1855, Vol. XXXVIII, p. 213) adds to the scanty data respecting the morbid anatomy of the pancreas injured by violence, an instance of wasting of this viscus, in a man of twenty-four years, who survived, for three and a half days, a fall of forty feet. It has been stated, at the beginning of this Section, that no case was reported of sudden death ascribed to a blow upon the abdomen, without attendant organic lesion. Current opinion is adverse to this statement, and opposite assertions have been made.1 On reviewing the evidence, I find no facts to justify a modification of the statement. There have not been wanting reports of alleged traumatic effects from the wind of balls.2 But since experience, fully in accord with theory, has shown that the air displaced by large projectiles undergoes no chemical or physical modification, and that its displace- ment cannot exert any deleterious effect upon the tissues, and this has been latterly demonstrated experimentally,3 such reports4 do not appear to merit serious consideration.5 1 Dr. F. II. Hamilton (A Treatise on Military Surgery, 1865, p. 322) asserts that "A large shct, whose momentum is nearly expended, may cause instant death as it falls, or obliquely impinges upon, or rolls over the surface of the belly. We have already mentioned, in our general remarks, an example of this kind which came under our observation. In such cases death is the result of the shock, and it is not necessarily accompanied with any lesion of the viscera." Turning to the general remarks referred to, on p. 192 of the work cited, there is found, first, a purely hypothetical case ; next, the case of Private Booth, of whom it is stated " Precisely where he was hit we had no means of knowing ;" and next, two cases of injury of the head. Surely neither one of these is "an example of the kind " under consideration. Yet the author reiterates his allegation in his Principles and Practice of Surgery, 1872, p. 101. "Surgeon B. Riiett, of the Marine Hospital at Charleston, regards (Cases of Injury to the Nervous System by the Explosion of Shell, in Am. Jour. Med. Sji, N. S., 1873, Vol. LXV, p. 92) "the capability of compressed air or wind from a missile to bruise or inflict visible injury" is still a " m:>oted point." Ho adduces the case of a Confederate soldier, on St. John's Island, " with a purple, yellow, and green bruise extending from the mamma to the ilium of right side, and from the umbilicus to the dorsum,'" who was " standing, with his rifle held by the barrel at arm's length and the butt resting on the ground, when a large shot or shell passed between himself and his rifle without touching either or moving him from his position. Immediately after he observed the discoloration he was sent to the hospital for fear of internal injury." Dr. RHETT adds, justly: " The case rests upon my evidence of the injury and upon the soldier's account of the cause "! 3 By Professor Pelikan's experiments, detailed in the Comptes rendusdes Seances de VAcademie des Sciences. Compare IiEGOUEST, op. cit., p. 110. 4 Surgeon GEORGE BURR, U. S. V., has published (The New York Medical Journal, 1865, Vol. I, p. 428) observations on Cases of Injuries of the Nervous Centres from Explosion of S.iells, without Wound or Contusion, " under the impression that they will constitute an additional variety in the list of injuries to the nervous system." He narrates, apparently without any ironical intention, phenomena which almost every military surgeon has had occasion to observe in persons who, during a cannonade, though unhurt, were badly frightened. 5 In addition to the references to sources of information respecting ruptures of the several abdominal viscera, that have been given, the reader may advantageously consult the chapter on ruptures or wounds of internal organs, in A Manual of Medical Jurisprudence for India, by Norman Chevers, M. D., Calcutta, 1S70. In a country where malarial poison is almost universally prevalent, ruptures of the liver and spleen from compara- tively slight violence are not uncommon, and numerous instances are here recorded. Seventeen new examples of ruptures cf abdominal viscera are collected in an original article in the Brit, and For. Med. Chir. Rev. for 1807, Vol. XXXIX, p. 183, by Dr. F. Ooston, of Aberdeen University. Case 10 of this series, describes a rupture of the cystic duct. Dr. Lidell's important dissertation on rupture of the abdominal and pelvic viscera (Am. Jour. Med. Sci., N. S., Vol. LIII, p. 340) will again claim attention in connection with injuries of the bladder. Dr. J. Q. A. Hudson, in a paper on Injuries and Wounds of the Abdomen, read before the Meigs and Mason Academy of Medicine, November, 1871, analyzes recent observations on the subject, without adding to them. Dr. F. D. LiSNTt: records (New York Jour, of Med., 1850, N. S., Vol. V, p. 27) a rupture of the jejunum, with some interest- ing features. Assistant Surge.m Seward (Trans. Med. and Phys. Soc. of Bombay, 1857-8) reports a careful autopsy in a case of rupture of the jejunum by a blow. Mr. Rivixg ion (Lancet, 1872, Vol. II, p. 848) relates a case of ruptured jejunum, in a brewer falling into a vat, remarkable for the absence of early severe symptoms. Dr. BURNET, of Newark (Phila. Med. and Surg. Reporter, 1839, Vol. XXI, p. 239), relates a case of rupture of the liver and kidney from a blow ; no jaundice, no haematuria, no marks of violence ; collapse, with syncope, and great pain in the right hypochondrium, the only marked symptoms; death in twenty-seven hours, when it was found that there had been profuse bleeding into the peritoneal cavity. Dr. riNNELL, in the reports of the New York Pathological Society (Phila. Med. and Surg. Jour., 1856, Vol. IX, pp. 420-587), records two cases of rupture of the ileum. Dr. Hesti:u (New Orleans Med. and Surg. Jour., 1852, Vol. IV, p. 278) describes the autopsy in a case of rupture of the spleen, remarka- ble as resulting in an abscess, which discharged through a perforation of the stomach. A fatal case of laceration of the gall-bladder, by a fall, is noted by JOHN BELL, in his Discourses, and also in his Principles of Surgery, new ed., 1823, Vol. I. p. 521. In the Lancet, Medical Gazette, and Med, Times and Gazette, the following instances of visceral ruptures, without external wounds, may be found : Of the liver, from falls, four cases, in Lancet, 1828-9, Vol. II, p. 725 ; Med. Gaz., 1829, Vol. Ill, p. 191; Ibid., Vol. XLII, p. 1048; Med. T. and Gaz., 1867, Vol. I, p. 522. From passage of carriage- wheels, eight cases: Med. Gaz., 1830, Vol. V, p. 127; Ibid.. 1845, Vol. XXXV, p. 879; Med. T. and Gaz., 185L, N. S., Vol. Ill, p. 234; Ibid., 1852, Vol. IV, p. 120; Ibid., 1855. Vol. X, p. 19 ; Ibid.. 1857, Vol. XV. p. 274 ; Ibid., 18C4, Vol. II, p. 553; Ibid., 1866, Vol. II, p. 253. From blows, four cases : Lancet. 1833-4, Vol. II, p. 562; Ibid., 1844, Vol. II, p. 115; Med. T. and Gaz., 1866, Vol. I, p. 8; Ibid., 1868, Vol. I, p. 393. Of ruptures of the spleen, eleven eases: Med. Gaz., 1829, Vol. Ill, p. 591; Med. T. and Gaz.. 1861, Vol. II, p. 435; Ibid., 1862, Vol. I, p. 33; I bid., 1865, Vol. II, p. 35; Ibid', l-oo\ Vol. I, p. 350; Ibid., 1863, Vol. II, p. 253; Ibid., 1867, Vol. I, p. 522; Lancet, 1826-7, Vol. I, p. 584; Ibid., 1857, Vol. II, p. 453; Ibid., 18f>l| Vol. I. p. -,87: and a case of recovery, recorded by Dr. Hyde Salter, Ibid., 1857, Vol. II, p. 413. See also cases by Drs. "Wilson and Playfaiii| Edin. Med. Jour., 1857, Vol. II, pp. 851, 898. and 058. Of ruptures of the kidney, eleven cases, including two recoveries: Med. Gaz., 1831, Vol. VII, p. 828 ; Med. T. and Gaz., 1858. X. S.. Vol. XVI. p. C3; Ibid., 1860, Vol. I. p. 76 ; Ibid., 1866, Vol. II, p. 253: Ibid., 1867, Vol. I, p. 522 ; Lancet, \m\-l\ Vol. I, p. 588 ; Ibid., 1845, Vol. II, p. 685 ; Ibid., 1851, Vol. I, p. 600; and two recoveries, Lancet, 1845, Vol. II, p. 684 ; Ibid., 1848, Vol. I, p. 685. SECT. 111.1 PENETRATING WOUNDS. 29 Section III. PENETRATING WOUNDS OF THE ABDOMEN. In examining the injuries of the head and chest that came under surgical treatment, the lesions of the soft parts were found to largely predominate numerically over the pene- trating wounds; the cranial cavity being protected by its bony case, and the thoracic cavity, partially protected by its bony and cartilaginous walls, being further defended by the upper extremities, the breastplate, belts, buttons, shoulder-scales, often by the musket, and occasionally by books, watches, or other articles carried in the breast pocket. In injuries of the abdomen, however, the number of penetrating wounds that came under treatment equalled, if it did not exceed, the number of wounds involving the walls only; for the abdominal cavity, though protected by the vertebral column behind, and partially by the lower ribs, and the broad wings of the innominata, is covered only by the soft parts on its anterior and lateral aspects. The belly is less defended than the chest by the upper extremities; yet, in some positions, the course of weapons or projectiles directed toward the abdomen is arrested or deflected by the forearms or hands, or by what may be held in them. The belly is also less protected than the upper part of the trunk by the accoutrements—the waist-belt and belt-plate, the cartridge-box and canteen—leaving a comparatively large surface exposed. Of the relative frequency of wounds of this region, some statistical information will be offered at the close of this Chapter, together with estimates of the resulting mortality. In treating of wounds of the chest, facts were adduced to prove that their gravity was commonly appreciated inadequately. Such an argument will be unnecessary in regard to wounds of the belly, for the deplorable fatality of this class of injuries commonly furnishes the subject for the first comment made on- them by systematic authors. It is said that Mr. Abernethy used quaintly to remark, that Nature would have nothing to do with these cases; but stood by and shook her head, and left the patient to his hopeless fate. But the true lovers of Nature, among whom,.it is to be hoped, all good surgeons are numbered, cannot permit any aspersion of their mistress, and will point to many beautiful exemplifications of her almost divine power, even in wounds of the abdomen, in the prevention of extravasation and in the repair of injuries by the effusion of lymph, in eliminating foreign bodies by artificial outlets, and in the process of hsemostasis. It is but too true, however, that these examples are the rare exceptions,1 and that, in imitating them or in aiding them, art can do but little.2 Apparently a large 1 JOHN BELL (The Principles of Surgery, London, 1826, Charles Bell's ed., Vol. I, p. 480) observes: " Thence it comes to pass, that in one short sentence we announce the general principles of such wounds—in one short and general prognostic we declare them to be fatal; we thus bestow but a few moments on their general character, while we spend hours in marking their lesser varieties, and in recording all the accidents and chance cures, collecting evidence about hair-breadth escapes, till wo almost lose sight of the general principle which proves such wounds to be mortal. This confusion must be peculiarly felt by a diligent student, who, the more he reads, the more he wonders, finds anuses at the groin, and miraculous recoveries in every book, and reads of cures, till he forgets that there are dangers." 2 Notwithstanding the most diligent and intelligent endeavors; for the operations devised by PHYSICK, Dui'UYTREN, and Prof. GROSS for the relief of artificial anus, and the investigations concerning enteroraphy by TliAVEits, JOBERT, and Dr. GROSS, if not of frequent successful applicability, are at least conceived in the true philosophic spirit of the inductive method: "Nou est fingendum, nee excogitendum, sed inveniendum quid Natura faciat aut ferat."—Bacon, De dignitate et augmentis Scienliarum. 30 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. number of recoveries are recorded in this Section; yet, relatively, the number is small, even in comparison with the fatal cases that appear on the hospital records, and insig- nificant, when this category is augmented by the multitude of deaths on the field.1 Many of the recoveries will be found, too, to be cases in which the peritoneal cavity was not. in reality, implicated, for there are considerable portions of the liver, spleen, kidneys, and colon, over which the serous investment is wanting. Of the obscurities of diagnosis, there will be abundant illustration in treating of special wounds. The surgeon, in estimating the prob- abilities, mentally recalls the position of the several viscera, A diagram (Fig. 10) may re- fresh the memory on these points.2 Since the War, outline figures have been furnished to med- ical officers, on which to map out areas of dulness on percussion, or to indicate entrance and exit wounds, and have proved advantageous in secur- ing precision and in economizing description. Wounds penetrating the abdominal cavity are separated, as elsewhere, into the groups of punc- tured, incised, lacerated, and contused wounds, and these varieties are further divided, by classi- cal writers, into four subdivisions, viz: 1. Simple penetration of the peritoneal cavity without in- jury or protrusion of the viscera. 2. Those with protrusion of the uninjured viscera. 3. Those with injury of the viscera without protrusion. 4. Those with protrusion of the wounded viscera, A large proportion of the shot wounds, with which we are mainly concerned, are comprised in the third subdivision. The few examples of cases belonging to the first two groups may be considered together; those comprised in the two latter, will be arranged under the heads of the different viscera that may be involved, and, when several viscera are implicated', will be grouped with that viscus of which the wounds are either the rarest or the most dangerous. Some recent observations3 indicate that, in the shock attendant on wounds of the belly that are soon to terminate fatally, there is a great and constant diminution in the animal temperature, as considerable as that which, when occurring in the course of some internal diseases, uniformly presages dissolution. Should these observations be corrob- orated and confirmed, the thermometric test will afford a more accurate basis for prognosis than any we now possess. 1 ()f the mortality of shot wounds of the abdomen as observed in the British Army in the Crimea, Dr. MATTHEW remarked: " Where penetration of the abdominal cavity by gunshot injury was considered to be beyond doubt, death was the rule, recovery the rare exception, only nine patients (including both men and officers) having survived, out of one hundred and twenty, where this was believed to have taken place, and even of this small number some of the cases were not quite unequivocal."—Op. cit., Vol. II, p. 328. - The obvious inaccuracies in the diagram, which is altered from one given by Mr. Thomas BRYANT {Practice, already cited, p. 308), are due to my failure to convey to the draughtsman a clear understanding of the alterations designed, and the want of time to prepare another cut. 'Consult UEMARQUAY'S paper de la Chaleur animale dans les Maladies chirurgicales, in the Noureau Dictionnaire de Medecine et de Chirurgie pratiques, I-'m. T. VI, p. 822, and Mr. Clark's comments thereon in his Lectures (1. r.. p. 288). The latter author has a chapter on the subject ia his Outlines of Surgery and Surgical Pathology, London, Churchill, 1872. which I have not yet seen. FIG. 10.—Diagram of some of the relations of the abdominal viscera. L L—Space occupied by liver in different positions and movements of diaphragm, A"—Xiphoid Cartilage. C—Colon. A' K—Kidneys. P—Pancreas. S—Spleen. [After Bryant.] SECT. III.] PENETRATIONS WITHOUT VISCERAL INJURY. 31 Simple Penetrations and Perforations without Injury of the Viscera.—Malgaigne1 denied the existence of this group of injuries, maintaining that the repletion of the abdominal cavity by the contained organs precluded the possibility of the intrusion of a foreign body without the infliction of some visceral lesion. This theoretical objection suggests the belief that such injuries are at least less frequent than is asserted by some writers. The cases of recovery, after penetrating wounds of the cavity, are not conclusive evidence of the absence of visceral lesions; for it is demonstrable that many punctures of the epiploon or of the intestines are followed by recovery. But autopsies and experiments on the cadaver establish, beyond doubt, the possibility of deep penetration, or even of transfixion of the abdominal cavity without visceral lesion, the foreign body gliding between the smooth and movable organs. Guthrie justly observes2 that it is easy to conceive of a blunt instrument, like the small end of a ramrod, being passed between the loose viscera of the abdomen without wounding any of them, but more difficult to understand how pointed weapons or ball should do so. Yet such exceptional cases are occasionally observed. Surgeon B. A. Clements, U. S. A., has recorded3 a case of bayonet wound through the abdomen in which the viscera apparently escaped injury, though frequent micturition and highly colored urine caused anxiety lest there might be lesion of the kidney. After a slight peritonitis, the man rapidly recovered. Surgeon B. J. D. Irwin, U. S. A., has related4 a still more remarkable example of a bayonet transfixion through the abdomen, without serious symptoms or results. Nine instances of bayonet wounds penetrating the peritoneal cavity without lesion of the viscera appear in the reports of the War. All but two were attended by traumatic peritonitis; but six had a favorable termination. If the diagnoses were exact in all of these cases, the proportion of recoveries would be less surprising than the number of deaths. If the wounds were really simple, unattended by visceral lesion, they should heal almost as readily as the punctures by a trocar in ascites:5 Case 150.—Private E. Flyiin, Co. F, 61st Illinois, was admitted into the Post Hospital at St. Louis, .October 18, 1864, from quarter?, with a bayonet stab penetrating into the abdominal cavity. The wound was situated to the right of the linea alba, about two inches below the navel. Cold-water dressings were applied and stimulants and anodynes were given. He recovered, and was returned to duty on March 14, 1885. Surgeon J. K. Rogers, U. S. V., reported the case. Case 151.—Private J. F. Morehead, Co. F, 130th Indiana, aged 33 years, was admitted into Clay Hospital, Louisville, January 21, 1835, with a bayonet wound penetrating the abdominal cavity, received at Louisville on the same day. On February 14th, the patient was transferred to the hospital at Indianapolis, whence he was returned to duty on March 26. 1835. Surgeon Francis Greene, U. S. V., reported the case. Case 152.—Sergeant J. O'Donovan, Co. F, 20th Massachusetts, aged 27 years, was admitted into Douglas Hospital, Washington, July 18, 1885, from the " Soldiers' Rest," with a bayonet stab in the epigastric region, received the day previously while endeavoring to quell a mutiny. The wound penetrated the peritoneal cavity and was followed by acute peritonitis, which 1 Malgaigne, Traiti d'Anatomic Chirurgicale, 26me 6d., 1857, T. II, p. 325. 2 GUTHRIE, Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands, from the Battle of Rnlica, in 1808, to that of Waterloo, in 1815, sixth edition, revised to 1855, p. 546. Examples of the form of injury referred to may be found in PARE, (Euvres Computes, ed. Malgaigne, T. II, p. 106; WISEMAN, Severall Chirurgicall Treatises, London, 1676, p. 373; UavaTON, Chirurgie d'Armee, Paris, 1748, p. 237; LA Motte, Traite Complet de Chirurgie, Paris, 1732, T. Ill, p. 125; Muys, Praxis Medico-chirurgica Rationalis. Leiden, 1682. 'Clements, Notes on Surgical Cases, in Am. Jour, of Med. Sci., N. S., 1861, Vol. XLII, p. 37: Musician, Co. E, 7th Infantry, aged 32 years. Bayonet, entered at extremity of left twelfth rib, and emerged through the right hypochondrium, two and one-half inches from the linea alba. 4Irwix, A Case of Severe Punctured Wound—Body transfixed by a Bayonet—Recovery, in Am. Med. Times, 1862, Vol. IV, p. 273: An athletic Apache Indian, 25 years old, a hostage, attempting to escape from a guard of United States troops, in a pass of the Chirricahui mountains, in February, 18G1, was knocked down by a sentinel, and "held pinned to the earth by a bayonet, which transfixed his body. The weapon entered the abdomen in the anterior upper angle of the left hypochondriac region, passed directly backward and downward, and made its exit a little below the posterior corresponding space, about two inches from the vertebral column. The victim was held in that position for some moments. * * * Momentary weak- ness was all that appeared preternatural in him. The amount of haemorrhage was very slight. He was tied and placed on his back ; kept strictly quiet, and the cold-water dressing applied. * * * Not a bad symptom appeared, and, on the fourth day, the wounds were perfectly healed by adhesive inflammation. * * * On the ninth day he walked to the place of execution," where the body was allowed to remain suspended in terrorem, so that an opportunity for post-mortem inspection was not afforded. 6Follix, Plaies de I'Abdomen, in Dictionnaire Encyclopedique des Sciences McUcahs. Paris, 1869, p. 148. ■r\2 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. Vi. was treated l>v opiates and other remedies. He recovered, and was discharged from service. The Examining Board for pensions at Boston reported, on February 21, 1870, that there was a small triangular-shaped cicatrix on the linea alba, five inches above the umbilicus. The applicant had recently an attack of apoplexy, and was still hemiplegia The disability was total, yet due to other causes than the wound. The applicant's claim for pension was rejected. _ Casf 153-Private J. O'Brien, Co. B, 46th Pennsylvania, aged 23 years, accidentally received a bayonet thrust m the abdomen, penetrating the peritoneal cavity, at Chattanooga, March 1, 1835. He was treated in hospitals at Chattanooga, Nashville, and Louisville, and ultimately recovered, and was returned to duty on May 19, 18fc>. Surgeon J. H. Phillips, U. S. V., reports the case. . , .. .T , ,,„ . , . Case 154,-Reportod by Surgeon H. Z. Gill, U. S. V.: Pt. Thomas Neil, Co. B, 17th New York: Bayonet stab in abdomen, penetrating the peritoneal cavity, but not injuring the intestines;" Lovejoy Station, Georgia, September 2, 18o4. Recovered, and does not appear on Pension Roll.1 The sixth is probably the case referred to by Assistant Surgeon B. Howard,2 U. S. A., as the first instance in which he successfully employed the occlusive dressing he described as a method, to be termed ''hermetically sealing:" Case i:,r,.—Private--- Camp, 18th United States Infantry, received a penetrating bayonet wound of the abdomen in November, 1832. The edges of the wound were approximated by metallic sutures, the surface was then dried and covered with a few shreds of charpie arranged crosswise, after the manner of warp and woof, and, upon this, a few drops of collodion were poured. The dressing remained intact until the wound was entirely healed, a period of a few days only. The patient recovered without symptoms of peritonitis. The three following cases terminated fatally from peritonitis, or from haemorrhage with shock: Case 156.—Private C. Hunt, Co. D, 1st Kentucky, aged 13 years, was admitted to Hospital No. 8, Nashville, June 1, H !4. with a bayonet wound of the abdominal cavity, inflicted by a sentinel on the previous evening. Simple dressings were applied. He died, probably from the effects of hemorrhage and shock, on June 10, 1834. No important vessel or viscus was implicated. Surgeon R. R. Taylor, U. S. V., reported the case. Cask ir>7.—Private R. Dow, Co. D, 78th U. S. Colored Troops, was admitted to the Corps d'Afrique Hospital, New Orleans, April 27, 1831, with a penetrating bayonet wound of the abdomen, received at the storming of the works at Port Hudson'. Simple dressings were applied, and the symptoms of acute peritonitis that had supervened were controlled by opiates, emollient fomentations, restricted diet, etc. The patient died on May 23, 1834. Surgeon F. E. Piquette, 83th U. S. Colored Troops, reports that the results of traumatic inflammation were the only internal lesions to be observed. Cash l.-;*.— Private J. Holderman, Co. E, 93th Pennsylvania, aged 33 years, was admitted to Stone Hospital, Washing- ton, August 20, 1834, from Forrest Hall Prison, Georgetown, where he had been confined on account of desertion. In an affray with the guards he had received bayonet wounds of the head, arms, and abdomen; he was probably laboring under delirium tremens when injured. The intestines protruded; being uninjured they were reduced, and the wound was closed with sutures and adhesive straps, and opiates were given in full and frequent doses. Death ensued August 24, 1834, from acute peritonitis. Assistant Surgeon P. Glennan, U. S V., reported the case. The following example of a sword thrust, penetrating the abdominal cavity, and followed by protrusion, but not wounding the viscera, was recorded:3 Case 159.—Private Scott, 31st New York, was stabbed with a small sword, November 15, 1831. The point of the weapon entered to the right of the umbilicus. The wound was closed with adhesive plaster and a compress and bandage, and the patient was placed on his back, with his body flexed. During the night a knuckle of intestine protruded, and became strangulated. Surgeon F. H. Hamilton enlarged the wound, returned the gut, which was dark brown, and secured the wound with sutures Quiet was enjoined, and, under the influence of opium, the pain and vomiting gradually ceased. Died November 19, 1831. The autopsy revealed no lesion of the intestines, nor internal hasmorrhage. In most of the foregoing examples, there was no visceral protrusion. The next two cases were accompanied by protrusion of the omentum, and exemplify the treatment of this complication by ligature and by excision: Case 160.—Private J. H. Westfall, Co. F, 11th Illinois Cavalry, aged 19 years, received an incised wound of the abdomen, in a brawl at Vicksburg, December 1, 1834. On the 6th he was admitted into Hospital No. 2, Vicksburg; the omentum was protruding from the wound. A ligature was placed around the protrusion, the wound was poulticed, and one- 1 In the report in Circular 3, S. G. O., 1871, pp. 101-2, Aeting Assistant Surgeons J. T. King and C W. YOUNG record (Cases 337, 338) instances of punctured wounds of the peritoneal cavity without visceral injury, promptly followed by recovery: and Assistant Surgeon J. YV. WlLLIAJIS, U. S. A., describes (Case 339) an instance of bayonet-stab in the left hypochondrium, in which the profuse bleeding suggested the probability of a lesion of the spleen ; but the patient rapidly recovered without suffering from peritonitis, or from ill consequences from the considerable extravasation of blood within the cavity. *H0WAKD, American Medcial Times, Vol. VII, p. 157. In this article, and in his letter in the First Surgical Volume, p. 497, Dr. Howard rofers to the case of a private of the 18th Infantry, and gives the date 18G1. In a special report (File A, 145, Div. S. II., S. G. O.) he gives the date Novem- ber. 18.iC, as stated in the abstract, and the man's name. No other information appears on the medical records of the 18th Infantry for I80I-GJ, nor is the man pensioned. 3 HAMILTON, A Treatise on Military Surgery and Hygiene, 1865, p. 377 six'i'. in.] PKNKT11ATI0NS WITHOUT VISCERAL INJURY. :« tliird of a grain of morphia was given. Poultices of linseed meal were continued until the 13th, when adhesive plaster dressings were substituted. The protrusion sloughed off, and the wound healed under simple dressings. The man was returned to duty January 13, lSii.">. Surgeon Robert F. Stratton, 11th Illinois Cavalry, reported the case. Westfall is not a pensioner. Case 1(51.—Squire McCavin, a freedman, aged 17 years, received a punctured wound of the abdomen with a knife, in an affray at Vicksburg, April 17, I860. He was admitted on the same day to the hospital for freedmen. The wound was about three inches to the left of the umbilicus, and parallel with it, the epiploon protruding about three inches; the bowels were not injured. The protrusion was cut off and simple dressings applied. The patient recovered, and was returned to duty May o, 18i->. Surgeon T. J. Wright, G4th U. S. Colored Troops, reports the case. Another case, that of Private Blaney, 21st Pennsylvania, a recovery alter protrusion of the unwounded omentum, was fully reported, with instructive comments, by Dr. Walter F. Atlee,1 who follows Robert and M. H. Larrey in advising that protruded omentum should be let alone, instead of the rule laid down by Boyer and advocated by the majority-of surgeons, that when healthy and intact it should be returned. This interesting ques- tion of the proper management of protrusions of the omentum and intestines may be deferred until examples of hernia of wounded viscera shall have been adduced. An instance in which the peritoneal cavity would appear to have been transfixed by an arrow, is recorded by Surgeon C. E. Goddard,2-U. S. A. The barbed, iron-headed arrow, twenty-six inches in length, entered three inches to the right of the spine of the fifth lumbar vertebra and emerged two inches to the right of the ensiform cartilage. Slight internal haemorrhage and circumscribed peritonitis ensued; but the patient recovered without other ill consequences. The arrow was sent to the Museum, and is represented in the wood-cut (Fig. 11). One case is reported in which a ramrod3 is supposed to have transfixed the abdominal cavity without injury to the viscera:4 Case 162.—Private Henry Manypenny, Co. D, 70th New York, was wounded at Wapping, July 23, 1853, and admitted to the 2d division hospital of the Third Corps. Surgeon C. K. Irvviue, 72d New York Volunteers, reports that a ramrod perforated the abdomen through the left groin. The symptoms were not extremely grave, and the patient was sent to Mount Pleasant Hospital on July 30th. The wound of emergence was in the left lumbar region. The diagnosis is recorded with brevity rather than elegance: "ramrod driven plumb through the guts." There was no serious peritonitis or other evidence of visceral lesion, and the man was returned to duty, cured, on September 23, 1863, as reported by Assistant Surgeon (.'. A. MeCall, U. S. A., and does not appear on the Pension Roll. Many of the alleged examples of transfixion or impalement are found on critical examination to be wonderful only in name, the intruding body gliding upon aponeuroses or dissecting up loose connective tissue, without injuring the peritoneal cavity. Thus, Dr. Maury5 gives a figure to show that a case described under 'Atlee (W. F), Case of Wound of tlie Abdominal Walls, with protruded Omentum, in Am. Jour. Med. Sci., N. S., Vol. XLIII, p. 89, S. In Circular No. 3, S. (I. O., 187], Assistant Surgeon E. A. KOEltl'Eit records (Case 31fl, p. 95) a case of an incised wound, with protrusion of unwounded intestines and of omentum. The viscera were replaced, the wound sewed up, opium administered, and ice-poultices applied to the abdomen. Assistant Surgeon P. J. A. CLEAIU' relates (Ibid., Case 317) a similar successful case. Acting Assistant Surgeon F. BARNES describes (Ibid , Case "18) a recovery after replacement of an immense protusion of nearly the entire intestinal canal. 2GODDARD, In Circular No. 3, S. G. O., 1871, p. 153, Case 473. 3Henxen* (op. cit., 2d ed., p. 402) records the recovery of a soldier shot through the abdomen by a ramrod at Badajos, in 1812. C.uthuie (Com- mentaries, Cth ed., p. 545) gives the oft-quoted details : Case of Private Carpenter. 43d regiment. See Case 13, in Gutiuui:, Wounds and Injuries of the Abdomen, 1847, p. 12. •Bessems (Annal. de la Soc. de Med. d'Anvers, Janv., 1815) records the case of a person transfixed by an iron spindle, which entered through the left flank and emerged to the right of the navel, without injuring the viscera or causing peculiar symptoms. Complete recovery followed in twenty days. Dr. F. H. Hamilton, of New York (Buffalo Meet. Jour., January, 1859, and Treat, on Mil. Surg., p. 333), has reported, from tlie practice of Dr. Tliroop, of Luzerne, Pennsjdvania, an account of a perforation of tlie belly by an iron rod half an inch in breadth, which entered the right inguinal region, and emerged two inches from the spine of the last dorsal vertebra, and was supposed to have traversed the abdominal cavity. But a few drops of blood were lost, only a slight stingiajf sensation followed the withdrawal of the rod, and the patient, a harness-maker, aged 25 years, was sitting up and playing the violin on the eighth day. Dr. C. Bell, of Concord, relates (Boston Med. and Surg Jour., 1851, Vol LIII, p. 509) an unequivocal instance of pene- tration of the abdomen by the sharp point of a joist, on which a man of 47 years fell, from a scaffolding in a barn, a height of fifteen feet. After slight localized peritonitis, the patient recovered. s TOWXSEND, Hospital Reports, Clinic, of P. P. Maukv, M. I>., in Phila. Med. and Surg. Reporter, 1870, Vol. XXII, p. 273. Fig. 11.—Kiowa arrow, the shaft divided in order to witlidrawthe barb- ed and feathered extremities from a man's body. Spec. 5(!43. One-fourth size of nature. ;U PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. tlie formidable title of "a tamping iron driven through the side," was, in reality, only a superficial flesh wound of the left hypochondrium.1 Protrusion of uninjured omentum or loops of small intestine occurred in punctured wounds of the abdomen, and were not infrequent in incised wounds. These injuries, rarely received in battle, were, unhappily, not very uncommon in brawls and affrays, and therefore were oftener inflicted by knives and dirks than by more soldierly weapons. The steel offensive weapons generally used in the armies during the "War are rep- resented in the wood-cuts (Figs. 12, 13, 14, 15) on a scale of one- tenth. Of penetrations or perforations of the abdomen by shot, without injury of the viscera, many alleged examples were reported, not less than nineteen being specially recorded under 'this head. Some of these were, undoubtedly, extra-peritoneal perforations in the iliac fossa; others might be suspected to.be simply flesh wounds in the flank. No case occurred that resembled Hennen's famous Case LXIV, of recovery from a wound from a grape-shot passing through the abdomen; but there were incon- testable instances of recoveries after musket balls had either * perforated or fairly lodged within the peritoneal cavity. Of the perforations through the iliac fossa with unequivocal penetration of the peritoneal cavity, the case of Major Power affords a good example, being attended by that rare complication of shot wounds, a protrusion of the intestines: Cask 163.—Lieutenant John Power, adjutant 16th U. S. Infantry, was struck, at the hattle of Murfreesboro', January 1, 1853, by a conoidal musket ball, which entered a little in front of the anterior superior spinous process of the left ilium, and passing downward and fig. 13.—Swords of forward toward the symphisis pubis, laying open the abdominal cavity, making an oblique J^gg^d officers" C°m Cavalry sabre! canal, two inches long, through the muscular walls. Surgeon John M. Todd, 65th Ohio, who records the case, could learn little of the immediate symptoms produced by the wound. He states that the officer, who was a large, muscular man, was brought from the field about twelve hours after the reception of the wound, and that through the long ragged wound a knuckle of the ileum, about two and one half inches long, protruded. The bowel was apparently uninjured, and, being properly cleansed with tepid water, it was readily reduced. The external wound was then closed by two points of interrupted suture, which were supported by adhesive strips, over which a compress moistened with cold water was laid; strict quietude was enjoined in the recumbent position. After twenty-four hours, violent inflam- matory action, of which the wound and its immediate surroundings was the focus, set in. The succeed- ing twenty-four hours witnessed the inflammatory action in its acme. It then involved the anterior and lateral surfaces of both thighs, and the body as high up as the umbilicus. The integument and subjacent connective tissues of the genitals participated in the inflammation and were enormously swollen. Thus matters continued for five days. [The report is silent as to the measures employed to combat the local inflammation, which appears to have been of an erysipelatous nature.] At the expiration of this time, however, hectic supervened, with rapid emaciation, and every indication foreboded evil. Supporting remedies, such as quinia, with beef tea and wine, were now liberally employed. On the evening of the seventh day from the inception of the inflammation, an abscess of the scrotum and adjacent parts, pointing at the upper posterior part of the scrotum, opened spontaneously and discharged copiously a very offensive sanie?. After this there was considerable sloughing of the loose cellular tissue. In the midst of the one't of" t*he purulent and sloughed matter the instrument of all the mischief, a conical leaden bullet, was discharged. Springfield After this the discharge gradually subsided, the entrance wound closed kindly by granulation, the sinus j'IG. 15, in the scrotum closed by the same process, with slight apparent loss of tissue. Appetite returned and —Lance. fhe patient rapidly recuperated, and in fifteen days from the date of his admission to the field hospital he was sufficiently ponvalescent to undertake a long journey to Nashville in an ambulance wagon, with every prospect of a speedy and entire recovery, i'here was no functional disturbance of the digestive tube or urinary organs. Lieutenant Power regained his u 1 BOVEH (Traite des Mai. Chir., 5eme 6d., T. VI, p. 10) justly observes: " Une epeo pent traverser de part en part l'abdomcn, sans iutSresser la peritnine. fpionpi en ne eonsiderant <|iio la position des deux orilircs, la penetration paruisso evidente." SECT. III. 1 PENETRATIONS WITHOUT VISCERAL INJURY. 35 accustomed vigorous health and returned to his regiment for duty. He was hrevetted major for gallantry; hut received liis lineal promotion as captain in 18!>5 only. He resigned from the army in September, 1*139. He has not applied for a pension. In some cases, the diagnosis appears to have been based upon the apparent direction of the ball and the negative character of the subsequent symptoms, no positive evidence being adduced in support of the assertion that penetration existed, as in the following: Casio 104.—Private G. B. Phelps, Co. F, Kith Connecticut, aged 2*l:.' PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. omentum and mesentery, but avoiding the hollow viscera, are very properly cited by writers on this subject as worthy of meditation by all military surgeons. There were a few -instances in which the viscera appear to have primarily escaped injury, yet finally, by ulcerative absorption—either the products of inflammation, or the missile, or some foreign substance carried in—gained admission to the digestive canal and passed away by iIn- natural passages. CAS1: KiS.-Sergeant II. T. Angel, aged 23 years, was wounded at Petersburg, October 28, lM-l, by a conoidal musket ball, which entered about three inches to the left of "and a little above the umbilicus. On November 2d, he was admitted into tlie 2d division hospital, Alexandria. A small mass, supposed to consist of omentum, protruded from the wound. The patient complained of no pain, and seemed quite comfortable except some slight oppression. His tongue was coated. Anodynes were given with a milk diet, and stimulants and tonics were employed to some extent. On November 7th, a haemorrhage took place from the rectum, amounting to about two pints, and again, on the 9th, the same quantity of blood was lost. Opium and acetate of lead seemed to check the bleeding, although he passed small quantities of blood once or twice afterward with his faeces. On the 7th, one of his feet became swollen and so remained. Pulse feeble, and ranging from 96 to 120. By November 12th, his appetite had returned, and there seemed to be an improvement in all his symptoms. He continued to improve until the 21st, when he had a chill; from this time he had one or two chills daily, with intense febrile reaction. On the 23d, he complained of loss of appetife. and weakness; but he was not troubled with pain until the afternoon of the 25th, when his breathing became quite short and more difficult, and there was pain, increased on pressure, in the abdomen. This condition continued until death, which occurred on the morning of November 26, 1S64. At the autopsy, the great omentum was found to be inflamed, thickened, and contracted in surface; there was no fluid in the peritoneal cavity. The surface of the parietal peritoneum was dark and inflamed, and the small intestines were adherent to it by numerous threads of organized fibrin. The missile had penetrated the abdominal cavity, passed through the mesentery, and between the intestines without perforating any of them, and had fractured and lodged in thc-body of the fourth lumbar vertebra, on the left of the aorta. A portion of the ileum, about two feet from the ileo-csecal valve, had become adherent to the peritoneum around the wound in the vertebra, and the intestine, at that spot, had ulcerated through, so that the discharges from the wound were poured into the intestine and thus carried off. The bleeding from the rectum must have entered the intestine through this ulceration, its source being very likely a lumbar artery. The small intes- tines were adherent to each other, and the tissue of their coats softened so that they tore in several places when handled. Acting Assistant Surgeon Thomas Bowen reported the case. An abstract is given, on page 584 of the First Surgical Volume, of the case of Private Thomas B. B-------, who was wounded at Petersburg, March 25, 1865, by a ball, which lodged over the transverse colon. He suffered from traumatic peritonitis of moderate intensity; but there was no indication of penetration of the bowel until April 29th, when, after an attack of tormina with'tenesmus, the ball (Fig. 17) was passed during defecation. In this case, it is quite possible that there was no primary lesion of the gut. and that the missile made its way into the intestinal canal by ulcerative absorption. The printed history closed with the patient's recovery, and discharge from the service on Sep- tember 22, 1865. Since then it has been learned that, in December, 1872, B-------was pensioned. His application for pension was accompanied by his photograph, in which the cicatrix of his wound was well shown. The protograph is carefullv copied in the accompanying wood-cut (Fig. 18). Medical Inspector F. IT. Hamilton, U. S. A., has recorded1 a somewhat analogous case, with a less fortunate result, the missile being eliminated through an abscess into th<> Via. 17.—Conical mus- ket ball voided at stool. Sjjix. 1.30!). Fig. 18.—Cicatrix from a wound made by a ball (Fig. 17) which lodged against the transverse colon. [From a photo- graph taken seven years after the inj tiry. ] tery, etc., and perhaps gone quite through the body; yet it is to be observed, that wherever there is a wound, and whatever solid viscus may be pene trated, the surface in contact, surrounding every orifice, will unite by the adhesive inflammation, so as to exclude entirely the general cavity, by which means there is one continued canal wherever the ball or instrument has passed; or if any extraneous body should have been carried in, such as clothes, etc.. they will also be included in these adhesions, and both these and the slough will be conducted to the external surface by either orifice.'' 1 HAMILTON I .!•'. H). A Treatise on Military Surgery and Hygiene, p. 35 _iuille( lying loose in the canal, i—Size and shape of bullet. [After from a rod of lead, according to the custom of the Asiatics.'' Cnrsisxs.] 38 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. however, an instance of a ball traversing the abdominal ?avity without injuring the viscera, and remaining, for seven years, encysted in the mesentery probably, and then, becoming displaced, causing the formation of a fibrous band, which became the cause of strangula- tion, the missile, meanwhile, entering the intestinal tube by ulceration. This very . remarkable case is recorded by Dr. William John Rundle, of Portsmouth, England. There is an interesting group of penetrating shot wounds of the abdomen, in which the missile, entering anteriorly or laterally, lodges in the iliac or psoas muscles. Nothing can be better than John Bell's description of these wounds.1 Most of them result, eventually, in paralysis or in hectic. When it is practicable to discover the track of the ball, it is generally found to have traversed the great intestine or the extra-peritoneal soft tissues in the iliac fossa; in rare instances, it may pass harmlessly between the c^ils of the small intestines. Possibly this was the course of the ball, in the following case, which is interesting though defective in many important details. The removal of a ball from its lodgement in front of the transverse process of a dorsal vertebra is a very difficult surgical achievement, and it is a pity that the reporter has not given a more.circumstantial account of the steps by which he accomplished it: Case 170.—Private Jacob White, Co. G, 13th New Jersey, aged 54 years, was wounded at Chancellorsville, May 3,1863. The wound was dressed at the field hospital, and, on the 7th, the patient was transferred to Washington and admitted to Carver Hospital. Assistant Surgeon E. F. Bates, U. S. V., who reports the case, states that " a mini6 ball entered two and a half inches above the anterior superior spinous process of the left ilium, passed through the cavity of the abdomen, and embedded itself in the psoas muscle to the left side of the last dorsal vertebra. The wound of entrance was of more than ordinarily large size, so that no difficulty was experienced in introducing the finger directly into the cavity of the abdomen, nor was inordinate pain suffered from the attempt." [Here the reporter fails to specify the results of this exploration, and leaves us in ignorance whether the finger came in contact with the small or large intestines or with any viscus, an unfortunate omission. He continues as follows:] " During the ensuing two months, pains of a dull character were constantly experienced through the whole lumbar region. It was not, however, until July 11,1833, that the locality of the ball was approximately diagnosed. At that time, a slight swelling appeared opposite the last dorsal vertebra. The patient was unable to sleep soundly at night, as before, and suffered uneasiness from the fact of being constantly bathed in perspiration. On July 20th, he was placed upon the table, and I extracted the ball from its position before the transverse process of the vertebra. Great relief was at once experienced ; in the course of an hour the patient walked well and easily. He was allowed full diet, with beef-steak, custard, and a half-pint or pint of sherry wine dailv. On August 17th, he was examined and recommended for sixty days' furlough ; the opening by which the ball was extracted had entirely closed, there being a slight discharge from the wound of entrance. It is probable that the transverse process of the vertebra was slightly injured; very minute osseous particles had, from time to time, escaped with the pus." He was readmitted from furlough on October 19th, and, on November 12th, transferred to hospital at Newark, New Jersey, whence he was returned to duty February 24, 1864, and, on January 2, 1835, he was discharged from service and pensioned. Though " unable to bear severe labor," he was on the list in September, 1872. Ravaton pretended to believe that it was possible to- discriminate simple penetrating wounds of the abdomen by the rational symptoms alone,2 and gravely formulated the signs of shot wounds interesting only the epiploon. In treating of visceral protrusions in abdominal wounds, and of the treatment of escaped omentum and intestine, there will be. occasion to exemplify, by numerous instances, that the gravity of simple divisions of the parietal peritoneum, and the danger from contact of the air with parts of the viscera, were formerly exaggerated. Evidence does not justify, 1 Cell (Discourses on Wounds, etc., Part II, p. 63) says: " Here also the patient is peculiarly exposed to wasting suppurations and to still greater dangers The ball, if it have entered near the navel, or upon the middle line of the belly, will stick in the lumbar vertebra, and will cause paralysis of the bladder and lower extremities, soon followed by death. If it have passed obliquely through the abdomen, or to one side of the middle line, it will lodge in the thick flesh of the iliac, or psoas muscle; and the patient, after having passed through the first dangers, feels little more than a weight and weariness of the loins ; but when he raises himself to sit up in the bed, the weariness is converted into pain. Sometimes the ball makes a bed for itself, and lies harmless in the loins ;—sometimes also, if the shot has entered near the pubis, by passing over the thigh, and has gone obliquely upward, there is a frequent draining cf matter, and a small fistulous sore; but most frequently of all, the outward wound closes, the patient is never relieved from a dull and heavy pain, never recovers the free use of his limbs, nor is able to support his body erect, but wastes under a slow hectic fever ; and when he dies, there is found a great abscess in the loins." -ItAVATON (Chirurgie d' A rmee, 17CS, p. i'28) observes: "Les coups de feu qui interessent l'epiploon, sont annonces par une douleur vague, tiraille- nient d'estomach. gonllement qui oeeupe tout 1'abdomen, envies de voniir plus ou moins frequentes, et qui augmentent a proportion de l'6tendue de la plaie ct de sa proxiinite de l'c?tomach. hoquot plus ou moins precipite." PENETRATIONS WITHOUT VISCERAL INJURY. 39 however, a modification of the old opinions regarding the fatality of deep wounds. It is true that a certain number of bayonet and sword thrusts through the body, and of instances of transfixion and of impalement, have been recorded in this Section, and that it is necessary to admit the possibility of the passage of balls or blunt weapons through the abdominal cavity without injury of the solid viscera or intestinal canal, since this has been demonstrated by dissection.1 Yet such exceptions are really very rare. Professor Gross formulates the rule justly in saying8 "the viscera seldom entirely escape in any case." Guthrie3 and M. Legouest4 remark on the difficulty of conceiving of the passage of sharp-pointed instruments among the viscera, without lesion, however smooth and polished the investments may be. This drawing of Vesalius (Fig. 20) will remind the reader of some of the obstacles to such a transit. The "numerous instances" of sword thrusts, bayonet stabs, and shot wounds through the abdomen that authors enumerate, when sifted, appear rather as much-reiterated instances,5 while many of them, when critically examined and shown incontestably to be examples of deep penetration or perforation, lack evi- dence of being unattended by visceral lesion, and prove only that slight lesions of this nature are not necessarily fatal. In his long career, Larrey observed only a single instance6 in which a ball penetrated the abdominal cavity without producing any immediately serious re- sults. Even in this case, a lesion, however trivial, existed; for, as M. Legouest remarks, there was a con- tusion of the intestine. It is remarkable that these alleged cases are more frequent in civil than in military experience, an anomaly not satisfactorily explicable by the imperfection of observations in time of war. Allowing 'Hence, notwithstanding Malcaigne's resolute denial (Traite d'Anat. Chir., T. II, p. 325), the majority of modern classical authors—BOYElt (TraiU des mal. chir., T. VI, p. 11), DUPUYTREN (Lecons orales de din. chir., T. VI, p. 428), and NEr.ATON (lStem. depath. chir., T. VI, p. 112)—teach that stabbing and cutting weapons and balls, after traversing the abdominal walls, may glide upon the smooth surfaces of the viscera without wounding them. JOHN Bell (op. cit., p. 60) admitted this: "In judging of wounds of the lower belly," ho said, " much must be taken into account, before we form our opinion. We are often likely to be deceived; we see tlie patient lying quiet and easy, while we know that he is on the very brink of danger; and there is often great confusion and alarm, when the patient is absolutely safe ; for balls sometimes turn so, that a shot shall pass through among all the b.nvcls without wounding one; though it must be acknowledged, that the belly is so full of parts essential to life, that there can hardly be a wound of the abdomen, in which one or other of the bowels is not concerned." 2 GROSS, A System of Surgery, 5th ed.. Vol. II, p. (>.">!). :> GUTHRIE, Commentaries, 6th ed., p. 54(i. 4LEGOUEST (Chirurgie d'Armee, 2eme 6d., p. 375): " Mais si Ton considere comme tres-problematiquc la possibility d'une plaie penetrante de labdomen par annes piquantcs ou par coups de feu, on est oblige d'admettre celle des plaies simples du peritoine par instruments tranchants, puisqu'on a vu quelquefois les intestins parfaitement intacts sortir a travers les solutions de continuite des parois abdominales." 61 will quote John Bell's explanation of Wiseman's case, and will not impugn that of the venerable La Motte, but may make my estimate of Garengeot and his cases appreciated, by comparing him, among contemporaneous authors, with Dr. Demme. As Bell says: "One man is known by one quality or failing, another by another manner. HEISTER is remarked for sober systematic writing after the right German fashion ; Petit for good sense, and sound and careful observation; and Garenoeot for tales like that .about the soldier's nose." "Our good old surgeon Wiseman," Bell notes elsewhere, "has said with great simplicity, as a great many have said after him, ' Thus it frequently happeneth that a sword passeth through the body without wounding any considerable part;' he means that a rapier or hall often passes quite across the belly, in at the navel, and out at the back, and that (without one bad sign) the patient recovers and (as has very often happened) walks abroad in good health, in eight days ; which speedy cure has been supposed to imply a simple wound, in which all the bowels have escaped. But we see now how this is to be explained ; for we know, that in a thrust across the abdomen, six turns of intestine may be wounded,—each wound may adhere; adhesion, we know, is begun in a few hours, and is perfected in a few days; and when it is perfect all danger of inflammation is over; and when the danger of inflammation is over, the patient may walk abroad; so that we may do just as old Wiseman did in this case here alluded to: ' Bleed him, and advise him to keep his bed and be quiet.' In short, a man thus wounded, if he be kept low, lias his chance of escaping by an adhesion of the internal wounds.'' oLaruev, Clinique Chirurgicale, T. I, p. 50. FIG. 20.—A—Ensiform cartilage. BB—Peritoneum and broken ribs reflected. C—Suspensory ligament. D D—Liver. E—Hound ligament. F F—Stomach (ciri hujus ventriculus cibis admodum erat turgidus). G—Spleen. N—Commencement of the large intestine. 0—Vermiform appendage. P Q V A'—Transverse colon. R—Sigmoid flexure, g — Bladder. [After Vesalius, Lib. V, Sexta Jigura.] 40 PENETRATING WOUNDS OF THE ABDOMEN. [chap. VI. due weight to this consideration, the Parisian "three days," of lcv>0, IS IS, and 1S.)1, should not furnish more of these exceptional cases than the wars of JNapoleon, or the Irish-American riots than all the battles of the Rebellion.1 A man of the 80th British regiment was shot through the belly, from the navel to the back, in India, and recovered without serious symptoms; but when he died of cholera six years subsequently, it was found that the jejunum had- been either contused or divided in three places.2 I can learn of no shot perforations of the abdomen without visceral lesions, in the Crimean or Italian wars; but have collected a few scattered illustrations in the foot-note, and must, in fairness, not forget to state that in the Franco-German War, so careful an observer as Dr. Bernhard Beck professes to have observed seven such instances.3 The diagnosis was verified by an autopsy in one only of the two fatal cases. The others would be more conclusive had not, in one of the recoveries, faecal fistula occurred. Of the other four recoveries it is ascertained only that ventral hernia supervened in one, and diaphragmatic hernia in another. Until the real tracks of the projectiles can be traced, these observations can have no great weight. It must be concluded, then, that really simple penetrating wounds of the abdominal cavity—that is, penetrations or perforations without visceral lesion—are very rarely inflicted, either by sharp or blunt weapons or by shot; and that most of the apparent exceptions are explicable by one or the other of two conditions: either that the true course of the 11 have already cited the alleged case occurring in the Southwark riots (p. 35, note). Dr. Sanborn (Boston Med. and Surg. Jour., 1849, Vol. XLI, p. 200) relates another: The case of Kelley, a lad of 14, wounded in the riots at Lowell, by a ball entering in the centre of the epigastrium and passing out four inches from the spine, fracturing the tenth rib. Vomiting, abdominal tension, and other signs of peritonitis were, combated by venesection, opium, cold lotions, absolute rest, and abstinence. On the twelfth day portions of clothing were discharged from the posterior wound, which then healed. The reporter is satisfied that the missile made a direct and not a circuitous course. Paillaud (Xote in Dupuytren'S Lecons orales, T. VI, p. 4(>) relates two instances, observed at IIotel-Dieu and Benujon, in July, 1830, of men shot through the body from the epigastrium to the side of the vertebral column without visceral lesion, and a third case (Relation chirurgicale du siege de la citadelle d'Anvers, 1833, p. 74) under his care at Antwerp, all of which recovered without serious symptoms. But while he would have these cases credited, he adds : " II ne faut pas trop s'abuser cependant sur le mode d'uetion de ces coups pretendus heureux,'' and admits that such cases are commonly attended by visceral lesion. In 1848, two similar cases (Gazette Midicale de Paris, 1848, and a paper by Dr. Gibb in the British American Journal of Medical and Physical Sciences, October, 1848, reprinted in New York Jour, of Med., 1849, N. S., Vol. Ill, p. 82) were observed at La Charite and at Val de Grace. In one of these cases it was not doubted, even by Velpoau, that the ball, which entered the right umbilical region and passed out to the left of the vertebral column, had traversed the abdomen. The patient succumbed to a suppurative phlebitis following a precautionary venesection, and the autopsy revealed that the ball had made a circuit on the aponeurotic planes! Among the wounded at the barricades, after the Coup-d-fttat of December, 1851, I had the opportunity of seeing two eases of supposed shot penetrations of the abdomen without visceral injury, one in M. Roux's ward at Ilotel-Dieu, the other in the service of M. MICTION, at La Piti6. One of these cases terminated fatally, and the diagnosis was disproved at the autopsy, lesions of the intestines, without extravasation, being discovered. Dr. B. Beck (Die Schusswunden, Heidelberg, 1850, S. 207) states: "I have observed two cases where musket balls entered and made their exit, without immediate opening of the intestines; one recovered completely in fourteen, the other in twenty-two days." BlLGUER (Chirurgische Wahrnehmungen, Berlin, 17b'3, S. 371) cites a case observed by Dr. C6ler at the battle of Loboschitz, in the year 175o, which is analogous to Hennen's case. A soldier was shot through the abdomen by a large shrapnel ball, which entered on the right and emerged on the left side. The wounds were large, ab*.ut five inches apart, leaving the uninjured intestines open to view. The only notable symptom was a large abscess in the pubic region, which discharged a piece of cloth of the man's uniform. Recovery was complete in three months. Ravaton (Chirurgie d'Armee, p. 23(1, et seq., Obs L and LI) relates two supposed instances of shot penetrations of the abdomen without visceral injury. Dr. Demme (Sludien, B. II, S. 129) finds it difficult to understand how French and British authors can call in question shot perforations of the abdomen without visceral injury, as he had satisfied himself, in repeated instances (mehrere Falle), that even grape-shot might traverse the peritoneal cavity without lesion of the contents. This assertion elicits from Dr. Beck the criticism, unhappily not unmerited, that he regards Dr. DEMME'S work "as a romance containing much that is interesting, and as a pleasing and complacent compilation of innumerable untruths (unwahrheiten) and unfounded and fictitious statements." s Private Paul Massoy. 80th British regiment, was shot in the abdomen at the battle of Ferozeshah, December 22, 1845. The symptoms conse- quent on the injury were so inconsiderable that Surgeon MacDonald thought the ball had coursed around the abdomen. The patient, however, stated that he had passed blood by stool. Recovery followed slowly; but appeared to be perfect. The man died May 13, 1851, of "blue spasmodic cholera." Surgeon J. H. Tayloii reported the autopsy, and with Dr. Williamson, who figures the pathological preparation (Military Surgery, 186"3, Plate V, opp. p. Ill, Xo. 1271 of the Xetley Collection), believed that the appearances indicated a perforation of the jejunum, in three places, by the ball. Professor Longmore (Article Gunshot Wounds, in Holmes's System, 2d ed., Vol. II, p. 207) thinks it more likely that the gut was contused than perforated. 'BECK (Chirurgie der Schussrerletzungen. Freiburg, i, B. 1872, S. 526) cites seven cases of penetrating shot wounds of the abdomen 'einfach p-iietrirende Wunden), with five recoveries and two deaths, observed in the hospitals of General Wcrders corps after the engagements, in 1870, about Metz. In one of the fatal cases, a man of the 112th Baden Infantry, wounded in the left hypochondrium by a ehasscpot ball, which fractured the twelfth rib, had traumatic peritonitis with icterus, nud died in seven days. At the autopsy the ball was found resting in the vertical column, having wounded none of the viscera. The other fatal ease (\Y------, 21st Baden Dragoons) was from a large mitrailleuse ball passing from the lower right hypochondrium, on the axillary line, to the loft of the navel. There was protrusion of unwounded intestines at the exit orifice. The patient died the day cf the injury and no necropsy was made. Of the fivo survivors: In the case of Private M------. J 14th Baden, a ball entered the right hypochondrium and lodged; there was secondary lesion at least of the transverse colon, for faecal fistula ensued. L------, lO'Jth linden, recovered after the supposed lodgement of a ball in the abdominal cavity. T------, t'5th Baden, also recovered after the lodgement cf a ball entering the right hypochondrium. A French prisoner survived a pcrf. rutin- wound, but had diaphragmatic hernia. K------. 111th liadru. recovered, with ventral hernia, after a shot wound, with alleged peuctration without consequent peritonitis. SECT. III.] WOUNDS OF THE STOMACH. 41 weapon or projectile evades the cavity it apparently enters; or else, traversing the cavity, is really associated with injuries of the viscera, with lesions usually unattended by extravasation, and susceptible of repair. Wounds of the Stomach.—The position of the wound, its depth and direction, the escape of food or drink, vomiting of blood, pain and-faintness, are the principal signs of a wound of this organ. Associated with them, there may be thirst, singultus, tympanites, small and frequent pulse with pallor, cold extremities, and other symptoms common to many forms of injuries of the belly, occurring even in some examples of non-penetrating wounds. The danger of extravasation is absent when the organ is empty, and the risk of haemorrhage is less as the lesion is distant from the curvatures. Wounds near the pylorus endanger the hepatic artery, and those at the cardiac extremity, the left coronary. ^\ ith some such description, systematic writers commonly preface accounts of wounds of this organ. But without dwelling on the semeiology and diagnosis, I will venture to say that apart from ocular evidence, or that derived from the introduction of the educated finger, extravasa- tion of the contents of the stomach is the only pathogno- monic sign of the division of its walls; and will hasten to the more instructive task of collating individual facts to exemplify that the complexity of the conditions under which the lesions are observed is such as to preclude much uniformity in the attendant phenomena, and that although bloody vomiting, coming on immediately after a stab or shot wound in the vicinity of the stomach, may afford a strong presumption of a lesion of that organ, it is an uncertain sign, that may be absent when the stomach is wounded, or present when the injury is simply a contu- sion of the stomach, or a wound of the liver or intestines. Dr. J. J. Chisolm1 entertains the most hopeful prognosis of any of the Confederate or Union writers who have adverted to wounds of the stomach, and endeavors to justify his teaching by the argument that soldiers most frequently go into battle with empty stomachs; but he specifies no instances of recovery. Dr. E. Warren2 omits wounds of the abdomen in his epitome. The compilers of the Confederate Manual? in a judicious analysis of the differential diagnosis of penetrating wounds of the belly, refer briefly to the significance of haeinatemesis. The Confederate States Medical and Surgical Journal, and the southern medical journals 'ClIISOLM, A Manual of Military Surgery, Columbia, 3d ed. 18G4, p. 349: "In gunshot wounds of the stomach the contents escape externally, and also into the peritoneal cavity, where, as extraneous substances, they light up general and, usually, fatal peritonitis. As soldiers most frequently go into battle without previously having had a meal, the ilaccid condition of the stomach, without contents to escape from this organ, is a great safe- guard in case of wounds, and hence perforating wounds of this viscus more frequently recover under these circumstances than when gunshot injuries are received under other conditions. The location of the wound is often, in the army, the only basis for diagnosis, as the escape of contents and vomiting of blood are not constant symptoms, and shock, which is usually present, is common to all wounds of the abdominal viscera." * WAliUEX (E.), An Epitome of /'radical Surgery, for Field and Hospital, Richmond, 18(53, pp. 402. 3.1 Manual of Military Surgery, prepared for ihe. t.'sr of the Confederate Slates Army by Order of the Surgeon General, Richmond, 1863, p. 62: 'If the stomach has been penetrated there will probably be vomiting of blood from the first." (') » FIG. 21.—Stomach and Intestinal Canal of the adult human subject. [After Brinton, in Cyclopsed. Anatom. and Physiol., Vol. V, Supplement, p. 307.] CP—stomach. C—cardiac. P—pyloric orifice. JI—small intestine. J"—jejunum. I—ileum. CC to A—large intestine, viz: CC—caecum. A C— ascending colon. T C—transverse colon. D C— descending colon. S F—sigmoid flexure or sigmoid colon. R—rectum, vl—anus. 42 PENETRATING wounds of the abdomen. [CHAP. VI. published since the War, contain no observations on the subject. Dr. D. 0. Peters1 has printed a case of recovery from a supposed shot perforation of the stomach, and this case lias been repeated, with some references to the literature of the subject, by Dr. J. A. Lidell2 and Dr. F. H. Hamilton.3 It is possible to adduce a half-dozen alleged recoveries that must be discredited as erroneous returns; a number of recoveries in which the gastric lesions are authenticated by the same evidence as was produced in the case recorded by Dr. Peters, to wit: the unsupported testimony of the patient; and some instructive fatal cases, of undoubted authenticity, attended with gastric fistulas or other complications. Punctured and Incised Wounds.—A few fatal examples, unattended by any unusual features, were reported.4 Recoveries from stabs, with complete solution of the walls of the stomach, are far less frequent than a superficial examination of the annals of surgery would lead the reader to infer.5 Cash 171 .—Corporal P. Wliittaker, ('<>. C, 1st Mississippi Mounted Infantry, was admitted into Hospital No. 2, at Vicks- burg. June 2(5, IS(!4. from the transport Diana, with a punctured wound in the epigastric region. He had vomited blood and was suffering from excessive nausea, intense thirst, with great anxiety and languor. The surface was clammy and the extremities were cold. He died on June 27, MM. No autopsy. The case is recorded by Surgeon Harmon Benson, 14th Wisconsin. Case 172.—Private J. W------, Co. B, 5th New York Artillery, was admitted into the Jarvis Hospital, Baltimore, March, 15, 1S(54, with a punctured wound in the left hypochondriac region. He had been stabbed by a bayonet, the point entering seven and one-half inches below the left nipple and six inches from the ensiform cartilage, at a point corresponding with the chondro-costal extremity of the ninth rib. He was drunk, and his bladder was paralyzed. The bladder was evacuated by a catheter, and simple dressings were applied to the wound. There was very little bleeding, and but little vomiting. On the 16th, he was comparatively comfortable. On the morning of the 17th, there was excruciating pain, vomiting, tympanites, and all the symptoms of traumatic peritonitis, with bloody vomiting, and blood in the stools. Death followed, on March 18, 18iJ4. At the autopsy it was found that the bayonet had trans- fixed the jejunum and the stomach, and that blood, faeces, and an ascaris lumbricoides had been extravasated into the peritoneal cavity. The preparation of the stomach, presented with the foregoing notes by Acting Assistant Surgeon B. B. Miles, is figured in the wood-cut (FlG. 22). The preparation of the jejunum is represented further on. Case 173.—Private E. Owens, Co. K, 4th United States Cavalry, aged 32 years, was admitted to Hospital No. 1, Nashville, March 27, 1834, with an incised wound of the stomach, received at Nashville on the preceding day. He died on April 4, 1804. The case is reported by Surgeon R. L. Stanford, U. S. V. Cask 174.—Private Robert Frazer, Co. C, 4th Illinois Cavalry, aged 20 years, was admitted into Gayoso Hospital, Memphis, from his regiment, April 17, 18(15, with an incised wound of the stomach. He died on the same day. Surgeon Daniel Stahl, U. S. V., reports the case. The preparation represented in the adjacent wood-cut (Fig. 23} was removed from a patient who survived a bayonet stab in the stomach for thirty-six hours. A branch of the right gastroepiploic artery was ligated. Hypodermic injections of morphia allayed the excruciating pain in this case, and cold milk, held in the mouth or against the fauces, relieved tlie excessive thirst better than ice. Assistant Surgeon E. Bentley, Fig. 22. — Section of inverted stomach punctured by a bayonet near the cardiac extremity. Spec. 2258. Flo. 23.—Stomach with the middle of the anterior wall punctured by a bayonet. Spec. 48(i7. [Ueduced to one-fourth.] 1 I'kikks. Cases in Military Surgery, in Am. Med. Times, 1863, Vol. VI. p. 160. The case is also recorded in Circular No. 6, S. G. O., 1865, y>. 25. The patient's name on the muster-roll is George Bowes, and appears variously as G. M. or G. H. Bowes or Bowers on the hospital registers *LlDEl.L, Injuries of the Abdominal Viscera occasioned by Fire-arms, in Am. Jour. Med. Sci., 18G7, N. S., Vol. LIII, p 350. Dr. LlDELI. gives Ilcnnen's summary of the literature, and notices the case cf St. Martin. 'Hamilton (F. II.), A Treatise on Military Surgery and Hygiene, 1805, p. 358. and Principles and Practice of Surgery, 1872, p. 115. St. Martin and Howes are the examples adduced. J Surgeon Clements has recorded (Circular No. 3, S. G. O., 1871. p. 91) a case of recovery from an incised wound, which was believed to involve the pyloric extremity of the *t..maeh. Acting Assistant Surgeon Hogg (Ibid., p. 101) cites a recovery from a punctured wound, supposed to have pene- trated the anterior wall of the stomach. In both cases there was haematemesis; but no extravasation. In the same report, page 100, Assistant Surgeon Bexti.ky relates a case, in which lie unavailingly practised gastroraphy. 5 The number of examples of recovery from unequivocal penetrating, punctured, or incised wounds of the stomach is not larffe. Tlie often quoted '"iso by Tli.WKliS (Edinb. Jour. Med. Sri.. I>20', Vol. I. p. 81) is accompanied by very valuable observations on wounds of the stomach. Dr. rnv.-ICK (Cll.soN s Institutes and Practice of Surgery, 7th ed., lebo, Vol. I. p. 121) was accustomed to relate in his lectures that Dr. AuciIEK. of liar SECT. III.] WOUNDS OF THE STOMACH. 43 U. S. A., gives a full account of the case, in the report in Circular 3, S. G. 0., 1871, page 100. Tbe stomach was in a state of repletion when the injury was received, and the ford county, Maryland, in a case of incised wound of the stomach obtained a successful issue by stitching the coats of the stomach t» the wall cf the abdomen. Dr. CHARLES Wji. Asillir (The Stethoscope and Virginia Medical Gazette, 1851, Vol. I, p. GOO) relates a case of recovery after protrusion of nearly the whole stomach, in a negro lad of six years, the contents escaping through an aperture in the anterior wall three-fourths of. an inch in length. The boy had fallen on the points of a pair of sheep-shears, which had entered obliquely, grazing- the left edge of the sternum and the costal cartilages. A single fine-silk stitch was placed in the middle of the wound, which was brought near the external one, which was sewed up. Dr. C. IlAFl'OLPT (Charleston Medical Journal and Review, 185."), Vol. X, p. 341) relates, at length, a recovery from a wound of the stomach bya bowie-knife. I cannot regard the evidence of complete penetration of the stomach in this case as conclusive. A report of an alleged recovery from an incised wound, three inches long, of the anterior wall of the stomach, closed by the interrupted suture, by I). O. Blaxciiaed (Oregon Physio-Medical Journal, 18fi8, Vol. II, p. 124), does not inspire confidence. Dr. BURRITT (Notes of Practice, in Phila. Med. and Surg. Reporter, 1871, Vol. XXV) records, as a recovery from an incised wound of the stomach, a ease in which the evidence does not at nil warrant the admission of any serious lesion of that organ. Dr. D. C. Peters (Am. Med. Times, ISti?, Vol. VI, p. lfil) alludes to a Mexican, stabbed in the epigastrium bya cheese-knife, who "had haematemesis and other symptoms which caused me to believe that the stomach had been wounded." Dr. F. II. Hamilton (A Treatise on Mil. Surg., p. 301) cites this as a recovery from "a punctured wound of the stomach," though Dr. Peters explicitly states that "introducing my finger into the wound I could not discover any wound of the stomach." AuciIKll's case, already noted, is detailed in the Medical Repository, 1812, Third Hexade, Vol. Ill, p. 315, et seq., in a paper entitled "A case of extraordinary recovery from wounded stomach, ivhicli occurred in the practice of the late Hon. John Archer, M. B., in a letter from his son, John Archer, M. D., of Maryland, to Joseph Glover, M. D., of Charleston, South Carolina." It is the more remarkable because food escaped into the peritoneal cavity, and half-digested matter, in which portions of cabbage were recognized, was evacuated through an abscess in the groin. Physick or GmsON reported the case erroneously ; the external wound only was sewed up, by an old soldier. Archer saw the patient on the third day and " thought it best to cut all the stitches * * * *; they were merely in the cutis and would have broken loose in two days more." The incision in the stomach was two inches long, and was made just after the ingestion of a full meal of bacon and cabbage and cider. Other American cases will be referred to under tbe head of Gastrotomy. Of those here cited, only the two recorded by ARCHER and Ashuy are incontestable instances of recovery from wonnds of the stomach, the observations of Drs. Clements, Hogg, Happoldt, Blanchard, BUR1UTT. and Peters being open to criticism. In the Annals of British Surgery, besides the case of Travers, already noted, is the remarkable case recorded by SCOTT (Medical Commu- nications, 1784, Vol. II, p. 78), of a sailor, aged 25, stabbed in the stomach by a small sword; there was no protrusion, and sutures were not employed. The patient recovered under the use of opiate and nutritive enemata. Forsyth's case (Medical Times, 1850, Vol. I, p. 494), of a constable stabbing himself with a bayonet, though endorsed by the editor (who blunders again in adducing Wiseman's rapier transfixion in the 'right hypochondrium," Chirurg. Treatises, p. 173, as a wound of the stomach), was plainly not a lesion of the stomach, the patient drinking and retaining " amazing quantities " of seidlitz draughts and cold water soon after the infliction of the injury. In Mr. Maunder's case. (Clinical Lectures and Reports of the London Hospital, 18(14, Vol. I, p. 120) the evidence of any direct lesion of the stomach is equally defective. The two cases reported by the Reverend James Fielii, of Antegoa (in the Philosophical Transactions, No. 371, p. 78, or Vol. VII, p. 500, of the abridgment, by Fames and MARTYN, 1734), of the negro father and son who inflicted vast gashes in each other's stomachs, which were stitched up by Mr. FOlUirsT, surgeon, so that in a month's time they were both perfectly cured, derive their only claim to authenticity from the place in which they were published. In the works of continental European surgeons, we find recorded in Hrvin's erudite paper (Mem. de I'Acad. royale de Chir., T. I, p. 591) the case of sword stab in the stomach successfully treated by Coghlan, a surgeon of Belle-Isle, which furnishes BOYER (op. cit., T. VI) with his argument for the utility of alum in haematemesis; and in the same exhaustive, but never exhausted, dissertation, the memorable cases of LESSERE (I. c, p. 592) and Carte rat (I. c, p. 594). In the Bulletin de la Faculte de Medecine de Paris, T. V, 1817, pp. 386, 391, et seq., are printed the much-cited observations of RUHSTRAT, Percy, and LABOCHE, of Antwerp, all three of which are in point, save that Ruhsteat had to deal with a lacerated rather than an incised wound. In two of these cases a modification of LeDrans looped suture was advantageously employed. Of more recent eases, that reported after Waterloo, by JOHN THOMSON, and mentioned by Henxex (op. cit., p. 443), of a pike stab in the stomach, the fact of complete ultimate recovery is not positively stated. But Laerey (Mem. et Camp., 1812, T. Ill, p. 91) records an unequivocal instance of recovery from a penetrating sword wound of the stomach: " J'ai la preuve que les plaies de l'estomac se guerissent tre\s-bien, et meme sans suture. Je rapporterai snecinctement, a l'appui de cette assertion, l'observation dune assess large blessure recue par un soldat de la garde vers la grosse extrSmite de ce. viscere, et produite par la pointe trfis aceree d'un sabre, qui pSnetra d'abord dans la poitrine entre la septigme et la huitidme cote, 16sa une petite portion du poumon, coupa le diaphragme, et perfora l'estomac dans la portion corres- pondante de sa grosse extremite. La douleur locale, les vomissemens sanguins, Tissue par la plaie des liquides que le blesse avalait; enfin, la direction elle-meme de la plaie, ainsi que sa profondeur, ne laissaient point de doute sur l'ouverture de l'estomac. Les premiers jours fureut tres-orageux. et le malade se trouva plusieurs fois aux portes du tombeau; cependant, a l'aide des rafratchissans, des saignees locales et genfirales, de la diete prolongee, des lavemens emolliens, et de la position du blessfe que je faisais teuir constamment sur le cote droit, la plaie se cicatrisa, et ce militaire sortit de l'hopital pour entrer dans les veterans de la garde. II a conserv-6 une hernie du poumon, qui se manifeste sous la cieatriee, et qu'il contient, avec quelque peine, au moyen d'un bandage fait expres." In the old collection of cases, a certain number of instances of recoveries from punctured and incised wounds of the stomach may be found; but care is requisite to discriminate original observations and to verify the authenticity of citations. Albucasis (De Chirurgia, Arabice et Latine, cura JOHANNIS Channing, Oxon., 1778, 4to, Lib. II, Sect. 85, p. 379) states that he once cured a knife wound of the stomach by the suture. Uiemerbroeck (Opera Omnia Anatomica, Ultrajeeti, 1685, p. 22) refers to cases collected by CORNAX and Schexckius, and gives a circumstantial account of a recovery he witnessed himself, in 1641, in a Batavian country boy, stabbed with a knife in the cardiac extremity of the stomach. I have not access to the great collection of JOHN SCIIENCKIUS, printed in seven volumes, at Freiburg, about 1580, but it is said to contain a paper by Oetheus (De vulneribus ventriculi sanalis) describing the case of a soldier at Marpaeh, in Fulda, who recovered from a stab in the stomach. The viscus was drawn out and stitched with sutures which were attached to the abnominal wall. HAMEL, in the Zodiacus Medico- Gatti.cus, October, 1680, Obs. II, p. 206, records the caseof "a young man named Crotte," of Lexovium (Lisieux), who fully recovered from a sword wound of the upper part of the stomach. Stalpari van der Wiel's successful gastroraphy is recorded in Ettmuller (HALLER's Disputationes, T. V, p. 670). Other unquestioned recoveries are recorded by Fceckler (De vulnere ventriculi duplicato, Erford, 1716), by DiJRR (De vulnere. ventriculi egregie curato, Leipsig. 1790), by LOUUET (Traite des Plaies, Paris, 1783, p. 221), by RICHTER (Chirurgische Bibliothelc, 1790, B. X, S. 203), by TEN IlAAE ( Verhandeling over de rttor- naamste Kwetzuuren, u. s. w., Rotterdam, 1781). The last five appear to have been recoveries without the use of the suture. Purmaxx (Lorbeer- Kranlz oder Wundartzney, Franckfurth, 1692, S. 410) records two cases of gastroraphy, which he successfully practised in the persons of Krespen and Mailer, soldiers of Colonel Cannon's regiment, and describes how he drew out the edges of the wounded stomach with a small hook and inserted one or two stitches. He adds that he never observed inflammation in such cases. He does not state whether they were punctured, incised, or shot wounds. Probably they did not belong to the latter class; for there is no allusion to paring of the bruised edges. Schlichtixg, in his Traumatologia Nod. Antiqua (4to, Amsterdam. 1748, p. 79), refers to a case he successfully treated by the looped suture, " after the precepts of BOHXius." A similar case, which I have been unable to verify, is said, by Hexnex, to be recorded by Kluyskkn'S, in the "Annates de la Litterature." As much must be admitted of the cases ascribed to Matth^eus (Diff. Med. Quaest), to Mexzel (Mis. Nat. Cur.. Dec. 11, Ann. 1, Obs. 1), and to Gayaxt, by Ettmullkr. There seems to be no reason to discredit the three cases which Fla.iaxi (Collezione de osservazioni e riflessione di chirurgia, Roma, 1803, Vol. I, p. 7) records. Brogiani, Parichini. and the subject of the ninth observation, appear to have recovered from incised wounds of the stomach. In the case of Pariehini, gastroraphy was practised. Of the recoveries with fistula, and of the cases of the Prussian, Bohemian, and French cultrivores, mention will be made elsewhere. Of cases recently reported, that of IlYRTL (Handb. der Tnpog. Anat., Wien, 1865, 8. 674) is well authenticated; and two, published by Professor BORSIERI, of Bologna (Bulletino delle Scienze Mediche, Nov., 1871), and a third recorded by Dr. Peyrani (Ln Sperimcntnle. Jan., 1871), border on the marvellous in their coincidence and in the rapidity of their uncomplicated progress toward recovery. Dr. Wigaxd (Mcmorab. VII, 12, 1862) gives an authentic case. 41 PENETRATING WOUNDS OF THE ABDOMEN [CHAP. VI. Fig. 24.—Ligature around a punctured membrane. described in treating of wounds of the intestines.3 Fig. 25.—Interrupted suture. Fig. 26.—Continued suture. symptoms usually ascribed to wounds of this organ were well defined. The stomach was drawn out, and the incision in its walls was closed by the interrupted suture; the viscus was t hon replaced, and the external wound was united in the same manner. There is still diversity of opinion as to the proper rules of practice in punctured and incised wounds of the stomach, even where the viscus protrudes or presents at the external wound. If the puncture is small, it is advised that the lips of the opening should be pinched up with a pair of forceps and a thread tied around it (Fig. 21), as practised by Sir Astley Cooper,1 for a wound of the intestine, and, with signal success, by Travers,a for a wound of the stomach by a razor, in the well-known case reported by him, with very valuable observations on wounds of the stomach from various causes. If the wound is a trifle larger, it is recommended that it should be closed by one or more points of interrupted suture (Fig. 25), placed by means of a delicate needle with fine thread, or else by some one of the ingenious stitches that will be In more extensive solutions of continuity, the continued suture (Fig. 26) or one of its numerous modifications may be required. Whether the sutures should be cut close to the knots and the organ returned unattached into the cavity, or whether the ligatures should be suffered to hang loosely from the external wound, or whether the lips of the wound in the viscus should be stitched to the abdominal walls, are points on which opinions are divergent, and which must come again under consideration in connection with the subject of suture of the intestines. Gunshot Wounds.—Xot less than nineteen cases of recovery from alleged shot wounds of the stomach were reported. The evidence, in each instance, has been examined, and the inferences are that, in some cases, the diagnoses had no foundation, and the erroneous returns were due to culpable carelessness or ignorance, the term stomach being sometimes employed by simpletons apparently as an euphuism for belly; that in other cases, hospital surgeons or pension examiners have related and endorsed the narratives of patients, and described as facts events which, if they ever occurred, transpired long before 'COOPER, A., The Lectures of, on the Principles and Practice of Surgery, with additional Notes and Cases. By FREDERICK TYHUELL London, 1827. Vol.111, p. 222. 2 TRAVERS. A Case of Wound, with protrusion of the Stomach: In FAin. Jour, of Med. Sci., 1826, Vol. I, p. 81. 3In wounds of the stomach, LeDran* advised the looped suture, or suture a anse, that bears his name (The Operations in Surgery of M. LoDrax. Translated by Mr. GATAKEIt, surgeon, 4th ed., London, 1768, p. 60), and which has been much advocated, apparently from theoret- ical considerations. It is simply the interrupted suture with the threads untied, but left long enough to twist the ends together into a cord (Fig. 27), to be brought out of the external wound, with a view of untwisting and separately withdrawing the threads. It is mentioned by all of the classical authors, and Professor GROSS (Wounds of the Intestines, p. 99) gives a figure of it, but expresses a doubt whether the inventor ever emplojed it upon the human subject. The basting or darning stitch (Fig. 28), the suture a points passes of French writers, devised by Bertraxdi (Traitcdes Operations de Chirurgie, tradnit de l'ltalien par Sollier, Paris, 1781, Chap. II, p. 15), was highly praised by such respectable authorities as Sabatieu, Desault, and BOYEB, though Dr. GKOfs does not find that they have adduced any facts in illustration of its efficacy. To obviate the dauger of separating adhesions by the traction necessary to withdraw the thread in this form of suture, Beclabd used two threads of different colors, and, when they were to lie withdrawn, made traction upon an end of one thread and the opposite end of the other, so that the wound, subjected to equal simultaneous tractions in opposite directions, was not disturbed, an expedient which LARREY and others have employed in various sutures. The form of suture employed is not specified in many of tire comparatively small lists of successful examples of gastroraphy. but Beraiw asserts (Diet, de Miid. T. XII. p. 302) that Lauoche and Percy, in their famous cases, employed the looped suture. Caetekat (Mem. de I Acad, de Chir., I. p. .-,04.1 mi cceded with the glover's stitch. Staliwiit vax iieii Wiel (Obs. Med., Cent. I. No. 39) and Field (Philosoph. Trans.. No. 371. p. 78) sewed the wall of the Momacli to the muscles of the abdominal parietes. 7.-L >'>ptdsuture; suture Lellrau s suture. FIG. 28.—Suture a points passe*, or basting stitch. Sutura transgressiva of Petit, Ber- th an Dl, and Sabatier. SECT. III.] WOUNDS OF T1IF STOMA Oil. 15 the patients came under their observation, and are destitute'of corroborative evidence; that, in a few instances, recovery followed injuries which careful and competent observers pronounced to be shot wounds of the stomach; finally, that, even in the latter small category, not more than one incontestable example of recovery was recorded. Lareful investigation of the recorded symptoms and progress of the six following cases has failed to, elicit any evidence in corroboration of tlie diagnoses of "severe gunshot wound of the stomach," with which they were reported. None of the names appear on the Pension List: CASES 175-130.—I. Imported by Assistant Surgeon 0. W. Cadden, Purnell Legion: Pt. J. Noch, Co. B, 95th Penn- sylvania, Gaines's Mills, June'J7, 1862; made prisoner; exchanged July 21; treated at Camden Street and West's Buildings hospitals, Baltimore ; discharged October 9, 18(12.—2. Reported by Surgeon P. N. Woods, 39th Iowa: dipt. J. M. Brown, Co. F, 39th Iowa; Parker's Cross Roads. Tennessee, December 30, 1832; resigned July Li, 18(i:!.—3. Reported by Surgeon W. Throlkeld, IT. S. V.: Pt. S. Leslin, Co. K, (ith Veteran h'eserve Corps, aged 45 years; Sandusky, Ohio, May lH,'l8. and May. ISU.'i, by Examining Surgeon Charles Cook, of Jersey City, Fig. 2!).—Cicatrices in a case of recov- ery from an alleged wound of the stomach. [From a photograph.] 46 PENETRATING WOUNDS OF THE ABDOMEN, [CHAP. VI. Fin. 30.—Scars of entrance and exit in a case of alleged wound of the stomach. [From a photograph.] who states, in a communication to this office, that " the ball entered one and a half inches to the right of the spinal column, below tlie last or lower asternal costa. passed upward and forward, perforathuj tlie stomach, and out one and a half inches below the sternum. Fluids swallowed continued to flow through the orifice below the sternum for about ten days. Was taken from the Held at Chancellorsville, after being wounded twenty-four hours, and carried to Libby Prison at Richmond. Rebel surgeons gave him no attention whatever for six days, considering his case hopeless. Complains that his food distresses him; of constant wrakni'ss at epigastrium, and of general debility." [This pensioner died February 25, 1870; but no post-mortem observations have been reported.] The patient whose history is next related, like many others, was incapable of appre- ciating the kindness which dictated an expectant treatment: Case 184.— Private P. H. Chick, Co. I, 3d Maine, aged 24 years, received a penetrating wound of the abdomen, by a conoidal ball, at the Wilderness, May G, 1864. He was taken prisoner and remained in the hands of the enemy until the wounds had healed, receiving little or no attention, his case being at first considered hopeless. He was finally paroled, and, on March 9, 1865, was admitted into Cony Hospital, Augusta, Maine. The ball had entered two inches below the ensiform cartilage, in the median line, passed through the diaphragm, and came out through the base of the right lung and tenth rib. The patient stated that air passed freely in and out of the wound of exit with a whistling sound, and that coffee and other fluids which he swallowed ran out of the wound of entrance for many days. Confederate Surgeons told him that bile came from the .wound of entrance. He was discharged from service April 21, 1835, at which time Surgeon George Derby, U. S. V., reports that he was well and strong, and his digestion was perfectly good. There was a ventral hernia through the rectus muscle— a tumor as large as a hen's egg—projecting at any expulsory effort. The right side of the body was a little sensitive in walking, so that he moves with the toes averted, bringing the foot down square instead of heel and toe. Examining Surgeon Edmund Russell reports, August 4,1865 : "Musket ball entered near the pit of the stomach and came out near the spine, fracturing two ribs. His bowels swell, and he suffers pain if lie does anything hard; is very weak." Examining Surgeon C. W. Snow reports, September 2, 1837: " Gunshot wound of right lung. The stomach was wounded by the same ball, I judge, from his statement of symptoms and from the course of the ball." This pensioner's condition was reported unchanged when he was last paid, Dec. 4,1872. An unusual proportion of alleged recoveries from shot wounds of the stomach were thus observed at Cony Hospital. The following case, reported by Assistant Surgeon D. C. Peters, U. 8. A., has been adduced as an irrefragable instance of recovery from a shot perforation of the stomach.1 It will be observed that there is no other evidence of the gastric extravasation and of the hsematemesis than the patient's statement. It is noticeable that Assistant Surgeons DuBois and Mackenzie, who successively had the patient in charge, made no note of these remarkable features : Case 185.—Private George H. Bowes, 8th Illinois Cavalry, in a skirmish, September 13,1832, was shot in the abdomen. ('aptain J. D. Ludlam, 8th Illinois Cavalry, certifies that this man " was shot in a cavalry skirmish, by the enemy, near Middle- town, Maryland, and left on the field. I afterward sent an ambulance and brought him in. I did jiot think he would live through the night. I saw him when shot, and I was commanding the squadron." Surgeon A. Hard, 8th Illinois Cavalry, does not refer to the case on his monthly report. As most of the wounded of the battles of South Mountain and Antietam were taken to Frederick the search for the patient was directed there, and it was found that Assistant Surgeon II. A. DuBois, in charge of Hospital No. 4. records that Bowes entered that hospital on September 19th, with a shot wound believed to involve the intes- tines. The particulars of the progress and treatment of the case are not recorded. On January 5, 1833, the patient was trans- ferred to the hospital at Camp B, Frederick, where Assistant Surgeon T. G. Mackenzie recorded the case without any details. On March 9th, the patient was transferred to Jarvis Hospital, Baltimore, and came under the charge of Assistant Surgeon D. C. Peters, in whose language a more detailed history may be given: "George H. Bowes, aged 19, a private in the 8th Illinois Cavalry, was transferred from Frederick, Maryland, to this hospital, March 7, 1863. The patient states that the day previous to the battle of South Mountain his regiment was in the advance, skirmishing with the enemy, when he became engaged in a hand to hand encounter with a rebel horseman. The man fired several shots at him with his revolver, one of which took effect in his abdomen. The ball entered the abdomen about two inches above the umbilicus and one inch to the left of the linea alba, traversed backward and slightly upward, and made its exit just beneath the tenth rib, at a point that is about two and one-half inches from the spinous process of its vertebra. The wound immediately placed him hors de combat, and he commenced to 1 An abstract of the case was printed in Circular 6, S. G. O., 1865, p. 25. Assistant Surgeon PETERS published a copy of his official report, in a paper entitled Cases in Military Surgery, in the Am. Med. Times, 1863, Vol. VI, p KiO. The case is the only example of recovery from a shot wound of the stomach, during the War, mentioned by Dr. HAMILTON, Treatise on Military Surgery. 1865, p. 360, and Principles and Practice of Surgery, 1872, p. 11". SECT. III.] WOUNDS OF THE STOMACH. 47 vomit blood, and it at the same time poured from his nostrils. The free haemorrhage caused syncope, which temporarily arrested it, but, at spells for the following seven days, he had a series of these haemorrhages. He further states that after receiving the wound he had bloody passages from his bowels, which gave him intense pain, and continued for about the same length of time. There was but a small amount of blood that escaped from the wounds. The surgeon who examined him on the field informed him that the ball had passed through his body. The injury was followed by acute inflammation, as he complains of having suffered much pain and tenderness in the whole abdomen, and says he had fever. He was confined to his bed, undergoing active treat- ment, for several weeks. Whenever he received fluids or solids into his stomach, he states that, for a period of two months, a part of the half-digested material would escape from the anterior wound and soil the dressings. From his system not receiving proper nutrition, he became very weak and emaciated ; but finally the wounds closed, and since then he has regained his health rapidly. The healthy action of the prima? via} is again fully established, but, owing to contractions formed in the healing of the track of the wound, he is bent forward, and cannot by any force straighten himself. The treatment at present is directed toward overcoming these contractions. Remarks : Cases of recovery from gunshot wounds of the abdomen are by no means uncommon ; but recovery from wounds of the stomach (and there is every probability this comes under that category) and other abdominal viscera are exceptional to the general rule." Private Bowes was discharged from hospital and from the military service April 2, 18ii3. His pension claim was admitted November 24, 1863, on his captain's certificate, already quoted, and a certificate of disability by Dr. Peters, which was substantially an extract from the foregoing report. The disability was rated as total. No further particulars are given by any pension examining surgeon. The pensioner was last paid in September, 1872, his condition being described as unchanged. The opinion of the- attending surgeon, in the following case, inspires less confidence than that of the pension examiner : Case 186.—Private George Hart, Co. G, 1st West Virginia Artillery, was wounded, during General Averill's raid, at Pocky Gap, August 26, 1863. Surgeon W. D. Stewart, U. S. V., noted the case as "gunshot wound of the stomach." The patient was taken prisoner and remained in the hands of the enemy until November 25, 1863, when he was paroled, and admitted into the post hospital at New Creek, West Virginia. He was discharged from service June 22, 1864. Pension Examiner George McCook reports, under date of July 11, 1864 : "The ball struck the fifth rib, left side, near its sternal attach- ment, was diverted, passed downward and lodged, inflicting an extensive injury on the rectus muscle. The ball was extracted. Suppuration followed. An abdominal hernia, embracing a circumference of six inches, has resulted. The abdominal parietes are weakened. A broad truss is required to control the rupture ; the ability to bend his body is diminished. Disability total and permanent." The next observation is important, because the symptoms immediately following the injury were observed and recorded. Unfortunately, the reporter suffered an interval of four years to elapse before placing the case on record. It may be ungracious to deny the exactness of his diagnosis, which, indeed, furnishes the most plausible explanation of the phenomena; yet none of the symptoms related are inconsistent with the hypotheses that the visceral lesions might have been limited to the left lobe of the liver or to the duodenum. Case 187.—Private Patrick Sweeney, 7th New York Cavalry, aged 21 years, was shot, in a quarrel at a brothel in Wash- ington, about midnight, January 4, 1862. In a special report, February 2,1836, Surgeon C. L. Hubbell, 7th New York Cavalry, states: " He stood with his side rather toward the man firing, and about ten feet distant. The pistol was a Colt's revolver, second size. The ball entered about an in jli below the last rib, directly underneath the cardiac region, and, passing through the stomach and liver, lodged just beneath the skin, at a point about four inches back of the crest of the ilium, near the outer border of the latissimus dorsi muscle. It was readily removed by a small incision. In about half an hour after the injury the man was brought to my regimental hospital, near where the Campbell Hospital was afterward located. He was vomiting blood profusely, and was almost pulseless. The first indication was to check the haemorrhage; this, and the vomiting also, was arrested entirely, at the expiration of twenty-four hours, by the constant application of cloths, wet in ice-water, to the hypogastric region. No drink whatever and no nourishment were allowed, except a little cold crust-water, in quantities of a teaspoonful only about once in an hour, although the thirst was urgent As it seemed to me that, in order to secure the union of the wound in the stomach, the organ must contract to its smallest possible size, and must rest, allowing only so much nutriment and drink as would sustain life and be easily absorbed. The dejections from the bowels were black and tar-like for several days, as in melaeua. On the second day, peritonitis with great tenderness and considerable tympanitis supervened, but, by the exhibition of large doses of morphia and the continued application of cold cloths, it was entirely subdued, and at the end of one week it was evident that all danger in the case had passed. No solid food was allowed until about the tenth day, but beef tea and oilier nutritious drinks were given in small quantities at a time. At the end of the sixth week he was able to walk about the hospital with a cane, and, at the time the regiment was disbanded, in March, appeared quite well, and was able to eat and digest the army rations. I shall always attribute the recovery in this case to the faithful use of cold wet cloths, producing contraction of the stomach and arresting the haemorrhage. I afterward saw, on different battle-fields, several gunshot wounds of the abdomen, all of which resulted fatally in a few hours. In none of them was the stomach perforated." Assistant Surgeon H. Culbertson's diagnosis, in the following case, is in disaccord with the conclusions of several other observers : Case 188.—Sergeant F. A. Barnard, Co. A, 37th Wisconsin, aged 25 years, was shot through the body by a conoidal musket ball, at Petersburg, June 18, lrtil, the missile entering the right hvpochondriuni and emerging at the left. He was PENETRATING WOUNDS OF THE ABDOMEN. [CHAP- VI. taken to the Ninth Corps Hospital, and treated by restoratives and simple dressings. Surgeon M. K. Hnguii. U- S. \ .. reports the case simply as a "gunshot wound of the abdomen." On July 24th, the sergeant was transferred to tho Fairfax Seminary Hospital, where Surgeon D. P. Smith, U. S. V., reports the injury as a wound of the left lobe of the liver. The patient was furloughed December 3d, and on January 6, 1865, transferred to Harvey Hospital, Madison, where Surgeon 11. Culbertson, U. S. V., reported the case as a " gunshot perforation of the abdomen, with wound of the stomach." The wound healed, and the patient was discharged March 8, 1-65, and pensioned. Examining Surgeon D. D. T. Hamlin, M. D., of Elk Horn, Wisconsin, reports. November 22. ISfio. the wound as "causing painful respiration, with some contraction of lower part of chest on both sides. Disability one-half and permanent." The live remaining cases of the group of nineteen recoveries from alleged shot wounds of the stomach cannot be accepted as such: Cah-.s 189-193.—1. Case of Surgeon Terwilliger (p. 577, First Surgical Volume): Pension Examiner E. Loughran, of lister County, New York, reports, October 16, 1871, that the ball passed "through the stomach, upper lobe of liver and lower lobe of right lung," which statement conflicts with those of numerous hospital surgeons who observed the recent wound.— 2. Private Christy, Co. F, 102(1 Ohio, Cold Harbor, June 4. 1864. reported by Surgeon K. Barr, 67th Pennsylvania, as receiving a " gunshot wound of the abdomen, penetrating stomach," which conflicts with other reports, and is unsustained by any probable ,(,s,i,noIlv._:?. Corporal T. Chapin, Co. F, 2d Michigan, Knoxville, Tennessee, November 24, 1863, died September 6, 1868; reported' by Surgeon A. M. Wilder, U. S. V., as a recovery from "gunshot wound of left side and stomach," an opinion not corroborated by Pension Examiner David Clark, of Flint, Michigan, or by the subsequent history.—1. Sergeant .7. II. White, Co. I). 53d North Carolina, Gettysburg, July 3, 1863, reported by Surgeon H. Janes, U. S. V., as recovery from a "gunshot wound of the stomach and liver," was paroled September 25, 1863.—5. Private J. C. Reamer, Co. F, 7th Wisconsin (ante, p. 25, Case 130), reported by Surgeon I. I. Hayes, U. S. V. The visceral injury appears to have been unattended by external wound. I presume that no writer on medical jurisprudence would contend that, in any one of this group, the evidence of recovery from a shot wound of the stomach was unimpeachable. In the four instances in which the contents of the stomach are alleged to have escaped by the wound, that fact is attested only by the patient's statement.1 In three instances, there are positive and uncontradicted statements by surgeons, unsustained by precise descriptions of symptoms; and, in twelve cases, the evidence is hopelessly conflicting or utterly inadequate. Fatal Complicated Shot Wounds.—Shot wounds of the stomach are seldom uncom- plicated. In reviewing the wounds of other abdominal viscera, many will be found associated with lesions of the stomach. Some cases that have furnished specimens for the Museum, or that presented features of especial interest, may be cited here. One is an example of a shot wound of the stomach complicated with wounds of the diaphragm and colon and with fracture of the spine : Cask 194.—Private John B------, Co. I, 9th Minnesota, aged 28 years, was wounded, in front of Nashville, December lti. 18li4, by a conoidal musket ball, which penetrated the left chest at the cartilaginous junction of the eighth and ninth ribs, three inches below the nipple. On the night of the same day he was admitted to Hospital No. 8, Nashville. The shock of injury was very great, and he suffered intensely from sharp pain in the chest and abdomen. There was, also, paralysis of motion and of sensation in the left lower extremity. Expectant treatment was used, but the patient soon fell into a collapse, and died at 8.30 o'clock P. ji., on December 17, 1864. At an autopsy, twenty-two hours after death, pleuritic adhesions were found; the capacity of the left pleural cavity was much diminished; the abdominal cavity showed evidences of intense peritonitis, and the viscera were softened and of a dark green color. The missile had passed downward, inward, and back- ward, and piercing the diaphragm near its anterior border, had left an opening two inches in length, through which a portion of omentum had escaped into the pleural cavity. It then entered the great curvature of the stomach about midway and passed out at the middle of the posterior surface (FlG. 31), leaving an interval of three inches between the openings. Thence it passed through the transverse colon, and faecal matter, with a large amount of* escaped blood, were found in the abdominal cavitv; it then struck the left anterior side of the body of the fourth Fn;. 31.—Posterior view of a stomach perforated " ■-,,•■,<<,■, , ■ ,,/* <• , by a musket b:iii: a. entrance; e, exit. Spec.3749. lumbar vertebra, grooving deeply its left border, passed against the left surfaces of [iieduoed to unc-iourth.] t]ie Spjna] COrd, fractured the left horizontal and spinous processes of the third 1 The grains of allowance, with which the statements of patients are to be received, are well exemplified in the following incident, in a debate in the New York Pathological Society, November 'J7, 18(i7 (The Medical Record. 1807-C8, Vol. II, p. 498): " Dr. HOWARD stated that he had met with several flesh wounds produced by pistol bullets at short range, and had invariably found that they healed by iirst intention. He did not think it improbable that a wound might be made in the stomach and yet close with equal rapidity, leaving hardly a vestige of its course afterward. Dr. S.\vn£ tuned that he had only seeu one case of bona fide gunshot wound of the stomach, and that was in the person of Beverley Cole, of California. In that instance there was vomiting and purging of blood, and a discharge of the contents of the stomach through tho wound. It was three years since ho had S"'*'T- »'-l WOUNDS OF THE STOMACH. 49 KlG. 33.—Inner surface of a portion of the great extremity of the stomach perforated through a fold by a pistol ball at close range. Spec. 1332. [ Reduced to one-fourth the size of nature.] First three lumbar vertebrae, the body of the second perforated by a pistol ball, which traversed the canal obliquely and escaped through the right lamina. Spec. 1331. [Reduced one-half.] lumbar vertebra, and was found immediately to the right of the spine of the second lumbar vertebra, underlying the integument and fascia of that region, very much changed from its original shape. The specimen of the vertebra (No. 3748) is represented in the fifth volume of Photographs of Surgical Cases and Specimens, A. M. M.. p. 18. The notes of the case and the specimens were contributed by Acting Assistant Surgeon H. 0. Ma}-. Another example of a shot wound of the stomach, associated with per- foration of tlu1 vertebral column, has been related in the First Surgical Volume, and was remarkable for the characteristic symptoms of the gas- tric lesion; which, on reference to the abstract of the case, on page 44o, will be found to correspond closely with the descriptions of sys- tematic writers. The case furnished to the Museum two pathological preparations, which are represented by the accompanying wood-cuts (Figs. 32 and 33).1 In a case that will be detailed in treating of wounds of the pancreas, Acting Assistant Surgeon T. L. Leavitt2 asserts that there was a shot perforation of the inferior curvature of the stomach "large enough readily to admit two fingers," the patient surviving fifteen days without the slightest functional gastric disorder. Obviously, this statement is simply incredible. In the interpretation of the next case, I cannot subscribe to the views of the experienced and competent reporter, Acting Assistant Surgeon B. B. Miles, although they are sustained by the officer in charge of the hospital, Dr. D. C. Peters. I think the faecal fistula was in the transverse colon, and that, in the very complicated pathological processes that took place during the hundred and eleven days the patient survived his injury, whatever gastric disturbance existed was of a secondary and comparatively unimportant nature: Case 195.—Corporal R. C. T----, Co. G, 5th Wisconsin, aged 21 years, was wounded, at the engagement at Hatcher's Run, February 7, 18:35, and was at once carried to the field hospital of the 1st division, Sixth Corps, in charge of Surgeon Redford Sharp, 15th New Jersey. The injury is entered on the register as a "gunshot wound of the side." and, while details of the early symptoms are wanting, collateral evidence indicates that the wound was supposed to be unattended by visceral complications. The patient was conveyed, in an ambulance wagon and by rail, over twenty miles, to the base hospital at City Point. Thence he was transported on a steamer to Baltimore and admitted to Jarvis Hospital, where the diagnosis—"gunshot wound of left side, perforation of stomach"—was recorded on the monthly report by Assistant Surgeon D. C. Peters, U. S. A. The patient was placed in charge of Acting Assistant Surgeon B. B. Miles, in whose language the further history of the case may be related: "Admitted February 11, 1835, with gunshot wound of left side, through the stomach, entering anteriorly, about two inches below the xiphoid cartilage, making its exit between the ninth and tenth ribs, about four inches from the junction of the costal cartilages with the ribs. Wound received at Hatcher's Run, February 6, 1H{>5. On admission, this man's faeces, instead of passing out the natural channel, were discharged through the wound for a considerable time; but, finally, the discbarge ceased and the fa?< e.3 passed out the natural channel. He continued to improve, and was so much better that he was able to seen the case, and the patient was now doing well. Dr. Hewit remarked that the case referred to by Dr. Sayre had been under his immediate care, being assisted by Dr. Valentine MOTT, jr., and Dr. C S. Tiutleh, and that the symptoms were as Dr. Sayre had related them, except that there was no discharge of the contents of the stomach through the wound. Dr. Sayre stated that he had merely reported the symptoms as they were detailed to him by the patient, some time after the accident." 1 All of the preparations exemplifying lesions of tho stomach by pointed or cutting weapons or by shot, that the Army Medical Museum possesses, have been figured in the text. The surgical reports show that many opportunities of supplying deficiencies, in this direction, have been lost. Medical officers shall not be suffered to forget that the compiler is also the curator of the Surgical Section of the Museum, always ready to remind them of their obligation to perfect the series of that rich collection. At the Museum of the Pennsylvania Hospital, Preparations 1305 and 130G illustrate, respectively, incised and shot wounds of the stomach; but are without histories (Cat., p. Gl). At the New York Hospital, Preparations 377 and 378 exemplify stabs, and 379 a pistol ball perforation of the stomach ; the patients survived these injuries forty-eight hours, two days, and three days, respectively, and all are reported to have died from peritonitis (Cat., pp. 17H. 179). In the Museum of St. George's Hospital, Specimen 196, Series IX, shows a large circular hole in the anterior wall of the stomach, caused by a charge of small shot (Cat., p. 449). In the Fort Pitt collection, Specimen 1035 is the stomach of a man with a shot perforation near the greater curvature; the patient survived eight hours (Cat., p. 14?). This is probably identical with 1125 Netley These eleven are all the modern pathological preparations of such lesions that I can find recorded. 2IiEAVlTT. The Tenacity of Human Life, in The Med. and Surg. Reporter. 18<;.r>, Vol. XII, p. 105. 5U PENETRATING WOUNDS OF THE ABDOMEN. |CHAP. VI. walk about his ward; but, owing to some imprudence or over-exertion, lie took a relapse and rapidly grew worse, so that he died Mav 2-\ h"\i5. Autopsy, twenty-four hours after death : On examination, both lungs were found adherent to the pleurae, but more especially the left. It was also so strongly adherent to the diaphragm that the diaphragm was ruptured in detaching the lower lobe of the lung. This lung was also covered with strong bands of lymph, and its substance was earnined. The spleen was adherent to the ribs and to the stomach, and also the diaphragm, and was covered with bands of lymph, and its substance was very hard. The left kidney was also adherent, somewhat contracted, and hard. There was extensive peritonitis, and both greater and lesser omentum were very black, as were also the small intestines, colon, and rectum. An examination of the stomach revealed a large cicatrix where it had been perforated by the ball. The stomach was forwarded to the Army Medical Museum, Washington, D. C, by B. B. Miles, Acting Assistant Surgeon. U. S. A." [The records of the Museum show that the pathological specimen was received at the Museum July 2i, 1865, and numbered (>t>4 on the preparer's book ; but the evidence of the lesion of the walls of the stomach was regarded as so unsatisfactory that the preparation was not admitted to the catalogue.] The following is an interesting instance of the lodgement of a ball in the stomach:1 Ca.se 19o.—Private James White, Co. A, 90th New York, was wounded at the battle of Cedar Creek, October 19, 1*'>1. The medical officer. Assistant Surgeon N. Stub, 90th New York, gives no particulars of the case. The patient was sent to the field hospital of the 1st division of the Nineteenth Corps. Ass't Surgeon John Honians, jr., U. S. A., reports that he had a "severe gunshot wound of the abdomen," and that he was transferred to Martinsburg on October 20th, but no further details. He was sent by rail to Baltimore, and entered Patterson Park Hospital on October 2:id. Acting Assistant Surgeon A. McLetchie reports the further progress and result of the case as follows: "On admission, he was able to walk up a flight of stairs without much inconvenience. On examination, I found that a minie ball had penetrated the epigastric region. Slight redness and swelling encircled the opening; the edges of the wound were everted. No discharge escaped from the wound. The patient complained of excruciating pain in the lumbar region. I had a flaxseed poultice applied to the wound, and recommended absolute rest, and a low diet of animal broths, with a little sherry wine. On October '21th, the patient reported a very restless night, with occasional vomiting of a glairy fluid. The pulse was small, at 94, the tongue clean, the urine free and clear. He was ordered to continue treatment, and to take a pill of one grain of camphor and two grains of extract of henbane every three or four hours. In the afternoon he had a healthy dejection. He had intense lumbar pain. He complained also of a sensation as of a globe in the throat. He takes his chicken broth sparingly. He is ordered a belladonna piaster (four by two inches) over the loins. October '25th, patient and nurse state there was a normal stool this morning. Occasional hiccough. October 27th, great pros- tration; difficulty of swallowing; frequent vomiting; pulse quick and small; skin clammy and cold. He died at half-past five o'clock a. m. At the autopsy, it was found that the ball, having penetrated the abdominal wall one inch above the umbilicus, had passed through the right lobe of the liver, then through the lesser curvature of the stomach, partially severing the duodenum from the stomach, and was found lying loose in the stomach." A patient survived a perforation of the stomach and of the spleen by a round pistol ball for ten days :2 Case 197.—Surgeon T. F. Perley, U. S. V., reports that Sergeant Cyrus E. Bussey, Co. K, 11th Maine, was admitted to the post hospital at Camp Berry, Portland, Maine, November 18, 1864, having been shot in the left hypochondrium by the accidental discharge of a pistol charged with a round ball. The missile passed between the cartilages of the fifth and sixth ribs, the attachments of the diaphragm, the cardiac extremity of the stomach, the spleen, and lodged in the long muscles of the back to the left of the spine. There was copious haemorrhage, and the contents of the stomach escaped by the wound. The fatal event did not take place until November 28, 1834. 1 Dupuytiien (Lecons Orales, T. VI, p. 454) says: "If a ball, after perforating the stomach, remains in that viscus, uo attempt to extract it should be made. Sooner or later it will probably be voided at stool." 21 can learn of no unequivocal examples of recovery from a shot wound of the stomach prior to the last decade of the eighteenth century. There is a case ascribed to Fallopius by ROMBERG and other writers; but 1 cannot find in the section de ventriculi vulnere of the Modenese professor (T. II. p. 395, of the Opera genuina omnia, Venetiis. 1606) any specific case of shot wound. FALLOPIUS says (T. II, p. 25G) "De ventriculo vero sanari ego aliquando vulnus, per quod egrediebatur cibus," but does not assert, nor does the context indicate, that this was a shot wound. There is also an account in the Ephcrmcrides Natune Curiosse, Dec. II. Ann. 1, Obs. 26, of a peasant who recovered, after a shot wound of the stomach, having voided a ball at stool a month after the reception of the injury. Probably the missile entered the transverse colon by ulcerative absorption. Possibly Purmaxx's two successful cases of gastroraphy (Lorbeer-Krantz, u. s. w., S. 410) were instances of shot wounds; but he does not so state. The first plausible recorded example is that related in Gerson's Magazin (B. IX, S. 260), of a French officer wounded at the battle of Kaiserslautern, in 1794. The wound remained open fifty days, during which period food often escaped. Then the wound closed permanently. Gerson saw this officer in 1807, with a deep cicatrix in the epigastric region. This case is probably identical with that observed by PERCY (Jour, de Med. de Leroux, Boyer, et Corvisart, 1802, T. Ill, p. 510) and commonly referred to by writers on gastric fistula (see GERARD, Perf. spont. de l'estomac, 1803, p. 70). The next recorded case is that referred to by Dr. Thomson (1. c, p. 103) in 1815, after Waterloo, a doubtful instance, the ultimate result being unknown. The case recorded by Breton' (Trans. Med. and PJiys. Soc. of Calcutta. 1825, Vol. I, p. 59), of a trooper attempting suicide, in 181'J, by discharging a pistol at the epigastrium, is destitute of the slightest evidence that the wound implicated the stomach, and writers must have repeated it without examination. Bf.aumont's famous case of St. Martin, wounded June (5, J822, is next in date. An authentic case, that occurred in Algeria, is recorded by Bauden's (Clinique des plaies d'armes & feu, 1836, p. 122): L-----, a grenadier of the 67th, was shot through the stomach, October 4, 183:1. There was haema- temesis, and liquids escaped by the wound for thirty days, when the fistula permanently closed. All that is really known of a case misquoted by Ballixgall (pp. cit., p. 351) is contained in the following sentence of Alcock'S summary of penetrating shot wounds of the abdomen : " One case of recovery occurred in an officer, in which there was lesion of the stomach." (Notes on the Medical History and Statistics of the British Legion in Spain. 1838, p. 50.) BECK (Die Schusswunden, 1850, S. 212) cites a case related to him by an Austrian colleague, where there was every indication of a wound of the stomach, and the ball was voided at stool. Nothing indicates that the Austrian may not have read of this case in the Ephemerides. In his excellent memoir on shot wounds of the stomach, TRIPI.ER (Peninsular Jour, of Med., 1856, Vol. IV, p. »') records the case of Dr. R. B. Cole, who accidentally shot himself, at San Francisco, June 3, 185-1. With the utmost deference for my old friend and chief, I cannot concede that the evidence he has adduced conclusively proves the existence of a penetrating wound of the stomach in this case. There was no escape of the contents of the stomach by the wound; liquids were soon swallowed and rotaincd: the hiccough and haematemesis are explicable without any lesion of the stomach ; SECT. III.] WOUNDS OF THE STOMACH. 51 The next case is one of several instances of associated lesions of the stomach and colon: Case 198.—Acting Assistant Surgeon J. H. Potter reports that "Private James Cochran, Co. (J, l.'ith Veteran Reserves, was wounded by the accidental discharge of a pistol, at Plullipsburg Barracks, February 5, 1865. The ball entered the left lumbar region, striking the transverse process of one of the vertebrae, perforated the descending colon and some part of the stomach. The injury was immediately followed by incessant vomiting, and by bloody discharges from the bowels. As soon as notified, I had the man removed to the hospital. I found the ball lodged in the abdominal wall, and extracted it. I made two visits subsequently, and left the patient quite comfortable for the night, having given the necessary instructions to the steward, In the morning. I learned that the second lieutenant of his company had assumed the authority of calling a resident physician, without my knowledge or consent, who had changed the treatment, though the patient was then comparatively easy. At the morning visit, February Cth, the patient was Morse, and he continued to fail thenceforward. Indeed, I had never entertained any hopes of his recovery from the first time I examined his wound. I remained with him that night. The next morning he died, February 7, 18().V Acting Assistant Surgeon Potter concludes by demanding a court of inquiry into the conduct of the line officer who intruded in the case. As frequently as any other complication, lesions of the lung and diaphragm were associated with shot wounds of the stomach. The following instance will further exem- plify that shot wounds of the stomach may interest the outer tunics only: Case 199.—Surgeon A. Chapel, U. S. V., reports that: Orderly Sergeant Eugene W. Field, 2d Maryland rebel cavalry, while attempting to haul down the national colors from a flagstaff, in Harford County, Maryland, was shot by a patriot, 73 years of age (in accordance with the spirit of the celebrated order of General Dix). The wounded man was sent to Baltimore, and entered "West's Buildings Hospital on the 14th, two days after the reception of his injury. There were numerous wounds, distributed over the right hypochondrium and epigastrium. The patient was suffering from the symptoms of traumatic pneu- monia conjoined with peritonitis. There was great tenderness on pressure at the epigastrium, and constant voniiting. Death ensued July 15, 1S64. Acting Assistant Surgeon A. Kessler reports the autopsy : " Upon laying the cavum thoracis open, a large quantity of dark partly coagulated fluid escaped; the cavum mediastinum was filled with a similar fluid. The right lung was found hepatized with the exception of the superior posterior lobe, that was comparatively healthy; the left lung was found entirely sound. The anterior and lateral portion of the right lung exhibited numerous marks of duckshot, some of which penetrated to a considerable extent. The heart was struck by a shot, which lodged in the outer wall; otherwise it was sound. The stomach was also struck by several shot, none of which, however, penetrated into the cavity, which was filled with a yellow fluid. The cardiac orifice was considerably inflamed, and a deep congestion extended over the largest portion of the lessor curvature; this accounts for the extreme tenderness of the stomach and the constant vomiting of the deceased. The liver was gray, ash-colored, and somewhat enlarged; numerous marks of shot were visible all along tbe right and left lobe, and also upon the peritoneum. The intestines appeared to be in a normal condition and showed no signs of being wounded." In other cases of this group, the patients escaped the immediate dangers of traumatic peritonitis, and succumbed from inanition, or exhaustive suppuration, or complex causes of constitutional irritation. Thus, the same reporter, Surgeon A. Chapel, U. S. V., records the case of Corporal Mcintosh, Co. D, 1st North Carolina, age 31, wounded at Cedar Creek by a round musket ball, which perforated the left lung, diaphragm, and stomach; the patient perished from exhaustion twelve days afterward, November 1, 1864. 2. Act- ing Assistant Surgeon W. B. Crain returns the case of Private J. Humbolt, 1st Illinois the subjective symptoms (" He tells me that, after a full meal, he feels the stomach dragging upon the ribs, and is .sure it is adherent to their inner surface," I. c, p. 7) are quite fallible. Dr. II. Culbeutson (Ohio Med. and Surg. Jour., 1859, Vol. XI, p. 301) reports the case of N. Speed, aged 19; penetration of the anterior wall of the stomach by an accidental discharge of small shot, February 6, 18.">9, being demonstrated by the presence, in the coagula vomited, of "the rough and flattened shot." In transmitting a copy cf this article to this office, December 23, 1871, Assistant Surgeon H. CulherTSON, TJ. S. A. (retired), adds: " Six months ago, I learned this young man was living and well." Dr. Sciioltz (Wiener Med. Wochenschr., 1864, XIV, 3, 4) reports the recovery of a student who attempted suicide by firing a pistol at the pit of the stomach. The ball passed through the stomach, midriff, and left lung. There was persistent vomiting of clots mixed with fluid blood, extreme thirst, and difficult breathing. Convalescence, retarded by the mental condition, was fairly established in eighty-one days. Dr. Sciioi.tz ascribes the successful issue to the absence of food in the stomach, and of bone splinters or other foreign bodies in the wound. Dr. K. Fisciieu (Militardrztliche Skizzen aus Suddeutschland und Bohmen, Aarau, 1807, X. G3) records, without particulars, a recovery from a "shot wound perforating the stomach from right to left, the entrance and exit orifices being five to six inches apart." This is probably identical with a case reported by Mr. F. II. Lovell (Cases of Gunshot Wounds occurring during the late War in Germany, in the Lancet, 18Gfi, Vol. II, p. . until he removed the wax tampon he habitually wore, and relieved the repletion. The fistula which MlDDEL- PORl'K (de Fistulis ventriculi externis et chirurgica earum sanatioae, accidente historia fistula: arte chirurgorum plastica prospere curatir, Vratislaviae, 18j:»i -uooe^fully closed by a plastic operation, though not caused by a wound, was consequent upon an abscess caused by a blow. Proiosor Gunthkr (Lehre von d;-i blutigen Opcratiouen, Leipzig, 18(10, B. IV, Sect. XV, S. 2!)) reproduces the plates accompanying this dissertation. Dr. Middeldoui'K, adding to Dr. .VUKCHlsnx's table, enumerates forty-six cases,—twenty-one men, twenty-three women, and two of undetermined sex,—and remarks that while among males tln>r tUtula> are more commonly duo to external violence, in woman the proportion of non-traumatic fistules largelj' preponderates. SECT. III.] WOUNDS OF THE STOMACH. 53 chest wound, the ball first striking and demolishing his watch, and, entering the chest below the left nipple, passing downward and backward, emerging nearly midway between the sternum and spine.'' And, elsewhere, Dr. Rush says: "there was not, to the best of my recollection, any very great gastric disturbance." Dr. Derby remarks: "The ball ■entered the left chest, in front, and so low as to make it doubtful whether above or below or penetrating the diaphragm," and says nothing of the consti- tutional condition; from which it may be inferred that there was no haemorrhage or gastric disturbance when Dr. Derby saw the case, twelve hours after the reception of the injury, and that the graver symptoms of the shock had passed off. Here it may be observed that Colonel C------was a man of small stature, thin and slender, active and resolute, but with greater strength of will than vigor of body. On a previous occasion, at Quaker Bridge, North Carolina, July G, 18G3, I was with him when he received a shell wound over the left clavicle, and, although he was not severely hurt, the immediate nervous depression was very marked. Arriving at Fort Monroe, Colonel C------entered the Chesapeake Hospital on May 18th, and was placed under the special charge of Assistant Surgeon E. McClellan, U. S. A., who prepared a circumstantial report of the case, and forwarded it from Hampton, although, unfortunately, no record of it, or of its reception at this office, can be found. Dr. McClellan's surgical register, however, supplies some of the facts of the case: "On June 9th, the probable position of the ball, between the seventh and eighth ribs, was determined, and the patient was anaesthetised by inhaling the vapor of a mixture of two parts of ether and one of chloroform ; and Assistant Surgeon E. McClellan, (». S. A., proceeded to extract the ball. The patient was in excellent condition for the operation, all of the bodily functions being normal, and the mind cheerful and hopeful, with bright anticipations of recovery revived by the discovery of the ball." The next entry is on June 30th : "A fistulous opening exists, connecting the inferior orifice with the cavity of the stomach, which discharges partially-digested food. Condition of parts healthy. Orifice of entrance completely cicatrized." Death resulted July 15, 1H!'>4, from exhaustion. Since the fore- going compilation was placed in the printer's hands, the following report of the case, which Dr. E. McClellan had the kindness to prepare, on learning of the miscarriage of the report previously forwarded, has been received: "Lieutenant-Colonel John G. C------, "23d Massachusetts Volunteers, was admitted to the officers' division (Chesapeake) of the United States General Hospital, Fort Monroe, Virginia, May 18, ISiil, suffering from a gunshot wound of the left chest, which had been received in action two days previously at or near Bermuda Hundred, Virginia. When Colonel C------, who was then in command of his regiment, went into action, he had in the left breast pocket of his coat a large watch and an iron comb. His coat was buttoned tightly, for the attack of the enemy which he was resisting was made at an early hour. When he was removed from the field, it was found that the ball by which he was wounded had struck upon and destroyed the watch and had broken to many pieces the iron comb. The ball being deflected, the wound of entrance was found to involve tbe fifth and sixth ribs a little to the back of the centres of the shafts, the direction being downward and backward; the bones were comminuted. It was supposed that the fragments of watch and comb had been lost when his coat was first opened. An examination made by the ward surgeon failed to determine the presence of any foreign body in the chest; all detached pieces of bone were remov-ed. The hospital being at the time overcrowded with wounded, my attention was not called especially to the case until June 9th. Suppuration was profuse, and, upon examination, the probe impinged upon a metallic body. The wound was enlarged, several pieces of bone were removed, and immediately behind them was found a conical ball, much flattened, and a brass wheel from the watch. The cavity- was carefully explored and a hard substance was found partly embedded in the tissue of the lung. This being removed, proved to be portions of the missing parts of the watch. Prolonged search, assisted by careful washing out of the cavity, obtained the remainder of the works and many portions of the iron comb. When satisfied that all foreign bodies had been removed, the wound was closed. The suppuration diminished, the patient rapidly gained strength, the wound closed to nearly its whole extent, and a favorable termination, was anticipated; but, early in July, symptoms of gastric irritation supervened, attended with hectic, and rapidly increased in severity. Emaciation was rapid, but the discharge from the wound was inconsiderable. A few days before his death, being present as he swallowed some brandy, he exclaimed: 'Doctor! it smarts my wound;' and, upon examination, the odor of brandy was found upon the dressing. Constant watching determined the fact that of all fluids taken into the stomach, a small portion was immediately present at the wound. The exhaustion became more profound, the emaciation was wonderfully rapid and extreme, and, on July 15th, he died calmly, of exhaustion, as brave and gallant a gentleman as ever drew sword. The autopsy determined the fact that a prong of the iron comb had escaped detection at the time of operation ; that its sharp point had become embedded in the bottom of the cavity, and that by its means a gastric fistula was established." Another patient survived his injury seven weeks, the gastric fistula appearing at the close of the third week: Case 201.—Corporal Roswell E. M------, Co. K, 1st Massachusetts Heavy Artillery, aged 23 years, was wounded at Spottsylvania, May 19, 1864, by a musket ball, which perforated the left chest from before backward, fracturing the ninth rib. He was taken to the field hospital of the 1st division of the Fifth Corps, and Surgeon W. R. DeWitt, jr., U. S. V., recorded the case in accordance with the foregoing facts. An expectant treatment, with simple dressings, was instituted, and the patient was placed in an ambulance train to be sent to the base hospital. On May 25th, the patient was admitted to Fairfax Seminary Hospital, under the care of Acting Assistant Surgeon York, who records that, "on admission, the patient suffered from great dyspnoea, with pneumothorax and tromatopncea, the air rushing in and out of the wound with the respiratory movements. The left lung was collapsed. On June 2d, there was a profuse and offensive discharge from the wounds, which continued until about June 9th, when there appeared in the discharges a portion of the fluids taken into the stomach, mingled with particles of solid food. There was no cough nor expectoration." No further account of the case is given for the ensuing month, when Assistant Surgeon H. Allen, U. S. A., records: "I saw this patient the first time in the afternoon of July 8th ; he was greatly emaciated, though strong enough to sit up on a chair to be examined. The ball had entered about one inch to the left of the xiphoid cartilage, passed backward and slightly downward, making its exit oh a level with the eleventh rib, about midway between its most convex portion and dorsal. Respiration was difficult, and each effort accompanied by a loud blowing, whizzing sound through wound of exit. Typical amphoric respiration was heard over the affected region posteriorly. Patient said that no 51 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. dyspncra came on immediately after the reception of the injury, but it was a symptom of a few weeks' duration. The lung sounds were clear (fremitus being present) down to the lower third of the dorsum of the chest, thence to seat of wound it was tympanitic with entire absence of fremitus. Imperfectly digested food occasionally escaped through the posterior opening inter- mixed with gastric juice. Patient was cheerful, complained of little pain, and was looking forward to an early transfer t«> his home. He died rather suddenly the following day. The foregoing note of Dr. York was all I could gather concerning the history of this interesting ease." Dr. Allen appends the notes of the autopsy: "Lungs: bronchial secretion large in quantity. Color of lungs light pink; in posterior part dark red. Near apex of left lung a tubercle, of the size of a hazel nut, was found. Pleura of lower part of left lung strongly adherent to parietes of chest. Heart normal. Pericardium contained rather a large quantity of light straw-colored fluid. Liver apparently healthy. Spleen about four inches by three, of very dark color and firm consistence. Patient had received a gunshot wound of left side of chest, ball fracturing seventh rib made its exit through the eleventh rib. An abscess, the size of a large orange, was found extending from an inch to the left of the median line to the wound in the middle of the eleventh rib; the abscess did not open into the pleural cavity. It contained about one ounce of pus mixed with dark fluid. The walls, which were of a greenish black color, were partly covered with thick pus. ^ A fistulous opening from the larger curvature of the stomach into the abscess was found. The fistula was more than half an inch in diameter, and, in appearance, resembled the anus of a chicken. Specimen was preserved and sent to S. G. 0., August 1, 18o4." [ The Museum reception book shows that two specimens were received from Fairfax Seminary Hospital on August 2d, a sternum and a humerus, which were mounted, and numbered 2914 and 2915 of the Surgical Series. There is no minute of the reception and rejection of any other specimen from Fairfax Seminary at or about that date. The absence of such a memorandum is conclusive evidence that the specimen was never in the preparer's hands, and affords a strong presumption that it was not received at the Museum. It is true, that among the vast number of specimens arriving at the Museum during that month, some were buried after a superficial examination, on account of being in an advanced state of decomposition; but it is believed that not much of value was lost in this way. The loss of the rare specimen in question, however it occurred, is much to be lamented.] A third patient lived eighty days from the date at which the stomachal fistula was first observed, one week after the reception of the injury: Case 202.—Private Robert B. E------. Co. I, 207th Pennsylvania, aged 24 years, was wounded in the general assault on the lines before Petersburg, April 2, ISO."). Admitted to the field hospital of the 1st division of the Ninth Corps. Surgeon A. F. Whelan, 1st Michigan Sharpshooters, recorded the case as a severe penetrating shot wound of the abdomen, complicated by a serious flesh wound of the forearm. An expectant treatment with simple dressings was ordered, and, on April 5th, the patient was placed on the hospital transport State of Maine, to be sent to Alexandria. Acting Assistant Surgeon W. H. Finn records the case on the register of the floating hospital as, from its direction, probably implicating the spleen. The patient was placed, on April 6th, in the third division of the General Hospital at Alexandria, where the ward surgeon registered the diagnosis as " gunshot wound of the abdomen, with perforation of the stomach," and the prognosis as " unfavorable." None of the foregoing records advert to the symptoms. The condition, on admission at the Alexandria Hospital, is thus recorded in an unsigned case- book : "A conoidal ball entered the abdomen on the left side between the eighth and ninth ribs, and passed completely through, perforating the stomach, and making its exit two inches below and a little without the right nipple. There is also a flesh wound of the right forearm, the same ball having passed through it. There was but little prostration of the system. The pulse was normal and the appetite good, and his food seemed to digest well. He suffered no pain; say#s his wounds are only a little sore. There were no symptoms of peritonitis. Prognosis unfavorable. April 7th, still cheerful and comfortable; pulse strong and normal; wounds were dressed with adhesive plaster and compress, with a bandage tight around the body. Appetite good; diet light and nutritious. 9th, still comfortable; on removing the dressing this day, after his breakfast, a large quantity of half- digested food streamed out of the wound. This occurrence was witnessed by Drs. Bentley, Mackenzie, and others, and afforded satisfactory evidence of the character of the wound. There were no specially untoward attendant symptoms. 11th, no change; pulse still good; eats and sleeps well; appears cheerful and contented ; there is some irritation of the cuticle about the lower wound, caused by the escape of the contents of the stomach. 13th, last night patient had an attack of colic from flatulence; was relieved by aromatic water; he seems as well as usual this morning. 22d, a little depressed in mind ; wounds look well; he takes tincture of sesquichloride of iron as a tonic; no food has escaped for two days. On the 24th, the patient was trans- ferred to Sickles Barracks." Sickles Barracks was the designation of another division of the General Hospital. The motive for the transfer is not indicated. It was probably to make room for fresh arrivals of wounded. Here the ward surgeon registers the case as a "perforating wound of the chest, with injury to the lung," and states that the patient "died June 29, 1^55, from exhaustion." There is no indication on Surgeon E. Bentley's reports that an autopsy was held; but he gives the cause of death as "gunshot wound of stomach." The absence of the pathological preparation is not alone to be regretted. There is no account of the later progress of the case. An occasional entry by Acting Assistant Surgeon E. Neal, on the prescription-book of Ward O, of Dover's powder with tannic acid, or of camphor mixture with bitter infusion, constitutes the only record of the patient that can be traced during the two months following his transfer to Sickles Barracks. In the three cases, the fistules were secondary, and, of course, incomplete at first. In Case 200, the communication between the cavity of the stomach and the exterior was not established until the seventh week from the infliction of the injury; in the second cast', the fistula was complete at the end of three weeks; in the third, at the beginning of the second week. One lived only a week after the fistula became complete; the second, four weeks ; the third, nearly twelve weeks. SECT. III.] WOUNDS OF THE STOMACH. 55 Any discussion of gastric fistules resulting from shot injuries would be incomplete without an allusion to the famous case of Hi. Martin, first investigated and made known That the celebrated Alexis is still (June, through the medical department of the Army 1875)1 living, at St. Elizabeth, Bcrthier County, Canada East, in the enjoyment of tolerable health, at the age of nearly seventy years, having survived his injury almost half a century,2 is proof that his abnormal condition is compatible with a reasonable longevity. The external appearance of the fistula (Fig. 34), which I have copied from an original drawing, printed by Beaumont in 1833, has undergone comparatively little modification since that time. The posterior wall of the stomach falls against the opening as a valve, and sometimes protrudes ; but no other retentive dressing is found necessary than a loosely folded silk handkerchief. The annexed diagram (Fig. 35) represents the relative position of the fistulous opening and the direction of movement impressed on in- gesta by peristalsis, as observed by Beaumont.3 The only other recovery, with gastric fistula, from a shot wound of the stomach, definitely recorded in surgical annals, is that of Maillot, wounded in Mollendorf s repulse of the French at Kaiserslautern, in May, 1794. In this little known, but authentic case, recorded by Baron Percy, the fistula gradually contracted, and ultimately closed. Reverting to the lesions of the stomach observed during the War of the Rebellion, it is possible to append to tbe history of the case of BowTes a very important addi- tion, which has been communicated since the abstract, on page 46, passed through the press. Dr. A. Hard, of Aurora, Illinois, formerly regimental surgeon of the 8th Illinois Cavalry, has written the following statement, FIG. 34.—Gastric fistula of Alexis St. Martin: "The engraving rep- resents the ordinary appearance of the left breast and side, "the aperture filled with the valve, the subject in an erect position. A A—the circum- ference and edge of the aperture, within which is seen the valve. B—the attachment of the valvular portion of the stomach to the superior part of the aperture. C— the nipple. D—the anterior portion of the breast. E—the scar where the opening was made with the scalpel, and the cartilages taken out. FFF—cicatrice of the original wound, around the aperture.'' [After Beaumont, op. cit., p. 25.1 Flo. 35.—Diagram to show the situation of the abdominal opening in St. Martin's case, and the jren- eral direction of movement impressed on the semifluid food in the digesting stomach. [After Dr. W. BllIX- TON, in TODli's Cyclop, of Anat. and Phys., Vol. V, p. 314.] i Dr. F. H. Hamilton CI Treatise on Military Surgery and Hygiene, 1865, p. 360) concludes his account of the case with the characteristic obser- vation : " We are not informed as to the precise period of his death or of its cause," and thus misleads NkudSrfeu (Uandbuch der Kriegschirurgie. Leipzig, 1867, S. 707) and his numerous readers. St. Martin has already survived this solecism seven years. 2 BEAUMONT (Experiments and Observations on the Gastric Juice, and the physiology of Digestion. Plattsburgh, 1833, p. 10) states that St. Martin, a Canadian, of French descent, was about eighteen years of age when wounded, June (i, ] 8^2. at Miehillimaekinac, when; Dr. BEAUMONT was then stationed as surgeon of the post, now designated Fort Mackinaw. 3For a full description of the early history of this case the reader is referred to Beaumont's work already cited. Another edition was published in Boston, in 1834. A nearly textual copy of BEAUMONT'S narrative was printed in the American Medical Recorder for 1825, Vol. VIII, p. 14, under the title of: A Case of Wounded Stomach. By JOSEPH Lovhll, Surgeon General, V. S. A. Very strangely the editor omitted to alter the pronouns or otherwise modify the history communicated by Dr. Lovell, and the reader is liable to be deceived, as was Professor Romberg (Liber Todlichlccit der Magenicunden, in Schmidt's Jahrbiicher, B. 4G, S. 230) (and as I was, for a long time), into the belief that Dr. LOVELL is relating his own personal observations. That Dr. Lovell was not responsible for this error, those familiar with his spotless reputation felt sure ; but the editor, Dr. Calhoun, has deferred his vindication for twelve months, printing in the December number of the Recorder (Vol. VIII, p. 840,—the article was printed in the January number) an obscure paragraph, with a brief allusion to the "mistake"! Soon afterward Dunglison described the case, with remarks on its physi- ological relations, in his Elements of Hygiene, Philadelphia, 18:i.">, p. 216. Interesting accounts of St. Martin's condition in May, 1856, during a visit to New York, may be found in the Medical and Surgical Reporter, Vol. IX. p. 305, and the Boston Medical and Surgical Journal, 1856, Vol. LIV, p. 260. An account of his visit to Cincinnati, in the same j-ear, is published in the Cincinnati. Medical Observer, 185G, Vol. I, p. 325. Dr. FRANCIS G. SinTII'f. papers on this case, entitled Experiments on Digestion, are published in the M-^ienl Examiner. 1856. X. S., Vol. XII, pp. 385-513. 56 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. which sets at rest the doubts I there ventured to express regarding that case, and estab- lishes it, beyond question, as an authentic instance of recovery from a shot perforation ot the stomach. Dr. Hard writes, March 18, 1873: * * "I recollect the case of Private Bowes very well. He was shot, with a mini6 ball, in tlie stomach, the day before the battle of South Mountain, near Middletown, Maryland [September 14, ISiW]. and came under my care immediately. The ball penetrated the stomach, as was proved by liquids which he drank escaping through the wound. I was unable to tin.l the ball. At first he suffered severely, and he vomited blood. He could not bear the recumbent posture; hut had his shoulders raised, lvinij in a semi-recumbent posture. I gave him opium freely, to allay pain. The next day, as I was obliged to go forward'with my regiment, the patient passed into another surgeon's hands. Since his discharge, Bowes has fully recovered; has married, and has children, and now resides at Crete, Cook County, Illinois." [See Case 185, p. 46, ante.] The following is an extract from a letter from Mr. Bowes, dated 130 Walsh street, Chicago, March 26, 1873: " Dfak Sir: Your letter of the 6th instant has just come to hand. As I do not reside in Crete, it has been some time m reaching me. It was about three months after I was wounded that the vomiting of blood stopped entirely. During the latter part of that time, it occurred only when I was moved from bed to bed. The escape of food stopped previous to that, I think about nine or ten weeks after I was wounded. I was not wounded on March 6, 1833, or afterwards." [A. G. Report of Illinois, 1867, Vol. VIII, p. 17-"), gives this erroneous date.] Then the observations of the War on this subject may be summed up as embracing four fatal punctured or incised wounds, one incontestable recovery from a shot perforation, a few recoveries from shot wounds in the gastric region, in which the diagnoses were not determined unequivocally, and nearly sixty fatal cases of more or less complicated shot wounds of the stomach. Deeply regretting the series of unfortunate incidents1 that impaired the value of some of these observations, in suppressing the light they might have thrown upon the morbid anatomy of these lesions, I have borrowed from Dr. Klebs the representation (Fig. 36) of the process of repair in a partial recovery from a shot wound of the stomach. The preparation was taken from a patient, Helsber, 88th Regiment (Baden), wounded August 6, 1871, at Worth, by a chassepot ball, which passed through the spleen, stomach, liver, diaphragm, left lung, right pleural cavity, and right humerus. He lived until August 24th, eighteen days: "Following the shot channel to the left, two shot openings were found in the stomach, one of which had united with the left shot open- ing in the liver, forming a funnel-shaped cavity, from the bottom of which a very narrow channel led to the liver shot channel. Opposite the first opening, at the fundus, was a circular opening in the wall of the stomach, one centimetre in diameter, with sharp edges, covered with mucous membrane, the basis of which was formed of closely attached reticulated tissue."2 The promptness with which incised wounds of the stomach may cicatrize, is exemplified by the case recorded by Dorsey,3 of a "man whose stomach was wounded after drinking Fig. 36.—Stomach laid open along the greater curvature to show a cicatrized shot track: a, cardia; b, pylorus; c, duodenum; ^omentum major; e, entrance and healed track; /, exit wound, with fistule; g, submucous shot-track. [After Klebs. Path. Anat. der Schusswund., Taf. VII ] 1 The loss of the pathological preparations in Casks 195 and 201, respectively, is a source of much chagrin. The specimen in the latter case would appear not to have reached the Museum. The disappearance of the other specimen I cannot explain. I recall a dried preparation cf a stomach submitted to me, with a deposit of lymph an inch long toward the cardiac end of the great curvature, with the inquiry whether it could be regarded as a shot cicatrix ; but can find nothing to connect this circumstance with the specimen in question. Habitually, at the Museum, when a specimen is rejected or discarded, a memorandum is attached to the history, statiDg the reason. In the absence of any such record, the fate of this preparation is left a matter of conjecture. 2 See, for a further clinical history of the case of Helsber, Sociw Kriegschirurgische Erfahrungen, Leipzig, 187:?. S. 93. 3 DORSEY, Elements of Surgery. 1818. p. 91. SECT. III.l WOUNDS OF THK STOMACH. 57 porter. The wound of the stomach was found, on dissection, completely healed; the patient died on the fourth day, of peritoneal inflammation." In several of the early fatal cases it was noticed that there was neither escape outwardly, nor extravasation within the peritoneal cavity, of the undigested food which partially filled the wounded viscus.1 But extravasation was the rule; and, as was indicated in referring to ruptures of the stomach (p. '2'2. and note 2, p. 27), the fatal issue was more prompt when the injury was received while the organ was in a* state of repletion.2 Hsematcmesis generally occurred very soon after the infliction of the injury; but it was not an absolutely constant symptom.3 There was commonly intense pain at the seat of injury. The pain was apparently in relation with the extent and acridity of the intra-peritoneal extravasation. Instances are adduced, unattended by extreme pain, in which blood was freely effused in the peritoneal sac; but, where the pain is described as excruciating, it commonly appears that irritating, undigested food had escaped into the cavity of the belly. Blood flowing into the stomacal cavity induced vomiting, followed by persistent hiccough. The external haemorrhage was seldom considerable. In most of the cases intensity of thirst was noted. Nearly all were attended by constipation, and many by dysuria. Thus, in several particulars, the facts observed were conformable to the deductions of theory. But there were many unexplained exceptions. The group of cases is so large, comparatively, that, added to the evidence existing in surgical annals, it should afford us a better approximative estimate of the frequency and fatality of wounds of the stomach than has heretofore been entertained.4 Contemporary authors still cite Percy's estimate that in punctured or incised wounds of the stomach four or five in twenty may survive.5 But if, from the time of Albucasis to the present day, a score of authentic recoveries from lesions of this class may possibly be gleaned, it would not be difficult to adduce many times that number of fatal cases, and a mortality rate of 99 would be nearer the truth than Percy's estimate of 75 per cent. The unequivocal recoveries from shot wounds of the stomach, with or without fistula, number only six or 1 Good accounts of autopsies in two such cases are recorded: one by Dr. 11. K. SMITH (Case of Wound of the Stomach, in the Medical Examiner, 1851. N. S., Vol. VII, p. 162;, in a case where there was no extravasation or vomiting, though the stomach was tilled to repletion, and the patient survived for twenty-six hours an incised wound an inch long near the cardiac extremity of the stomach. Another, by Dr. RAFAEL (Western Jour, of Med. and Surg., 1849, Vol. IV, p. 113), where there was no extravasation, though the stomach was "half full of ingesta.'' 2 Teipler and Dr. Chisolji (ante, p. 41, note 1) are at variance as to the probable average condition of the soldier's stomach in action. It dees not appear to be a question to be determined a priori. Tripler (Peninsular Jour, of Med., 1856, Vol. IV, p. 1) says : '■ In the aggregate number of wounds received in battle, it is fair to presume that no inconsiderable proportion will involve the stomach. When a General can choose his time for engaging the enemy, he will be careful to secure to his men a good meal beforehand. Men, generally, go into action with the stomach well filled. Occupying, as it does under these circumstances, so large and so central a space in tho body, it can hardly escape in the indiscriminate lesions conse- quent upon a well-directed fire. And yet, few military surgeons have seen many cases. Hennen says he never treated one. * * There can be but one reason for all this—that is, that this lesion is almost invariably and speedily fatal. The stomach is so important an organ in its functions, in its relations, and its nervous connections, that it will rarely bear so severe an injury as that of a gunshot wound. Hennen remarks: ' Baron Percy calculates that out of twenty cases, four or five only have escaped; this, however, is a most favorable average.' Sir G. Ballingall thinks Percy has abundant reason to be satisfied with his success, and that the experience of others will hardly warrant us to expect a like result. A just prognosis as to the issue of gunshot wounds of the stomach cannot be deduced from the result of penetrating wounds fr.mi other causes, whether accidental, or due to operations for the extraction of foreign bodies. The circumstances are altogether different, and, in the latter case, time, place, and other accidents can all be com- manded. The gunshot wound, on the other hand, partakes of the nature of a violent blow upon the stomach, a circumstance of itself frequently fatal; its extent is greater than most other penetrating wounds, its shape irregular, its situation as likely to be the most unfavorable as any other, and, in general, the time of its infliction will be when the stomach is distended with food. So that it appears to me, that even when the sufferer reaches tho hospital alive, the most unfavorable prognosis is the only prudent one in every case." 3 For an interesting case by Dr. RliEO, with a discussion on the occasional absence of this symptom, by Drs. GllOSS, Woodward, and HARRIS, refer to the Proceedings of the Pathological Society of Philadelphia, in the Am. Jour. Med. Sci., IhIO, N. S., Vol. XL, p. 121 et seq. 4 According to Ma HON (Vol. II, p. 122) wounds of the stomach were pronounced mortal, by the faculty of Giessen ; absolutely mortal, by that of Frankfort; lethal, at Leipsig; not necessarily lethal, at Helmstadt. Bohn and Teichmeyer held that all complete divisions of the walls of the stomach are fatal, and that escapes are miraculous, while Albekti, B03U1IAAVE, and VALEXTINI, in his Pandects, considered only those wounds mortal that implicated the great curvature, the cardia, or the pylorus. 6 Percy, Bulletin de la Faculte de Midicine de Paris, 1818, T. V, p. 390. There could not be a better exemplification of the tenacity of error. PEI'.CY was generally a very accurate writer, and would have been-thc first to explain that he was merely hazarding a rough guess. But this sentence has been accepted as a record cf the vast experience of the best-informed military surgeon of his day, and has beeu repeated, without examination, by almost every writer on the subject. It is often ascribed to LARREY. As late as 1869, Mr. BLENKIXS (Additions to COOrEK's Dictionary, p. 831) tells us that wounds of the stomach "arc very fatal. Baron LARREY calculates (!) that four or five only, out of twenty, survive." 8 58 PENETRATING WOUNDS OF THE ABDOMEN. |ciiai\ vi. seven.1 A large proportion of the injuries of this group must be sought in the returns of those killed in action. Of shot wounds of the stomach that come under treatment, the percentage1 of recovery is small. The sixty-four cases of the War of the Rebellion that came under surgical observation, presented a single instance of undoubted recovery, after a shot penetration of the walls of the stomach. Of shot injuries without penetration of the viscus, three wore followed by secondary gastric fistulae, and eventually terminated fatally. In the single example of lodgement of a ball .in the cavity of the stomach, there was no question of gastrotomy,2 an operation unlikely to be called for in military surgery. iThe five cases of Maillot (1794), St. Martin (1822), the grenadier reported by Baudexs (1833), the case of Speed (1859), and that of Bowes (1864), can alone be regarded as well-attested recoveries from shot perforations of the stomach. In the cases recorded by BECK, SdlOLTZ, Fischer and LOVELL, TlUTLER, Thomson, Breto.v, there is doubt either in regard to the extent of the injury or the value of the evidence. Dr. E. Trenor (Western Lancet, 1872, p. 68) admits that the evidence cf penetration of the stomach in a recovery reported by him is not conclusive. M. SliDILLOT (/. c. p. 407) gives credit to a case of traumatic fistula of the stomach resulting from a gunshot wound, which is reported by THOMASSIN (Obs. iatro- chirurgiques deJ. Covillard, and notes, Strasbourg, 1791). Covillard, a surgeon of Montelimart, wrote in 1633-40. From Thomassin's citation, it would appear that he describes from hearsay this gastric fistula, in a soldier wounded in the battles of the Prince of Harcourt against the Spaniards (about 1639). M. Sedillot says that " Falloeius relates that he had cured a man and a woman of wounds of the stomach, from which food escaped. The woman had been perforated (tr.ivorsee do part en part) by a leaden ball, and God, he says, saved her, because she had resumed chaste and holy habits after having been a strumpet," and refers to the commentary de vulneribus capitis, cap. XII. M. SEDILLOT translates, almost toxtually, from SCIIl'.NCKirs (06*. Med. Rar., Leyden, 1644, Lib. Ill, p. 332), who quotes FALLOPIUS as follows: "Nam sanavi mulierem, et hominem u quibus egrediebatur chylus, et cibus. Sanavi mulierem, glande percussam plumbea ab antericri et posteriori parte. Et hanc Deus sanavit: quia meretrix quondam fuit, jam caste et sancte vivit. * * Fallopius de vulneribus capitis, cap. XII." The reference is to the commentaries of Fallopius on Hiitocrates, de vulneribus capitis. Other writers refer to the miraculous case of tho reformed harlot as in the twentieth chapter of FALLOPIUS, de vulneribus particularibus; but neither here, nor in the commentaries, is this passage to be found, either in the Venice edition of 1606, of the genuine works of Fai.lopii'S. or in the Frankfort edition of 1600. In the text, I have allowed for one or two instances of cicatrization of wounds of the stomach, with death from complications. Those with an appetite for the marvellous can consult Dr. Grant's Case of Gunshot Wound of the Heart and Stomach, in the Charleston Med. Jour, and Rev., 1857, Vol. XII, p. 303, in which the patient is said to have survived for twenty-six days a shot perforation of the stomach and right ventricle of the heart. 2In treating of wounds of the stomach, Hexnen (op. cit., 3d ed., p. 443) remarks: "The histories of the Bohemian, Prussian, and English 'cultrivores,' in some of whom the knives have been cut out, and in others discharged spontaneously through the coats of the stomach and parietes of the abdomen, as well as many other instances on record, are very encouraging in cases of injuries of this organ. * * * The industrious Plouequet * * * has exceeded all other authors for the vast number of cases he has amassed." When the repetitions are eliminated, the number is anything but vast. Mr. Bryant (A Practice of Surgery, 1872, p. 314) states the number of successful operations for gastrotomy as seven. Mr. Durham (Holmes's System, 2d ed., Vol. II, p. 549) professes to enumerate seven, inadvertently duplicating the first by the fourth, and really naming six cases. Since the revival of this operation, in 1849, by M. Sedillot, the old chronicles have been again ransacked for illustrations. Larrey (Mem. de Chir. Mil., T. Ill, p. 90). remarking that "ees faits sont extremenient rares," tells us that he was shown at Konigsberg a small knife that "a eultrivor named Andreas Gucuheid swallowed in 1613. The grave symptoms that supervened led Dr. Gruger, a Polish surgeon, to do the operation of gastrotomy ; it was done May 29th of that year, and the peasant lived ten years afterwards." The good baron is evidently citing from memory. The peasant's name is not very incorrectly given, but there is an error of twenty-two years in the date. The knife was swallowed May 29, 1635. Gastrotomy was practised July 9, 1635, by Dr. Daniel Schwabe, of Konigsberg, in the presence of the faculty. Hevin, in his encyclopaedic memoir, already cited (Sur les corps etrangers arrestes dans Vcesophage, Mem. de I'Acad. royale de Chir., 4to, T. I, p. 595), informs us that the case of this Prussian peasant is recorded by several writers, of whom he specifics Cluverus (not Gruger), in the second volume of his history of Prussia (Epitom. Histor., Lib. II, Cap. II), and BECKER (in the appendix to the Ephemerides, Dec. II, ann. 5 and 8, Obs. 167). In fact, Becker prints a portrait of the patient in his paper, dated 1643. Menzel also refers to him (Mis. Nat. Cur., Dec. II. ann. I. Obs. 1). SOUTH (Notes to Chelius, Am. ed., Vol. Ill, p. 106) correctly refers to this case as quoted from Becker of Dantzig. by Barnes (Edin'j. Philosoph. Jour., 1824, Vol. XI, p. 323), who gives the name of the peasant as Andrew Grun- beide. but wrongly names the operator "Shoval.'' This misprint is copied by Froriep; and Gunther (Die Blut. Op., B. IV, Ab. XV. S. 26), remark- ing on the identity of the case, wonders where FRORIEP found the name of the operator as "Shoval," the correct name being plainly Schwabe, that of a well-known lithotomist. Olivkr (Philosoph. Trans., Jones's ed., oth Vol.) tells us that he saw the knife at Konigsberg, in 1685. It was kept in a velvet bag in the library of the king of Prussia. It was six and one-half inches (English) in length. .Mr. Durham (Holmes's System, 2d ed., Vol. II, pp. 549-550) tabulates this case twice. Thus the Prussian eultrivor, Grunheide, on whom Schwabe practised gastrotomy in 1635, has played many parts, figuring as Schwabe's case, Gruger's, Shoval's. Becker's, and Menzel's. and referred to by the careless even as Hevin's or Larrey's case, the case or cases in the Philosophical Transactions, in the Ephemerides, and cited in an incredible number of collections. There was a second Prussian eultrivor, a woman, from whom IIenricii Bernard HiniXEn, of Rastenbourg, felicitously excised a knife, in 1720 (Relation von der ermlandischen Messer- schluckerin. Konigsberg, 1720). This case is cited by Hevin, Haller, and a multitude of others. Mr. Durham incorrectly dates it "about 1743." The Bohemian knife-swallower played protean parts also, excusably, perhaps, as he was a juggler, Matthews by name, who lived in the suburbs of Prague, in 1602. The erudite Hevin (1. c, p. 596) also relates this case, from CROLLIUS (in Prof. Chym. regal. Basil. Ephemerides, Dec. 2, ann. 10. Obs. 1). Gastrotomy was successfully practised by FLORIAN Mathis, surgeon to the Emperor Leopold. There were two (so called)' English cultrivores; though one, John Cummings, was an American sailor, whose case, yet remembered by old people in Boston, is related by M.yrcet (Med. Chir. Trans., 1823, Vol. XII, p. 52). The history of the other, William Dempster, of Carlisle, is related by Barnes (Edinb. Philosoph. Jour., 1821. Vol. XI. p. 319). Gastrotomy was not practised in either case. There is no question regarding the successful gastrotomy by CAYROCHE (Bull, de la Faculte de Med.. 1819, T. VI, p. 447), in the case of Madame S------, aged 24, who swallowed a silver fork, in 1819; nor of the successful excision of a silver spoon from the stomach of a soldier in 1823, by Dr. L------, endorsed by Sedillot (Contributions a la Chirurgie, 1868, T. II, p. 456): nor concerning the successful gastrotomy for the removal of a bar of lead from tbe stomach of a man named Bates, aged 27 years, by Dr. JOHN Bell, of Wapello, Iowa (Boston Med. and Surg. Jour., 1860, Vol. LXI, p. 489; reported also by Dr. T. B. Nkal, in The Med. Examiner, N. S.. 1855, Vol. XI,' p. 193). Two cases of alleged successful gastrotomy, reported by Dr. Charles B. New, of Rodney, Mississippi ( Western Jour, of Med. and Phys. Sci. 1838. Vol. XI. p. 551), and by Dr. A. Ewing, of Bayou Sara (New Orleans Med. and Surg. Jour., 1853, Vol. IX, p. 764), are not usually included in the summaries of this operation. The editor of the American Journal (Vol. XXIV, 1839, p. 261) remarks of the first, that it is "nothing short of miraculous." Ihe treatment to which "the negro man—the property of John E. Hammons, Esq., of Carroll County, Mississippi,"—was subjected, in "the second case, appears to be regarded as equally outside the domain of surgery. The story of the stick, ten inches long, removed from the stomach of Mateo Sanchez, in 1830. by Francesco Garcia Y Garcia (El Porcenir Medico, 1854), translated for the Medical Examiner, 1855, Vol. XI, p. 91, by Dr. W. S. W. RUSCHEN- BERGER, is akin to this group. Baron Larrey's recollection (Me^wires, T. Ill, p. 90) of seeing, as a student, Professor Frizac, of Toulouse, remove a knife from the stomach of a canal porter, through an epigastric incision, uniting the wound in the stomach by two stitches, and the wound in the walls by the quilled suture, though explicitly recorded, appears to have been overlooked; and the case f the young man described by M. Bonsso.v SECT. III.] WOUNDS OF THE STOMACH. 59 FIG. 37.—Jobert's sutur" Fio. 38.—Lembert's snture. Neither was gastroraphy employed in any case. This resource merits more consideration than it receives ; for the majority of recoveries from wounds of the stomach have been instances of the successful use of sutures.1 The complexity of shot wounds, and the attendant lesions of neighboring organs, com- monly forbid recourse to this expedient. But in accessible shot wounds of the anterior wall, this means of arresting fatal extravasation should not be neglected. I regard the refresh- ing of the bruised edges in gastroraphy and enteroraphy as unnecessary. In the modern methods of applying sutures to the alimentary canal, inversion and approximation of the serous surfaces is universally sought. (See Figures 37 and 38.) Now in all shot wounds of the digestive tube that I have examined, the loss of substance is mainly confined to the muscular, connective, and mucous tissues, the serous membrane remaining sufficiently organized to hold stitches. It will be sufficient to unite these surfaces (adosser les sereuses), and what sloughing of the inner tunics there may be, can discharge into the digestive cavity.2 (Sedillot, 1. c, p. 463), who showed the cicatrix, through which a fork had been removed from his stomach, to Professor Caizergues and other members of the faculty of Moutpellier, is also omitted from the later enumerations of successful examples of gastrotomy for the removal of foreign bodies. Many unsuccessful operations have been done for the alleviation of the condition of patients with stricture of the oesophagus. Mr. Durham records nine: two by M. SEDILLOT (/. c, pp. 184 and 494), in 1849 and 1853: one by FENGER, of Copenhagen, in 1854 (Arch, fur Path. Anat. and Phys., B. VI. S. 350); two by Mr. C FORSTER. in 1858 and 1859 (Guy's Hosp. Rep., 3d Ser., Vol. IV, p. 13, Vol. V, p. 1); two by Mr. S. Jones, in I860 and 1860 (Trans. Path. Soc. of London, Vol. XI, p. 101, and Lancet, 1866, Vol. II, p. 6C5) ; one by Mr. T. B. CURLING, in 1866, (Lond. Hosp. Rep., 1866, Vol. Ill, p. 218); one by Mr. A- Durham, in 1868 (Guy's Hosp. Rep., 3d Ser., Vol. XIV, p. 195). To these may be added a fatal case recorded by Mr. THOMAS Bryant (Tlie Practice of Surgery, 1872, p. 316); one by Dr. F. F. Maury (Am. Jour. Med. Sci., 1870, N. S., Vol. CXVII, p. 365); and one by Dr. LOWE (Lancet, 1871, Vol.11, p. 119); one by Mr. Thomas Smith (Trans. Clin. Soc, London, 1872, Vol. V, p. 236); two by Mr. \VM. MacCORMAc (Idem, p. 242). one in his own, and the other in the practice of Mr. Le Gros CLARK; and one by Dr. F. Troup (Edinb. Med. Jour.. 1872, Vol. XVIII, p. 36). Thus, there are six authentic instances of successful gastrotomy for the removal of foreign bodies, viz: Matihs's, in 1602; Sciiwabe's, in 1635; Huuners, in 1720; Cayroche's, in 1819; Dr. L-----'s, in 1833 (attested by M. Sedillot) ; and Dr. Bell's, in 1823. There are also the five less credited successes, of FrisaC (about 1790) ; the Montpellier case, related to M. Sedillot by M. BOUISSON (about 1828) ; of Garcia, in 1830; and those of Drs. NEW (1837) and Ewing (1852). I find one unsuccessful gastrotomy for the extraction of foreign bodies recorded, but cannot verify the reference. Gunther (I. c, S. 27) ascribes to GlOck, in America, in 1856, an unsuccessful gastrotomy for the removal of a laryngeal probang accidentally intro- duced into the stomach. On the other hand, when performed for obstruction of the oesophagus, gastrotomy has resulted fatally in sixteen instances, at least. Dr. AsHHURST (Am. Jour. Med. Sci., N. S., 1873, Vol. LXV, p. 487) refers to another fatal case reported by Mr. Mason. M. Sedillot (Contri- butions A la Chirurgie, T. II, p. 405) gives "the name gastro-stomie (yao-rrip, stomach; aTojia, mouth) to the operation of establishing a permanent opening in the walls of the stomach," and Dr. AsHHURST (Am. Jour. Med. Sci., 1873, N. S., Vol. LXV, p. 487) adopts Gastrostomy as a more accurate name. But as, in the sixteen or seventeen attempts upon the human subject, an incision into the stomach has, and a permanent opening into its walls has not, been accomplished, it appears to me more accurate, as well as more in conformity with surgical idiom, to retain the name gastrotomy, and to restrict its application. 1 There is no recorded example of successful gastroraphy for shot injury unless one of Puhmann s cases may have been of that category; but of the rare recoveries from incised and lacerated wounds of the stomach, many, and these the best attested, were treated by suture. Since compiling the note on page 42, I have compared the chapters of Schenckils (06.?. Med. Rar., Leyden, 1644, p. 332) and of Stalpart van der YVlEr. (Observat. Rar., Leyden, 1687) on this subject, and am the more convinced of the rarity of authentic instances of this group, and of the correctness of Purman.n's conclusion that a fatal result can rarely be avoided except by gastroraphy, The student must not confound, as many have done, the accounts of successful gastroraphy by Galen (Meth. Med., VI, 4), Cei.sus (De re med., VII, 16), Aluucasis (De chirurgia, II, 379), Haly Auisas (Pract., IX, 43), Riiazes (Cont., XXVIII), Pare (CEuv. comp., 6d. Malg., II, 108), Van Swikten (Comment., 311), Fauricius ad Aquapendente (CEuv. chir., II, 53), and SPRENGEL (Hist, de la Med., XVIII, 21). They are all treating of sutures of the abdominal parietes under the name of gastroraphy. But Puumann's two cases; Schlicting'S; the Marpach soldier operated on by JOHN Sctie\ckelius (identical with the case reported by (ETHEL'S, HlLDESHJS, and Sciienckius), Kuiistkat'S case, identical with that recorded by Kluyskens (An. de Litt.med. Urang., Ghent, T. HI, 289); Lahoche's case ; Carterat's, Percy's. Tkavkrs's, and Ashby's case, were all examples of the successful application of the suture to the walls of the stomach. I do not include the successful gastroraphy ascribed to Stalpart van der Wiel ; for he only states, /. c, 156) that such an operation was related to him by a Belgian surgeon named Godefridus. The originality of the cases related by VEGA (Comment, in Hippoc., 1576, Lib. VI, p. 869) and Wolfius (Obs. Chir. Med., 1701, p. 83; vulnus ventriculi sanatum) is equally open to doubt. The case ascribed by Sedillot to Scultetus (Armament, chir., Francofurti, 1666, p. 85, obs. 58) was assuredly not a wound of the stomach. When the cases of gastrotomy and gastric fistula are also abstracted, there remain only the cases of Louuet, LARREY, and a very few others, of recovery from wounds of the stomach without the use of the suture. 2 Extended bibliographical references on the anatomy, physiology, and medical pathology cf tho stomach have been compiled by various authors, very fully as regards older authors, by PLOUCQUET (Repertorium, T. HI. Article Ventriculus), and later by Copland (Dictionary of Pract. Med., Am. ed., 1859, Vol. Ill, p. 1017), and Baic.E-Delorme (at the conclusion of tho article Estomac, in the Z»i'c(. de Med., T. XII, p. 383); but I have met with no comprehensive surgical bibliography. The much-cited dissertation of ETTMULLER (De Vulnere ventriculi programma, Lipsia?, 1730, No. 143, Vol. V, p. 167 of llALLER'S Disputationes, Lausanna?, 1756) sums up, in four pages, the dicta of the ancients respecting wounds of the stomach; but contains an account of only one case, related to ETTMULLER by a surgeon of Paris. Wexcker's narrative has been already cited. Berard (Diet, de Mid., T. XII, p. 306) criticizes the accurate Samuel COOPER with unmerited severity, alleging that " le chirurgien anglais, qui sonvent cite a faux, a 6t6 plus malhcureux ouplus inexact que jamais dans le passage que je viensde transcrirc," i.e., in adducing Jungen (?) as an authority on wounds of the stomach. " La dissertation de JL'NGEN, que j'ai lue, ne renferme aucune observation de fistule de l'estomac." COOPER does not allege that it does; but simply that "further information connected with this subject"—of wounds of the stomach—may be found in it, which Is true. Curiously, both compilers 60 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. Fig. 39.—A diagram of a vertical longitudinal section of the jejunum as seen under a low power (about 50 diameters): or, villi; 6, follicles of Licberkuhn; c, submucous connective tissue; d, circular muscular fibres; e, longitudinal muscular fibres ; o, subperitoneal connective tissue; p. peritoneum. Wounds ok the Small Intestines.—Of the complications of penetrating wounds the abdoiiMT.. lesions of the small intestines are the most frequent, and contribute the largest contingent to the general mortality. The great length of this viscus and its position (Figs. 20 and 21) account for this liability to injury. Wounds oft the small intestines are often multiple,1 because of their convolutions. Of the three divis- ions of the gut, the ileum is the most exposed, next the jejunum, while wounds of the duodenum less frequently come under treatment.2 The minute anatomy of the intestine explains some of the pecu- liarities in the appearance of solutions of its con- tinuity. In punctured wounds, the opening is contracted by the circular and longitudinal fibres, and closed by the eversion of the mucous lining.3 In transverse wounds there is slight gaping from the contraction of the longitudinal fibres; but the calibre of the intestine is diminished by the contraction of the circular muscular layer and the pouting of the mucous membrane, and the escape of contained matter is impeded. In complete transverse sections of the gut, the divided extremities are separated and puckered, so that it is commonly impracticable to distinguish the upper from the lower portion except by the escape of fa3cal matter. In large longitudinal wounds,4 the contraction of the circular muscular fibres (Fig. o9,d) produces wide gaping of the edges, and readily permits the BERARD and Cooper, blunder in confounding the dissertation of F ABRICIUS, a professor at Helmstadt (de lethalitate vulnerum ventriculi, Helmst.. 1751, iu Schlegel's collection, II. S. 199), with that of Juncker, of Halle (whose name they misspell " Jungen"). JUNCK.ER, in his paper de visccrum laisonibus rite dijudicandis et congrue tractandis, Halle, 1745, and also in his Conspectus chirurgix medicse, Halae, 1720, claims to have observed several instances of recovery from wounds of the stomach. The dissertations of J. B. ROBERT (De ventriculi vulneribus, Leyden, 1770) and of D(5rr (De ventriculi vulnere egregie curato. Lipsiae, 1790) I have been unable to obtain; nor can I find the paper of HORN (De ventriculi ruptura, 8vo, Berol, 1817), cited by COOPER and others, though in MURSINNA's Journal fur Chirurgie, u. s. w., 1808, B. I, S. 3, there is an interesting report by General- arzt HORN of a recovery after a stab wound of the stomach. Riciiter's remarks on this subject (Chirurgische Bibliothek, Gottingen, 1790, B. Ill, S. 552, B. X, S. 203), Dfsault's case (Journal de Chirurgie, Paris, 1792, p. 48), and Morand's three cases (Opuscules de Chirurgie, Paris, 17C8, T. II. pp. 147, 148), and Heyfelder's paper Die Verletzungen des Magens rucksichtlich ihrer Tbdlichkeit in Heckkr's Liter. Annal, 1828, S. I), may be profitably consulted, and Romberg's exhaustive medico-legal dissertation (Uber Tbdlichkeit der Magenwunden in gerichtlich-medicinischer Hinsicht. Schmidt's Jahrb., B. 46, 1845, S. 230) is worthy of attentive study. M. Follin presents a good exposition of the subject in the article Plaies de l'estomac in the Dictionnaire Encyclopedique des Sciences Medicates, 1869, T. I, p. 159. The bibliography of ruptures of the stomach has been referred to in notes on pp. 22 and 27 ante. In two recent inaugural dissertations, Dr. Henrici (XJeber die Wunden des Magens, 75 S., Leipzig, 1864) and Dr. Hermann (Ueber die Schuss- und Stichwunden des Magens, 16 S.) have industriously collected many examples of wounds, ruptures, fistules, and operations for gastrotomy. Neither author appears to have verified his references by consulting the original publications, and Dr. Henrici is misled into the frequent reiteration of identical cases. Some cases are adduced by BlRKHOLZ, Diss, de gastrotomia, Lips., 1805, and by Marcus, De fistula ventriculi, Berolini 1835: but altogether the bulk of ancient and modern information on the subject is to be f.iund collected in the articles cited from SCHENCKIUS, IlEVIN, and Sedillot. 1 Travers, An Inquiry into the Process of Nature in repairing Injuries of the Intestines. London, 1812. 2 Jobert, Traite theorique et pratique des maladies chirurgicales du canal intestinal. Paris, 1829. 3 This eversion, which is almost constant, depends mainly upon the relaxed ccmdition of the mucous lining on contraction of the circular and longitudinal muscular fibres. It is possibly f.vvored by the contraction of the minute muscular layer between the follicles and connective tissue described by Professor Ernest BRUCKE (Uber ein in der Darmschleimhaut aufgefundenes Muskelsystem, in den Berichten der Wiener Akademie, Feb. 1851), but this is so minute that its influence must be very small. 4Gkoss. .Ire Experimental and Critical Inquiry into the Nature and Treatment of the Wounds of the Intestines. Louisville, 1843. At page 10. Professor GROSS relates the fallowing experiments: "LA longitudinal incision, two lines and a half in length, immediately contracted to one line and three-quarters, with a sufficient amount of eversion of the mu-ms lining to close the resultant orifice. 2. A similar wound, four lines long, diminished in a few seconds to three lines, by one line' and a half in width ; it assumed an oval shape, and the internal membrane protruded on a level with the peritoneal covering, leaving no perceptible aperture. 3. An oblique cut, seven lines in length, contracted to five, by two and a half in width, with marked eversion of the mucous lining. 4. A transverse wound, two lines and a half long, was reduced almost instantaneously to two lines in diameter; it was of a rounded form, and the two outer tunics of the gut retracted so as to expose the mucous membrane. 5. In another experiment, in which the incision, likewise transverse, was half an inch in extent, the orifice assumed a rounded, oval shape, and was reduced to four lines, by two and a half in width, the internal coat exhibiting, as in the other cases, a pouting, or everted arrangement. These observations are interesting chiefly as showing the efforts which nature institutes to close a breach of this kind the very moment almost it is inflicted. It is doubtless by a process of this description that the effusion of stercoraceous matter into the peritoneal sac is so generally prevented in those cases in which the solution of continuity is of small extent, not exceeding, for example, a few lines in diameter, and where, consequently.it amounts rather to a puncture than a wound. The eversion of the lining membrane forms a striking and constant feature in injuries of this character, and may be compared, in its effects, to the contraction and retraction observed in the extremities of a divided nrtci v ' SECT. I1I.1 WOUNDS OF THE SMALL INTESTINES. 61 escape of the contents of the bowel. With a few conditional reservations, wounds of this portion of the alimentary canal are justly regarded as almost necessarily fatal; not because the visceral lesion is in itself destructive, for it is susceptible of prompt repair,1 but because the conditions that will secure the peritoneum from the ingress of foreign matter are so rarely fulfilled. In the few instances of recovery that will be adduced, the fortunate issue was due to the agglutination of the injured wall to neighboring parts through plastic exudation and the escape of the intestinal contents externally. Even in these exceptional cases, there is room for doubt whether the lesions really existed in the small intestine, whether in fact the faecal discharge did not proceed from an opening in the colon. Ruptures of the small intestines without external injuries have been noticed on pag\- 22, and reference is there made to the obscurity of the symptoms of that lesion. In wounds, the demonstrative evidence by sight or touch may be superadded. The escape of the intestinal contents, or their appearance upon the vulnerating instrument alone, afford certain proof of penetration of the intestinal canal. Of about six hundred and fifty cases of penetrating wounds of the abdomen returned during the War as mainly implicating the intestinal canal, only about fifty are distinguished as lesions of the small intestines exclusively; eighty-nine were set down as wounds of the large intestines; and over five hundred as cases in which the portion of the canal injured was not discriminated, or as instances in which both portions were interested. Punctured and Incised Wounds.—As the facts adduced on pages 31 and 32 would indicate, lesions of this description were uncommon, and most of the-examples were the results of stabs inflicted in private brawls.2 Very few sword or bayonet wounds involving the intestinal canal came under treatment, though a number of examples of such injuries were observed on the bodies of those slain in battle.3 In the case of Private J. W—-----, cited on page 42, a bayonet stab in the left hypochondrium, the jejunum, as well as the stomach, was perforated. The preparation of the inverted intestine is shown in the adjacent wood-cut (Fig. 40). The characteristic triangular form of the punc- ture is noticeable. Four or five other cases were reported. Faecal extravasa- tion, promptly followed by fatal traumatic peritonitis, appears to have attended them all. The absence of protrusion of the wounded viscera, in this series, was remarkable, and explains why sutures were so little employed. Since the piG.4o.—Bay- War, this means has been twice resorted to successfully. onneTeUuium" Spec. -2-2%). Case 203.—Private W. Tilan, Co. H, 1st Virginia Artillery, aged 19 years, was stabbed while in camp at New Creek, Virginia, November 13, 1864. The weapon, a knife, penetrated the abdominal cavity and wounded the small intestines. The patient was taken immediately to the post hospital. -There was no protrusion of the viscera. Simple dressings were applied, and opiates were administered. Acute peritonitis set in, and the patient died on the following day, November 14, 1864. The case is reported by Acting Assistant Surgeon W. B. Crain. Case 204.—Private D. F. Chappel, Co. L, 1st New York, a stretcher bearer of Battery D, 5th U. S. Artillery, received a sabre thrust in the abdomen, at Petersburg, June 18, 1864. He was admitted to the hospital of the Fifth Corps on the same day. He was suffering from severe shock. The wound had been dressed at the front, the walls being united by sutures and 1 HIPPOCRATES (Aphor. VI, 24) declares: "'Evripiov r\v JiaKocij rS>v kcTtriiv ti, ov £vfj.t)\CTai "; si quid gracile intestinum persectum sit, non coalescit. Fernelils (Universa medicina, Genevae, 1670, Lib. VII, cap. 8, De externis corporis affectibus, p. 633, de vulnere intestinorum) comments on this aphorism. AVei:f.R (De curandis intestinorum vulneribus, Berlin, If-30) gives a list of commentaries en it. 2 Mr. Le GROS CLARK (Lectures on the Principles of Surgical Diagnosis, 1870, p. 299) justly observes: "Recorded instances of recovery, after a penetrating wound of the abdomen with a sharp instrument, are rare; and such fatal result, as the general consequence of wound of intestine, when hi communication with the peritoneal cavity, is in accordance with tho issue of experiments which have, from time to time, been performed on the lower animals, and especially recorded by Mr. Travers, and more recently by Dr. Gross, of Philadelphia. For, the conditions suppose the escape cf some portion of the intestinal contents, whereby acute peritonitis is established; and from this cause, as in similar lesions otherwise produced, fatal collapse follows." 3 See reports of Surgeon J. R. SMITH, U. S. A., and of Assistant Surgeon H. E. BROWN, 70th New York, cited in the surgical report of Circular N*o. 6, S. G. O., 1865, p. 40. i\2 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. Fie. 41. —Section of ileum, showing everted mucous membrane at the two orifices of a stab- wound. Spec. 568!'. supported by adhesive straps and bandages. It was not deemed proper to disturb the dressings. There was already a good deal of tympanitis and considerable pain. The depression was so great that it was necessary to give brandy. Morphia was also freely administered. Tlie patient was transferred to general hospital at City Point, June 19th, and died on June 20, 1MII. The case is reported by Surgeon W. S. Thompson, U. S. V. The particulars of the autopsy are not recorded; but, from the scat and direction of the wound, it was inferred that it penetrated the small intestines. Case 205.—Private J. Gossett, Co. D, 12th East Tennessee Cavalry, entered Hospital No. 19, Nashville. January 2, 1864, having been "stabbed in the belly by a sword." There was no visceral protrusion ; but extreme pain and tension indicated the probability of lesion of the intestine. The intense peritonitis was not controlled by the free administration of opium. The case, reported by Surgeon John W. Foye, U. S V., terminated fatally, January 8, 18f>4. The following case, though not belonging to the war series, may be noted here, as having furnished a pathological preparation to the Museum. It was recorded in 1867, by Surgeon J. T. Ghiselin, and the specimen was transmitted in 1870, by Surgeon J. H. Bill. It will be observed that the appearances, as accurately represented in the wood-cut (Fig. 41), of punc- tured stab wounds of the intestine, are not dissimilar to those sometimes observed in small shot wounds (see Fig. 47, on page 70). In preparations preserved in alcohol these lesions are not readily distinguished: Case.—Bugler Dennis W------, 1st U. S. Cavalry Band, in a quarrel on July 2, 1837, at Fort Vancouver, received a stab, from a butcher knife, in the right groin, a half inch above Poupart's ligament. He died on July 8, 1867, of traumatic peritonitis. In the next case it was necessary to apply ligatures to several branches of the mesenteric artery, and enteroraphy1 was very properly though unsuccessfully practised:2 Case 206.— D. Brazee, a freedman, aged 2"> years, received a punctured wound of the abdomen, from a knife, in a fight on the steamer Cook, at Vicksburg, June 5, 186.">. He was conveyed to the hospital for freedmen. The wound was two inches in length, and was situated one inch to the right of the left anterior superior spinous process of the ilium. Knuckles of the jejunum and ileum protruded. The intestines were cut in three places, and several branches of the mesenteric artery were divided. Surgeon T. J. Wright, G4th U. S. Colored Troops, closed the wounds of the intestines by sutures, ligated the wounded branches of the mesenteric artery, and enlarged the opening and returned the intestines. The wound of the parietes was then closed by sutures, and simple dressings were applied. Death resulted on the next day. Extravasated blood and faeces Avere found in the cavity. Acting Assistant Surgeon C. A. Costar reported the case. ■Consult, in Circular No. 3. S. G. O., 1871, pp. 93 and 94, an interesting account by Acting Assistant Surgeon W. H. Doughty, of a case of visceral protrusion with an incised wound of the ileum, where enteroraphy was successfully practised, and the utility of ice-poultices in moderating the subsequent inflammatory process was manifest.—Ibidem, p. 96, for Acting Assistant Surgeon S. W. Blackwood's less fortunate case of enteroraphy, in a cast* in which the ileum and jejunum were wounded in five places.—Ibidem, p. 153, for Acting Assistant Surgeon H. S. KlLBOURNE's case of unsuccessful suture of four wounds in a loop of the jejunum, transfixed by a Kiowa arrow. A very interesting report of a case of successful enteroraphy in the person of Private H. Jacobs, Co. L, 3d Cavalry, stabbed in the left of the hypogastric region, at Little Rock, February 20, 1866, a wound three-fourths of an inch in length in the protruding ileum being united by two interrupted sutures, is printed by Acting Assistant Surgeon R. G. Jennings, in the Chicago Medical Journal, 1866, Vol. XXIII, p. 243, and the Boston Medical and Surgical Journal, 1869, N. S., Vol. Ill, p. 377. Assistant Surgeon E. V. Deueli. forwarded a report and photograph of the case, which would have appeared in Circular 3 had not its publication been anticipated by Dr. Jennings. 2 In American medical journals the following instances of recovery with enteroraphy from punctured and incised wound of the small intestines have been recorded by the following writers: 1. S. WHITE (The Medical Repository, 1807, Second Hexade, Vol. IV, p. 367), glovers' suture of the ileum after enterotomy for the removal of a silver spoon; rapid convalescence. 2. J. D. McBltAYEU (West. Jour, of Med. and Surg., 1843, Vol. VII, pp. 1, 81, 161), protrusion of two feet of small bowel transversely punctured by a knife; single interrupted suture; convalescent in twenty days. 3. Dr. A. It. Kili-atrick ( West. Jour, of Med. and Surg., 1844, No. VIII, p. 100), division of ileum of eight lines by an axe; one point of interrupted suture; ends left, and bowel kept in contact with the abdominal wall; temporary fascal fistula; attained complete recovery. 4. Dr. W. II. Van Buuen (New York Jour, of Med., 1847, Vol. VIII, p. 170), longitudinal wound of small intestine closed by two interrupted sutures; knots cut close; wounds in parietes enlarged and gut reduced; prompt convalescence. 5. Dr. F. D. LENTE (New York Jour, of Med., 1850, Vol. V, p. 23), two wounds of ileum; ligature of the mesenteric vessels ; two interrupted stitches in one and one in the smaller wound of the gut; reduction; rapid convalescence. 0. D. B. HlLLIARD (Med. Examiner, X. S., 1850, Vol. VI, p. 147), incision in ileum closed by continued suture; end of thread cut close to knot and protruding bowel returned ; slight peritonitis ; bowels moved by enema on the ninth day. 7. Dr. I. A. COONS (Ohio Med. and Surg. Jour., 185-', Vol. IV, p. 386), protruding wounded ileum treated by the glovers' suture; end cut short; bowels replaced; recovery in six weeks. 8. Dr. L. A. DUGAS (Southern Med. and Surg. Jour.. Is52. Vol. VIII, p. 407), two wounds of small intestine, one nearly severing the gut; closed by cat-gut sutures; rapid convalescence. 9. Dr. J. J. Chisoi.m (Charleston Med. Jour, and Rev., 1853, Vol. VIII, p. 615), stab in left hypogaster; protrusion of ileum ; wound half an inch long closed by two interrupted stitches ; replacement. 10. Dr. J. C. McGee (New Orleans Med. and Surg. Jour., 1854, Vol. XI, p. 23), ileum wounded longitudinally in two places; four stitches in the larger and one in the smaller wound; recovery without a bad symptom. 11. Dr. ROUARDS (Memphis Medical Recorder, 1856, Vol. V, p. 412), large dirk wound of intestine, closed by glovers' suture; wound in abdominal wall enlarged and bowel replaced; wound in parietes closed by interrupted stitches; patient resumed his ordinary avocations in three weeks. 12. Dr. \V\ CORSON (Phila. Med. and Surg. Jour., 1856, Vol. IV, p. 225). puncture of small intestine by a broken glass bottle; circular ligature; replacement of protruded gut; recovery. 13. J. J. McELHATU (New Orleans Med. and Surg. Jour., 1858. Vol. XV, p. 182). two punctures in ileum closed by circular ligatures; transverse cut an inch long in jejunum, through which several lumbricoid worms escaped; closed by five points of Lembert's suture; recovery prompt and complete. 14. Dr. A. LorEZ (North Am. Med. Chir. R. S. G. ().. 1865. p. J5 3891 SECT. III.] WOUNDS OF TIIK SMALL INTESTINES. 65 The following interesting case, of which abstracts were forwarded by Surgeon Hewit, from Hospital No. 5, at Frederick, and by Assistant Surgeon Weir, from Hospital No. ], was regarded by those surgeons, as well as by Dr. J. M. Green, of Aberdeen, Mississippi, and Acting Assistant Surgeons Uherbonnier and Nicolassen, as an unequivocal example of recovery from a shot wound of the small intestine. Dr. Nicolassen describes the earlier history of the case: Case -OS.—Private Sterling Sanders, Co. K, 21st Mississippi, was wounded, at the battle of Antietam, September 17, 1862, by a minie ball, which, "entering the right lumbar region near the crest of the ilium, pierced the small intestiuc, and made its exit at the umbilicus. From the field he was taken to a barn in the neighborhood, which had been converted into a hospital by Dr. Green. 17th Mississippi, C. S. A. For the first twenty-four hours nothing but a sip of cold water was given to him. Then he took about two tablespoonfuls of beef soup twice a day, but which would make its appearance at the wounds, which were not more than two inches apart, 'almost as soon as swallowed,' as he expresses it.- The discharges from the wounds were black and tar-like. In the course of a week, he began to eat a little hard cracker softened in milk. The evacuations from the wounds coutinued for twenty-one days. No unpleasant symptoms had arisen except occasional colic and chill; no irritability of stomach, no symptom of peritonitis whatever. The treatment had been low diet, lint to absorb the discharge, and scrupulous cleanliness about the wouuds. On October 8th, he had the first natural passage, and the wounds began to granulate. On October 17th, he was removed to Sharpsburg and placed under the care of Dr. Young. He began to take light solid food now, such as bread, crackers, small pieces of beef, chicken, or turkey, once a day. During his stay in Sharpsburg, the wounds closed up entirely; but his removal to this hospital, on November 2oth, caused them to open again, and, for twenty-nine days, again faecal matter was discharged through them, though he had two natural passages every day. The same scrupulous cleanliness has been observed. December 213th: nothing but wind has escaped from the wounds since December 24th. He has two natural passages daily. His appetite and general health are very good, and have been, ever since he was wounded. He walks about a little. December 2Sth, continues to do well; wounds apparently closed." On December 29th, the patient was transferred to General Hospital No. 1, Frederick, and placed under the care of Assistant Surgeon E. F. Weir, IT. S. A., who continues the record of the case as follows: "January 22, 1333, doing well; general health good. February 4th, going about the ward, and continues to do well; wounds do not occasion any inconvenience, and are nearly healed; ordered compress and bandage over them. February 10th, patient having entirely recovered, is, to-day, sent to the South." In the next two cases, the fact that recognizable ingesta repeatedly appeared, at the orifice of the wound, within a half hour after being received into the stomach, was regarded as conclusive evidence that the solution of continuity was in the upper part of the digestive tube. It will be seen, hereafter, that the same phenomenon was observed in cases in which the lesion was, beyond question, in the wall of the colon: Cask 209.—Private James D. Bishop, Co. D., lGth Mississippi, aged 22 years, received a gunshot wound of the right side of the abdomen, at Antietam, September 17, 18G2. He was removed to a field hospital, where he remained until October 6th, when he was transferred to the hospital at Camp A, Frederick, in charge of Assistant Surgeon William M. Notson, U. S. A., who records that "the ball, which had not been removed or discharged, entered about three-fourths of an inch to the right of, and on a level with, the umbilicus, producing a wound of the small intestines. On admission, faecal discharges were occurring from the wound, and none whatever from the anus. The patient, who was in a very weak and enfeebled condition, was supported by the use of tonics and stimulants. His general health slowly improved; the wounds in the flesh gradually healed, and the discharge of pus, which, at first, was profuse, continually diminished; and, on the 4th of November, all discharge from the wound ceased. On the 6th, he complained of pain, with some distention of the abdomen; one ounce of castor oil with twenty drops of tincture of opium was administered On the next morning a copious dejection took place by the natural channel, the first since the patient was wounded. There was still some slight discharge of pus from the wound, but this ceased in the course of a day or two. The bowels were not moved again until November 10th, when griping pains again occurred. Oil and laudanum again administered; free evacuation by the rectum again ensued. After this time, there was no discharge from the wound, which soon completely healed. The patient, at the end of April, 1863, was able to walk about, with every prospect of a speedy convalescence." On March 14. 1833, Bishop was transferred to Baltimore, and was admitted to the National Hospital. Acting Assistant Surgeon E. G. Waters forwarded the following details of the progress of the case: "A round musket ball entered the abdominal walls in a line with, and two inches to the right of, the navel, passed backward and outward. opening one of the intestines, and lodged. The patient stated that much of the liquid food and drink he took after the injury continued, for six weeks or more, to appear at the orifice of the wound and escaped therefrom. This was constant after each meal, and generally occurred about half an hour from the time of swallowing his food. The wound still discharging when he was admitted, satisfied me that the missile, or some foreign body, was lodged in the walls of the belly or in iis cavity. Accord- ingly, on March 21st, examination with the probe detected a hard irregular substance exterior to the abdominal cavity, and about six inches from the orifice of the wound. April 1st, conducting a catheter along the canal, at the extremity of which the foreign body could be detected, an assistant depressed the staff and thus elevated the integuments upon its point. An incision of suitable length was then made perpendicular to the walls of the belly, and about an inch internal to the crest of the ilium, when the bullet was secured and removed. It appeared to have encountered the patient's belt-buckle or some similar hard body, was flattened and expanded into two ala;. It presented very much the appearance of a saddle with its flaps spread apart, and it was easy to see how the intestinal coats could have been slit bv the passage of this sharp-edged mass in their vicinity. I 9 66 PENETRATING WOUNDS OF THE ABDOMEN. [chap. vi. could not gather from his account that he had suffered from peritonitis, although the peritoneum must have been divided to a sensible extent. On May 2(i, 1S>3, the man was convalescent, and was discharged from the hospital and sent South, his wound improving, though still fistulous. He had not been, at any time since his admission, able to hold himself erect, though in this particular his attitude was much improved at the time of his discharge." There is no reason to doubt the ulterior complete recovery of this man, though no further precise information has been obtained concerning him. Cask 210.—Private Daniel C. Mover, Co. H, 5th Pennsylvania, aged 21 years, was wounded at Gaines's Mill, June 27, Hf>2. lie was taken prisoner, and remained in the hands of the enemy until July 20th, when he was paroled, placed on board the steamer Louisiana, and conveyed to Baltimore. He was admitted into Camden Street Hospital, under care of Acting Assistant Surgeon E G. Waters, who makes the following report of the case: "Mover was wounded while lying down, the ball entering the left side of the abdomen, two inches above and three and one-half inches exterior to the umbilicus, and one and one-fourth inches below the margin of the ribs; the projectile then passed downward, backward, and outward, emerging, posteriorly, about one inch from the crest of the ilium, and three inches from the spinal column. He was carried first to a neighboring house, and thence to Savage's Station, remaining there some two weeks; thence to Richmond, where he remained at the railway station three days, and thence, by cars through Petersburg, to City Point; thence by steamer to Baltimore. He was indescribably wan, haggard, and emaciated on his admission, and when I first saw him, having no knowledge of the particulars of his case, I took occasion to reprove him for having enlisted, thinking he was at least seventy years old. He told me that no dejection, in tlie usual manner, had taken place for four days subsequent to the injury; but that the contents of the bowels had escaped through the posterior orifice of the wound. His aliment had also been extruded frequently in the same way, and he had remarked this particularly on the discharge of the seeds of some blackberries a lady in Richmond had given him. This fruit appeared in the discharges from the posterior wound a few minutes after being swallowed. For some days after admission, his attendants spoke of a discharge possessing a faecal odor and appearance, issuing occasionally from the wound in his back. He was much distressed with bedsores on different parts of his body, especially by a large one, following an abscess, which formed superficially around the right elbow joint, produced, doubtless, by pressure on that point, in his efforts to avoid resting his weight on the bedsores. His bowels were kept soluble, and he was inclined on his face and belly. August 20th, the wound posteriorly, after remaining healed for eight or ten days, reopened suddenly and gave exit to unequivocal ordure. This discharge continued three days, and was repeatedly witnessed by the writer. The patient was again kept in a horizontal posture, inclined forward to bring the discharging orifice uppermost, when this disagreeable condition was speedily checked. The orifice closed again, and, in a few days, the patient was permitted to move about the ward, then down to his meals, and, finally, he was sent to Camp Parole, Annapolis, September 19,1862, cured. At this time he had regained his flesh and strength, and exercised daily without inconvenience or fatigue." He was subsequently transferred to Broad and Cherry streets Hospital, Philadelphia, where Surgeon John Neill, U. S. V., reports him to have been discharged April 30, 1863, on account of "phthisis pulmonalis." Under date of October 1,1872, Pension Examiner Edward Allister, of Goshen, Indiana, writes that the pensioner "suffers constantly from pain and weakness through the back and loins, and is unable to perforin manual labor. He also suffers from a hernial protrusion at the seat of wound of exit. The bowel makes its exit at cicatrix of wound, and extends to the left of the point of exit. At this date, it was about three inches in length and half as wide. The pensioner represents it as being, at times, much larger, and quite hard; which I have no reason to doubt. Disability total, of the third grade. Weight, 160 pounds; age, 30 years; respiration, 19; pulse, 80." Last paid December 4, 1872. In the next case, there was no other evidence of lesion of the small intestine than the rational signs, and these were not recorded with precision : Case 211.—Private Joseph Irwin, Co. B, 29th Pennsylvania, aged 33 years, received a shot wound of the abdomen at Gettysburg, July 2, 1863. He was admitted on the same day to the field hospital of the Twelfth Corps, and a wound of the abdomen, with injury of the intestines, was diagnosticated. No mention is made of the symptoms or treatment. On July 23d, the patient was transferred to the Camp Letterman Hospital, and admitted into ward B, under the charge of Acting Assistant Surgeon Charles S. Gauntt, who entered on the medical descriptive list, that a mirii6 ball had entered the abdomen at a point three inches above the umbilicus, and made its exit four inches to the right of the fourth lumbar vertebra, Simple dressings to the wound and full diet constituted the treatment. The patient's condition improved, and, on October 12th, he was transferred to Satterlee Hospital, Philadelphia. The ward surgeon gives the following details of the case: "A conical ball entered the back, in the lumbar region, about two inches to the right of the spine, and lodged under the skin in the median line two inches above the umbilicus, whence it was cut out July 4,1883. The wound in the front has healed; that in the back is nearly well. He has had considerable swelling and pain in the bowels, and vomiting, and difficulty in passing water. About two weeks after the reception of the injury, he was affected with rheumatic pains in the shoulder, followed, at the end of the third week, by inter- mittent fever, from which he recovered in a fortnight. On admission, he still complained of the rheumatic pain in the back and iu the knees. The treatment consisted of tonics, sedatives, laxatives, and liniments. On the 22d. it is noted that several loose, very light dejections occurred; patient complained of chills at night. He had mercury with chalk, and then treatment was addressed to the rheumatic complications, the alkaline method being pursued for some weeks; then iodide of potassium was re.-orted to, with scarified cups near the most painful parts." On January 26, 1864, the ward surgeon repeats the diagnosis of " lesion of the small intestines, and peritoneum;" but does not advert to tympanitis, bloody stools, or other signs that might have furnished the basis of such a diagnosis. The patient remained in hospital, but no treatment is noted after February, 18:34. Iu March, Irwin was made ward-master. In April, 1865, he was still on duty in this capacity, but recommended for the second battalion of the Veteran Reserves. This recommendation appears to have been unfavorably considered, and the man was discharged from service May 15, 18(35. His name is not upon the Pension List. The five foregoing cases are the only instances of recovery from shot wounds of the abdomen, reported during the War, in which there was any plausible ground for suspect- SECT. III.J WOUNDS OF THE SMALL INTESTINES. 67 Fig. 43 —Shot perforation of the duodenum. Spec. 1772. ing that the small intestine was the seat of lesion. Of the many fatal cases recorded, necroscopic details are generally wanting; but, in a small proportion of them, the exact seat of injury is noted, and, in a few, the pathological preparations are preserved. 11 ounds of the Duodenum.—Opportunities of observing the symptoms attending shot wounds of this portion of the digestive canal were very infrequent. Commonly, shot injuries of this portion of the intestinal canal are accompanied with mortal lesions of adjacent parts. As the descending and middle portions have no proper peritoneal coat, but are only loosely fixed between the laminse of the meso-colon,1 it is possible for the gut to be wounded without extravasation of its contents into the great peritoneal cavity. In a case related on page 50 (Case 191), in which the stomach and liver were also implicated, and the duodenum nearly severed, the patient survived the injury eight days. In a case which furnished the illustration of shot perforation of the duodenum represented in the wood-cut (Fig. 43), the ball also penetrated the liver and right kidney, and death, from haemorrhage, ensued in a few hours. It is deeply to be regretted that in the following case, in which life was prolonged for twenty-four clays after the reception of the injury, no precise record of the symptoms has been preserved :2 Case 212.—Private James M------. Co. F, 14th New Jersey, aged 27 years, received a penetrating wound of the abdomen, at Winchester, September 19, 1864. The missile, a conoidal ball, entered at the right side of the epigastrium, at the edge of the ribs, and emerged through the right buttock. Ho was admitted, on the same day, to the hospital of the Sixth Corps. He was an emaciated subject. [The case book contains no further information respecting the general condition of the patient after receiving the wound. The degree of collapse, the presence or absence of haematemesis, the precise nature of the feculant discharges from the upper orifice and its probable origin, the extent to which the symptoms of peritonitis were present, cannot be determined.] Water dressings were applied to the wound, and ferruginous preparations and opiates were administered, with milk punch. A farinaceous and milk diet was allowed. Faeces escaped freely from the wound of exit, and also from the wound of entrance, for a few days. After this, frequent and continued alvine ejec- tions took place through the natural channels. Death resulted on October 12, 1864. At the autopsy, it was found that the ball, entering the right side of the epigastric region, had carried away about half of the calibre of the duodenum, near the orifice of the cystic duct (FiG. 44). It had then passed obliquely downward and backward, through the cascum (Fig. 45), above the ileo-cascal valve. It then struck the right ilium, notching its crest about midway. It then traversed the gluteal muscles and emerged through the right buttock, the line of its direction being nearly straight. The exit wound of the cascum adhered firmly to the fascia of the internal iliac muscle. There was a con- siderable quantity of blood and pus along the ascending colon. Inflammation and traces of gangrene of the epiploon were noted. The specimens and notes of the case were contributed by Acting Assistant Surgeon W. Leon Hammond. In two other cases,3 this portion of the intestinal canal was the principal seat of injury; but few particulars were noted: Case 213. —Private J. Stewart, Co. B, 7th New Jersey, on picket duty, November 28,1834, received a musket ball wound iu the epigastrium, implicating the duodenum. Surgeon C. Sehlbach, 7th New Jersey, reports that he lingered for two days, in a very weak state, at the field hospital of the Second Corps, and died November 30, 1884. Case 214.—Corporal R. Bessey, Co. A, 17th Vermont, aged 19 years, was wounded at Hanover Court House, May 31, 1834, by a musket ball, which entered the right hypochondrium, and emerged to the right of the tenth dorsal vertebra, implicating the duodenum and probably the liver. There was hsematemesis and extreme epigastric tenderness and pain, followed by bloody stools. Surgeon James Harris, 7th Rhode Island, enjoined absolute rest, with abstinence and opiates. The 1 HOENEU, Special Anatomy and Histology, Sixth ed., 1843, Vol. II, p. 40. 2Dl"PUYTREN (Lecons Orales, T. VI, p. 4G4) remarks of shot wounds of the duodenum: "La Nature a seule des ressources contre cette lesion: le chirurgien n'y peut rien faire." 3 Surgeon C. H. Alden, U. S. A., has recorded (CASE CXXVII, Circular 3, S. G. O., 1871, p. 43) a case of wound of the duodenum by a pistol ball, speedily fatal from attendant lesions of branches of the superior mesenteric artery. Lakuey (Mem. de chir. mil., T. Ill, p. 456) has detailed a very remarkable recovery from a sabre wound of the duodenum. FIG. 44.-Portion of duodenum lace- rated bya musket ball. Spec. 3378. FIG. 45. — Portion of cascum perforated by a musket ball. Spec. 3379. 68 PENETRATING WOUNDS OF THE ABDOMEN. |ciiap. vi. patient was, however, sent to Washington, and Acting Assistant Surgeon E. B. Harris, at Emory Hospital, reports that there was much tension and tenderness of the abdomen, with nausea, and dejections tinged with blood. The case terminated, fatally, June 18, 18G4. Wounds of the Jejunum.—The upper two-fifths of the remainder of the small intestine includes a portion of the canal but slightly protected by bone or by parts of the equip- ment, and is very liable to perforation by shot. These wounds are often complicated by lesions of the adjacent viscera, or of the mesenteric arteries, and are not infrequent in the bodies of those who have perished on the field from haemorrhage from the great blood- vessels of the abdomen. In the condition its name implies, in wounds of this gut, the danger of immediate extravasation is commonly postponed. But this condition depends upon the period of the digestive process at which the wound may have been inflicted. Even if received during fasting, the patient is not secured from the intrusion of entozoa into the peri- toneal cavity, as exemplified by the following case:1 Case 215.—Private John IV------, Co. H, 4th Virginia Cavalry, Colonel Mosby's command, was wounded, at Warrenton Junction, May 2, 1833, by a carbine ball, which entered the left side of the abdomen just above the iliac crest, and passed out the opposite side. He was admitted to the 1st division hospital, at Alexandria, on the same day. He suffered intense pain, which was but slightly relieved by anodynes, and died, in great agony, on the 5th. At the autopsy, it was observed that considerable inflammatory action had taken place; the bowels were agglutinated together, and there was a thick deposit of yellowish lymph. The small intestine was perforated in two places (Fig. 45), Vl.r" ■*''—Sections cf two anj from the openings, which were large and ragged, a number of lumbricoid worms had crawled porti'ins of ileum, each tr.iv- i o » o ^o crscii and nearly divided into the cavity of the abdomen. Faecal matter, also, had been extravasated. 1 he preparation and %ec. im.dA °aHMne bal1' tlie notes of the case were contributed by Surgeon Charles Page, U. S. A. Another result of a shot wound dividing the greater portion of the circumference of the jejunum, about ten feet below its origin, was the formation of a huge stercoral abscess, communicating with the exterior by the entrance and exit channels. The patient survived the injury four weeks, marked scorbutic symptoms appearing toward the close: Cask 213.—Acting Assistant Surgeon Albert Newman reports that "Private Samuel G. Matkins, Co. D, 14th Missouri Cavalry, was admitted into the post hospital at Lawrence, Kansas, June 23, 1835, about three o'clock P. M., having received a wound about an hour before by the accidental discharge of a Remington revolver. The ball entered to the right of the lower lumbar vertebra, and lodged under the skin about an inch above the internal abdominal ring, from which place it had been removed by incision before admission. When admitted, the wounded man was suffering great pain, and there was much tender- ness of the abdomen. He had constant and intense desire with inability to micturate, and begged to have his urine withdrawn by the catheter. He was ordered two fluid drachms of laudanum, to be repeated in two hours. At nine in the evening, he was sleeping quietly. He had voided his urine, which was perfectly clear. Ordered two grains of powdered opium every four hours, and tepid water dressing. On June 24th, the patient was comfortable, sleeping most of the time; pulse, 139; treatment continued. On June 25th, the patient had rested well; fajcal matter was discharging freely from the wound in front; no tympanitis; ordered beef tea; other treatment continued. On June 23th, the patient said he had no pain; he was slightly wandering; he had vomited; pulse, 118; treatment continued. June 27th, had rested well; said he had a little occasional pain, but not much; treatment continued. June 28th, was restless yesterday afternoon, and turned upon the right side; pulse rose to 120; said he had pain this morning, but was now quiet; pulse, 100; treatment continued. June 23th, free from pain; pulse, 100; skin, cool; ordered, every four hours, a powder containing two grains each of opium and sulphate of quinia; beef tea with rice. June 30th, no pain; skin below the natural temperature; pulse, 93; treatment continued. July 1st, comfortable; pulse, 104 ; treatment continued. July 2d, easy; pulse, 100; treatment continued. July 3d, tranquil; pulse, 93; ordered the powders to be continued at the same intervals, but to contain but one grain of opium with two grains of quinine; beef tea, with rice continued. July 4th, easy; faecal matter discharging from the lumbar wound; a dark slough protruding from the original wound; pulse, 96; treatment continued. July Cth, had much pain in the night; had four alvine dejections, which, the nurse says, were natural in appearance; faecal matter discharging from both wounds ; pulse, 9? ; treatment continued. July Gth, says he had extreme pain in his bowels during the night; sloughs have separated from the wounds, of which the edges are irritated by the discharge. There is considerable, but not excessive, tenderness over the entire abdomen, which is much shrunken; pulse, fc> ; ordered powdered opium and sulphate of quinia, two grains each, every four hours; beef tea and rice continued. July 7th, had rested well; craved more food; the faecal discharge from the wound in the back had ceased; pulse, 83; chicken and toast allowed; other treatment continued. July 8th, pulse, 84 ; complained last night of great pain in the bowels and difficulty in passing urine. An additional two-grain dose of opium procured repose. July 9th, pulse, 84; faecal discharge from the lumbar 1 JACOTIUS (Comment, in Hippoc. coaca prsesagia, Lib. I, Aph. 17, as quoted in SAXDIFOKT'S Thesaurus, Vol. II, p. 118) discusses in detail wounds of the jejunum, and records an instance of recovery from an incised wound. SECT. 111.) WOUNDS OF THE SMALL INTESTINES. 69 wound has recurred ; treatment continued. July 10th, comfortable ; pulse, 84 ; treatment continued ; extreme attention to clean- liness enjoined. July 11th, pulse, 84; complains of pain in the left side, in the region of the spleen ; fascal discharge from the wound in the back again ceased ; faecal discharge from the inguinal wound recurred at more or less regular intervals of from two to four hours, instead of oozing away continuously as heretofore ; treatment continued July 12th, pulse, 84; still complains of pain in the left side. July 1:5th, pulse, 84 ; rested well. July 14th, pulse, 84; had slept but little; had pain in the left side; the back and sides of the trunk are covered with small, irregular, purple spots and lines, which do not disappear on pressure; a patch of similar spots an inch in diameter, so thickly crowded as to be almost continuous, at the left and near the lower end of the sternum, to which point he refers his worst pain; says he feels very weak; skin cool; some lividness of hands and feet; ordered a tablespoonful of wine every two hours. July 15th, says he has rested well; pulse, 88; several new spots upon the chest and upper part of the arms; lividness of hands and feet less; treatment continued. July 16th, pulse, 84; some new spots lower down upon the abdomen ; lividness of hands and feet increased; continued treatment. July 17th, pulse, 84 ; spots extend down upon the left forearm ; one spot upon the left thigh. July 18th, pulse, 84 ; spots extend down upon the hips behind ; temperature and color of skin unchanged. July 19th, pulse, 84 ; has had two dejections by the rectum ; some faecal discharge from tlie lumbar wound was nearly filled with granulations. July £0th, pulse, 8*; restless. July 21st, pulse, 104; lividness increased; purple spots over both legs. The next morning the pulse was at 112, very small. Died at noon, July 22, 18G5, four weeks from the date of the reception of the wound. The autopsy was made three hours after death. Rigor was well marked; great emaciation; abdomen much contracted; intestines bound together by strong adhesions; upon separating these adhesions, numerous small collections of clear pus were disclosed, none of them exceeding in quantity a teaspoonful; the small intestine was found completely divided about ten feet below the duodenum ; the portion of small intestine below the division was contracted almost to the size of a goose quill; this portion of the gut communicated with the wound in the groin, and also with that in the loin. Surrounding the right psoas muscle was a cavity of sufficient size to hold a quart, separated by adhesions from the remainder of the abdominal cavity. The upper portion of the small intestine opened into the cavity, which was half full of fascal matter." The instances in which a ball, traversing the abdomen, wounds more than one convolution of the intestines, are, unfortunately, numerous.1 This circumstance has such an important relation to the question of enteroraphy in shot wounds that it is well to accumulate evidence concerning it.2 Case 217.—Noted by Assistant Surgeon W. S. Woods, U. S. V.: Private J. Benton, Co. B, 3d Cavalry, aged 30 years, was shot through the body, May 10. 1864. by a conoidal musket ball at short range, while resisting arrest, and was immediately admitted into the post hospital at Benton Barracks, St. Louis. He sank rapidly from the effects of hoemorrhage, the treatment consisting of cold applications to the abdomen and the employment of styptics. He died May 17, 1864. The ball had divided the jejunum five and one-half feet from the pylorus, and again eight and one-half feet below the stomach ; finally the ball traversed the colon eighteen inches above the anus. There was much extravasated faecal matter. Case 218.- Private R. M. Wells, Co. F, 8th New Hampshire, aged 23 years, was wounded in the abdomen by the accidental discharge of a musket while on picket duty at Natchez, October 29, 1364. He was at once admitted to the Officers' Hospital at Natchez, under the charge of Assistant Surgeon A. E. Carothers, U. S. V., who states that " Wells and a comrade were practising with their bayonets, when his comrade's gun was accidentallj' discharged; the ball entered the belly about one and a half inches to the left of the median line, midway between the umbilicus and ensiform cartilage, passed across and backward, and made its exit through the posterior third of the crest of the right ilium. There was incessant vomiting and hiccough, and the man suffered terribly until he died, eighteen hours after the casualty. An autopsy, made twenty hours after death, showed that the ball had passed between the lower curvatures of the stomach and the transverse colon, behind the colon, dividing a large branch of the colica media artery, across the abdomen, cutting the upper end of the jejunum entirely across in four places, and emerged from the abdominal cavity just in front of the attachment of the caecum, extensively fracturing the crest of the ilium in its exit." It then entered the skull of a comrade, causing his death in twelve hours. Case 219.—Corporal W. J. Wells, Co. B, 144th New York, aged 19 years, was wounded in the abdomen at Honey Hill, November 30, 1864. He was taken to the regimental hospital, where Surgeon John R. Leal, 144th New York, records the case as a "gunshot wound of the bowels; mortal." On the same day, the patient was transferred to the hospital at Hilton Head, where Assistant Surgeon John F. Huber, U. S. V., notes the injury as a "lesion of the small intestines from a fragment of shell." Death resulted December 2, 1864. A knuckle of the jejunum was divided, and the contents of the bowel had passed into the peritoneal cavity. Other examples will be given under the head of wounds of the ileum. 1 LECOUKST, Chirurgie d'Armee, 26me 6d., p. 385: ' Les lesions des intestines par les coups dc feu sont presque toujours multiples." See, also, Baudens, Clinique des plaies darmes a feu, p. 326. 2 Pathological preparations of shot wonnds of the small intestines are not common. I have found none in this country, except in the Army Medical Museum. The following are noted in the catalogues of foreign museums : In the collection at Fort Pitt are two specimens—No. 1162, presented by Surgeon Roe, 28th Ilegiment, shows a fistula at the point of entrance of tho ball through the eleventh left rib, through which the faeces were voided; the gut was impervious below the wound. No. 1163, donated by Assistant Surgeon Tighe, shows the small intestine wounded by a ball in three places, and the mesentery in one (Cat., I. c, p. 157). This is probably identical with specimen 1272, at Netley (WILLIAMSON, I. c, p. 113). In the Hunterian Museum, specimens 1176 and 1179 of Series of XXIII are portions of jejunum with shot wounds, with everted edges and copious lymph deposits. They are from the same subject, the officer who fought a duel in Hyde Park, September 4, 1783, and was attended by Hunter, who adduces these facts in proof of the rapidity of the formation of adhesions about shot wounds of the intestine (Cat., I. c, Vol. Ill, p. 68, and Hunter, On the Blood, Inflam- mation, and Gunshot Wounds, 1794, p. 546). In the Netley Collection, No. 1271 is a portion of jejunum, believed to have been perforated in three places by a musket ball. A memorandum of the case is printed in Note 2, on page 40. 70 PENETRATING WOUNDS OF THE AI5DOMEN. [CHAP. VI. Dr. T. S. Hovne1 has sought to determine, by experiments on the cadaver, the number of wounds of the intestine likely to be inflicted by a ball traversing the abdominal cavity. The conditions of his experiments deprive the results of value. Less questionable data are afforded by field experience. In a case observed by Alexander, in the Crimea,2 a musket ball, entering near the umbilicus and passing out close to the sacrum, was found to have wounded the small intestines not less than sixteen times in its passage. If such were an ordinary effect of shot perfo- rations of the abdomen, there would obviously be no room for surgical intervention. But it is not very common for more than two convolutions to be wounded, or the wall of the small intestines to be perforated in more than four places,3 in the cases that reach the hospital, as is proved by an examination of the pathological records. Musket balls commonly divide a considerable portion of the calibre of a small intestine; carbine or pistol balls sometimes make two perforations of its walls;1 and, occasionally, a small projectile may perforate the intestinal \ wall at a single point, and lodge within the gut, as in the case which furnished the specimen represented in the wood-cut (Fig. 47). In such cases, the usual eversion of the mucous tunic ensues, and the appearances are not to be distinguished from those resulting in a true pun:tured wound, inflicted by a sharp-pointed instrument, as is exemplified by a comparison with the specimen delineated on page 62 (Fig. 41). The following is a minute of the case : Fig. 47.—Portion nf jejunum perfo- rated at une point by a round pistol ball. The mucous membrane is much everted at the orifice. Spec. 841. [Half size.] Cask 2'20.—Assistant Surgeon W. D. Wolverton, U. S. A., reports that Private Josepli M- -, Co. H, 11th Infantry, was admitted to post hospital, Camp Grant, September 10, 1866, with a gunshot wound in the abdomen, received in an affray with a negro. The ordinary treatment of absolute rest, with opiates, was enforced. Faecal extravasation, immediately followed by intense peritonitis, with great depression from shock, led to a fatal termination on the following day, September 11, 18oo. Acting Assistant Surgeon E. Thomain forwarded the specimen to the Museum. Assistant Surgeon A. A. Woodhull observes (Cat., p. 491): "The solitary follicles and villi are enlarged, as if the subject were suffering under intestinal disease when wounded." It is difficult to suppose that the application of a circular ligature, or in the closure of the orifice in the gut by a point of interrupted suture, would have accelerated the fatal event in this instance. In the instances in which balls are voided at stool, very soon after the reception of a shot wound in the abdomen, it may fairly be presumed that the missile has penetrated the intestinal wall at one point only. It is probable, however, that in most of these cases, the projectile has gained admission to the canal through some portion of the wall of the large intestine. 1 Hoyne. On the Nature and Treatment of Gunshot Wounds of the Intestines, with Experiments on the Cadaver, in the New York Med. Jour., 1865, Vol. I, p. 106. This writer fired eighteen pistol shots at the bellies of dissecting-room subjects, and inflicted ninety lesions of the intestines, or an average of five with each ball, and concluded that "in view of the experiments above recorded, it is apparent, we think, that the method of procedure recommended by Legouest must prove eminently dangerous." This complacent estimate of the value of these experiments is accompanied by the admission that in one of the injected bodies "the organs were slightly displaced.'' Properly controlled laboratory experiments are of utility in elucidating many points relating to the effect of projectiles upon the tissues; but correct conclusions are not attained by converting a mutilated dissect- ing-room subject into a target, with a view of demolishing an hypothesis the experimenter disapproves. 2 See Deputy Inspector Alexander's letter to Mr. GUTIIIllE (Commentaries, 6th ed., p. 576). The man was stooping in the act of defecation when wounded. 3 In eight of twenty shot injuries of the small intestines noted in Circular 3, S. G. O., 1871, the number of intestinal lesions" were noted. Counting lesions without division of the wall, the largest number of distinct wounds of the gut in any case was eight. In two instances, only one portion of the gut was wounded. The aggregate of distinct intestinal lesions, in the eight cases, was thirty. In twenty cases noted in this subsection, the aggregate of the distinct intestinal lesions was fifty-nine; in two cases noted in the First Surgical Volume (pp. 445-449), of shot perforations of the abdomen, the small intestines were wounded at two points, in each instance. In thirty-three cases of shot wounds of the small intestines, in which the lesions were recorded with exactness, collated from the works of Lamotte, Ravatox, Bordenave, Percy, Lahkey, Guthrie, Baudexs, and Professor Billroth, and from papers in various journals, including the observation of Director General Alexander, above cited, the aggregate of distinct intestinal lesions ivas seventy-three. Grouping the sixty-three cases, the aggregate of distinct intestinal lesions is found to be one hundred and sixty-six, or 2.63 intestinal wounds for each shot. In this estimate, what VOGEL (Saxdifoet's Thesaurus, Vol. II, p. 110) terms "twin wounds," that is, perforations of the opposite sides of the gut on the same level, are counted as distinct lesions. SECT. III.l WOUNDS OF THE SMALL INTESTINES. 71 PIG.48.—Carbine ball, size of nature, removed from the abdominal cavity after death. Spec. l--'31fc. Fig. 49.—Two loops of ileum, with shot perforations. Spec. 1231a. [Re- duced one half. ] Wounds of the Ileum.—Very many fatal shot perforations are found in the coils of the lower three-fifths of the small intestine. Somewhat protected posteriorly and laterally by the vertebral column and the wings of the innominata, it is fully exposed in the umbilical, hypogastric, and right iliac regions : Cask 221.—Private Charles B-----, Co. L, 8th New York Cavalry, aged 2:! years, was wounded at Beverly Ford, June S), 1863. He was conveyed to Washington on the next day, but died in the ambulance on the way to Lincoln Hospital. An autopsy was made by Assistant Surgeon II. Allen, U. S. A. The wound was in the median line, five inches above the pubis; the stomach was distended with gas; the intestines were natural in position, not abnormally distended, but greatly discolored by liBeniori'liage. A moderately sized venous clot was found on the inferior surface of the omentum. The cellular tissue about the mesentery was emphysematous. The posterior part of the abdo- men was filled with a large black clot, in the midst of which was an ascaris lumbricoides. The missile, a conical carbine ball (FlG. 48), was found in the pubis on the right side of the bladder, lying on the peritoneum. The lining of the oesophagus was usually pale; the epiglottis presented a peculiar appearance, its mucous lining being of a purple color, with several dark grayish spots upon its laryngeal surface. The liver weighed thirty- four and one-fourth ounces, and was of an intense green color; the kidneys were extremely- flabby and anaemic, and the cellular tissue surrounding them, emphysematous. Tlie right kidney weighed five and one-half ounces, and measured five by two and one-half inches; the left weighed six and one-half ounces, and measured five by two and one-half inches. The spleen weighed four ounces, and measured four and one-half by three inches. Two sec- tions of the small intestine, showing perforations by the missile, are figured in the wood-cut (Fig. 49). The specimens were contributed to the Museum by Surgeon G. S. Palmer, U. S. V. Case 2'2'2.—Private William Sneider, Co. L, 5th Cavalry, Missouri State Militia, is reported by Surgeon H. Culbertson, U. S. V., to have been admitted into tbe hospital at Rolla, Missouri, September 17, 1863, with a penetrating wound of the abdomen by a minie ball, received accidentally. Death resulted, from shock, eight hours subsequently to the infliction of the wound. The necropsy showed that the ball passed through the left iliac region, wounding and dividing the ileum, coursed backward to the outer side of the crural nerve, through the iliacus internus, the ilium, and came out about one inch to the left of the lumbo-sacral articulation, and to the left of the ileo-sacral articulation. CASE 223.—Surgeon William G. David, 6th Regiment, Corps d'Afrique, reports that Private Terrence Boreau was wounded by the accidental discharge of a pistol, in quarters at Port Hudson, Louisiana, March 23, 1864". The ball entered the left iliac region and lodged, causing death in thirteen hours. The necropsy revealed the following lesions: The missile had passed through a knuckle of the small intestines, as also a knuckle of the sigmoid flexure of the colon; perforated the diaphragm, and lodged in the lower lobe of the left lung, causing extensive engorgement of the lung. Case 224.—Private J. T. McDowell, Co. H, 21st New Jersey, aged 25 years, was wounded in the abdomen at Chancel- lorsville, May 3, 1863. He was taken to the field hospital of the 2d division of the Sixth Corps, and was subsequently conveyed by ambulance to Washington, and admitted, on the 8th, into Douglas Hospital. Acting Assistant Surgeon H. L. W. Burritt, who had charge of the case, states that the "patient was shot through the sacrum, which was much comminuted; the ball came out about an inch above the pubes. Fasces escaped freely externally; no natural action of the bowels took place. Two grains of morphia were given daily and extra diet ordered. The patient was failing when he was admitted, but lingered a few days, and gradually sank, with symptoms of peritonitis. Died May 11, 1883. A post-mortem examination was made six hours after death: The bullet entered at the left ala of the sacrum and emerged in the hypogastric region, one inch above the pubes. The peritoneum was deeply injected, and the peritoneal sac contained a dark greenish and sanguineus mixture of faecal and serous effusion. A fold of the small intestines was twice perforated by the ball, but the bladder was uninjured. Gas and fasces passed from behind into the gluteal muscles." Case 225.—Edward Moorer, a colored teamster, employed in the quartermaster's department, was shot in the abdomen in a brawl at a grogshop in Georgetown, October 12, 1862. He was taken to the Union Hotel Hospital, under the charge of Assistant Surgeon A. M. Clark, U. S. V., who reports that a "pistol ball had entered the left side about two and one-half inches from the spinal column, grazing the crest of the ilium, and emerged in front, two inches above and a little inside the anterior superior spinous process. Death occurred about forty-two hours after the reception of the injury. The autopsy showed three perforations of the intestines—one through the descending colon, and two through the ileum. The abdomen was distended with clotted blood, which had proceeded from one of the mesenteric veins. No extravasation of fascal matter could be determined. All the other organs were normal." Case 226.—Private David P. Taylor, Co. I, 5th Michigan Cavalry, was wounded in the abdomen on the morning of March 24,1863, at Washington, by the accidental discharge of a Colt's revolver. He was at once removed to Lincoln Hospital. There was some vomiting, small pulse, and extreme restlessness. No movement of the bowels occurred; the patient passed a little urine. He died March 26, 1863, at 3.50 o'clock A. M., nineteen hours after the reception of the injury. A post-mortem exam- ination was made nine hours after death: "Subject firm, and very well developed muscles. Height, six feet and one-half inch. No post-mortem rigidity present. The brain weighed fifty-four ounces. Small amount of reddish fluid in the lateral ventricle. Choroid plexuses pale. The abdomen when opened was found to contain a considerable quantity of gas. The cellular tissue PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. about the umbilicus was found distended with blood. The intestines were inflated with gas, and were intensely congested. The intestine was bound to tlie peritoneum, in very many places, by fleshy exuded lymph. Dark, red colored effusion, with blackish clots, was found at the posterior part, amounting to two and one-half quarts. Effusion to the amount of twelve ounces was found in the pleural sacs. The ball entered the median line of the abdomen three inches above the pubis, passed obliquely backward, keeping to the left side of the vertebral column, fracturing the transverse process of the left side of the third lumbar vertebra at its base, and was cut out, by the attending surgeon, from beneath the fascia. The small intestine was perforated in two places by the missile. There were adhesions on the right side, generally of a recent character. A portion of the small intestine, perforated by the ball, was saved to be sent to the Surgeon General's Office.'' The specimen was not received at the Museum. Case 227.—Assistant Surgeon J. B. Bcllangee reports that Private John Glandcll, Co. K, Mosby's troop, aged 3') years, was wounded in a cavalry fight at Warrenton Junction, May 2, 1863. The missile entered the abdomen at about the centre of the left iliac region, passed obliquely downward, and lodged somewhere in the upper part of the left thigh. This patient was a strong man, and lingered in continual agony until May 5th, when he died. The autopsy revealed the marked results of inflam- matory action. The lower part of the ileum was perforated and extensively laid open. The general subject of the applications of sutures in wounds of the digestive tube will be considered hereafter; but the following facts regarding enteroraphy in cases of shot wounds of the ileum, with protrusion, may properly be placed here. In the first case, three wounds in the protruded ileum were secured by the continued suture. The autopsy revealed two other wounds in the intestinal canal—one in the jejunum, the other in the ascending colon. There was no fascal extravasation, however, fatal gangrene of the small bowel rapidly supervening. The very instructive pathological preparations from this case are preserved in the Museum, and are represented in Plates II and III. The nearly complete transverse division of the circumference of the gut shown in Plate II well exemplifies the less extent of injury to the serous than to the mucous and muscular tunics that I have insisted upon as characteristic of shot lesions of the intestines : Cask 228.—W. W------, colored, was, on May 23d, 1865, at 12.30 o'clock p. M., admitted to the L'Ouverture Hospital, Alexandria, with a gunshot penetrating wound of the abdomen. An unsigned abstract of the case, believed to be in the hand- writing of Acting Assistant Surgeon Thomas Bowen, was sent, with the pathological specimens, to the Army Medical Museum. Surgeon Edwin Bentley, U. S.V., is understood to have operated in the case; but there is no positive record on the subject. "The missile had perforated the right ilium just below the crest, about five inches back of the anterior spinous process, and in its course upward had wounded the ileum, emerging near the umbilicus. On admission, nearly three feet of the intestines protruded. Three wounds were found iu the protruding bowel—two were small, and the third nearly divided the intestine to the mesentery. All three were sewed up by the glover's stitch. The patient's pulse was quick but full, and the breathing short. He died at noon, on May 24,1865. The autopsy, twelve hours later, revealed a clean-cut round wound, the size of a cherry-stone, just below the crest of the right ilium, and a ragged wound the size of a peach-stone to the right of the umbilicus. The lungs were in a healthy condition; pericardium and heart, normal; liver, rather pale; spleen, remarkably free from blood, looking as though soaked in water, on section; kidneys, fatty. Some coagula of blood, and fluid blood and serum in the abdominal cavity. A small bunch of omentum lying in the anterior wound; this and all parts of the omentum pretty fully injected; ileum throughout irregu- larly injected in tracks of a pink color, but now and then almost black. A penetrating wound with everted edges, size of a cherry, about eight or ten feet from the end of the jejunum. About eighteen inches from this was a wound almost completely severing the intestine (FlG. 50) to the mesentery, but sewed up, and beyond this were two smaller ones (FlG. 51), also sewed up. No wounds were observed beyond this in the ileum. The external anterior surface of the ascending colon, opposite to and just above the perforation in the innominate bone, was torn open. A little outside of the colon was an opening through the perito- neum. The iliacus internus muscle and the circular hole in the ilium were lined with fragments of bone pointing forward. No fragments of bone were felt externally behind this per- foration in the haunch bone; and the opening into the bone from the outside was cleanly cut and with smooth edges." There had been no plastic exudation, either at the breaches of continuity that were united by suture, or at those in the jejunum, colon, and parietal peritoneum. There were circumscribed infiltrations of blood in the submucous connective tissue in the vicinity of Fig. 50.—Section of ileum, slit open to show the interior (.f the gut, with sutures closing- a shot wound. Spec. 4389. FlG.51.-Anot her portion of the same ileum, with shotperforations sewn up. Spec. 4390. [Both prepa- rations are reducedtoone- fourth.l *Jj?k' : "■■•:• &% '••' ,£, '"■ fc ' ■M 't'V's ':$*%* ^^no or ;he !|.fum * ' h Med and ^urs; Hist of the War of the Rebellion PartEYol.I. Opposite page 72. Ward phot. J.Bi«n Lirti PLATE II. ENTERORAPHY FOR A SHOT WOUND OF THE ILEUM. No. 4390. SURGICAL SECTION. skc-t. m.j WOUNDS OF THE SMALL INTESTINES. 73 each of the five rents in the intestine. The continued sutures had not satisfactorily inverted and approximated the serous membrane, and some of the punctures were pat- ulous, as though made bya needle unnecessarily large. This was mostly noticeable in the two small oblique divisions, of which an exterior view is given in Figure 51, and an interior view in Plate II, opposite. Tlie nearly complete division illustrated by Figure ;>0, and, of the size of nature, in Plate III, placed further on, was securely closed, but not with that careful apposition of the serous surfaces that is essential. Another instance of entororaphy, in a frightful case of shell wound of the abdomen, with fracture of the pelvis, and protrusion of the intestines, is recorded by Brigade Surgeon Oliver A. Judson, U. S. V., in a letter to Medical Director Tripler: Cask 2-20.—"On the afternoon of April 17, 1862, a shell, thrown from a battery about the centre of the enemy's works at Yorktown, exploded near a group of men of the 1st brigade of General Hooker's division, belonging to a reconnoitring party. Five men were injured. Private Jerry Luther, Co. G, 2d Rhode Island, had his left forearm shattered, by a fragment of the shell, to such an extent that it hung merely by shreds of skin. A large piece of the same projectile entered the abdominal cavity, to the left of the linea alba, fracturing the anterior superior spinous process of the ilium, and causing the hernia, perhaps four or five feet in length, of the small intestine, with a portion of the descending colon, and of the omentum. There was also a small wound from a third fragment, in the left thigh The small intestine having been wounded transversely through half the circumference of the gut, Sargeon Judson applied five stitches by Jobert's method, and the wound was apparently closed sufficiently to prevent the escape of fasces. The external wound was then dilated suffk-iently to permit the return of the protruded intestine, and it was not deemed advisable to molest the patient further on that occasion. His arm was supported on a splint; a full anodyne dose was administered, and stimulants were freely given. On the morning of April 18th, Surgeon St, J. W. Mintzer, 26th Pennsylvania, removed the forearm. Luther continued to sink until six in the evening, April 18, 1SJ2, when he died." These cases are the only two exceptions that have been found, after careful search, to the too absolute statement on page 26, of the preliminary report in Circular No. 6, S. G. 0., 1865, and, so far, the annals of military surgery appear to be barren of instances of successful suture of the small intestine after shot injuries, though recovery has ensued, with temporary faecal fistula, where sutures were employed.1 In shot wounds of the large intestines, as will be seen, more fortunate results have been achieved, by enteroraphy. In reviewing the shot wounds of the small intestine, I find no imitation of the excellent practice of Larrey,2 who, in a case of complete division of the ileum by a ball, approximated the ends of the gut to the external wound. From the special pleading of those who denounce the employment of sutures in shot wounds of the small intestines, it might be inferred that recovery through the unaided efforts of nature was not infrequent, and it would be supposed that some plausible proof that patients under such circum- stances would have a better chance of life without surgical interference3 was readily accessible. But those who advocate this view present no facts in support of their dogmatic assertions. I have sought to collect, at the beginning of this article, the clinical evidence 1 Mr. I. S. Gissing records (British Med. Jour., 1838, quoted in Charleston Med. Jour, and Rev., 1858, Vol. XIII, p. 677) a case of enteroraphy in the ease of John Jeffries, aged 17 years, wounded by the bursting of an iron cannon. Through a lacerated wound in the right flank, a mass of intestines and omentum protruded. One of the protruded convolutions of the bowel (probably a portion of jejunum) was burst through to the extent of a quarter ter of an inch, from which came fluid faeces and pure bile. Mr. GISSING placed three fine interrupted sutures through the wound in the intestine, cut the ends close to the knots, replaced the bowel, and closed the external wound with adhesive strips, and opium was administered in full doses. Sloughing ensued, and fascal fistula; but by the ninth day, faeces passed by the rjctum ; the wound closed and the putient regained excellent health. 2Lauuev (Mem. de. Chir. mil. et Camp., T. II, p. 160) says: " M. N*** recut, 0. l'assaut du Caire, an VIII (179!)), un coup de balle au bas-ventre, qui lui coupa les parols .i.usculeuses de cette cavit6 du cot6 droit, et une portion de I'intestin il6on. Comme je me trouvais sur le champ de bataille, je lui administrai les premiers secours: les deux bouts de I'intestin 6taient sortis, eloignes l'un de l'autre et boursouffles; le bout supfirieur 6tait renvcrsS sur lui-ineme, de maniere que son rebord r€treci, comme le prepuce dans le paraphymosis, gtranglait le tube intestinal; le cours des matieres en fitait inter- cept6, et elles s'accumulaient audessus du retr6cissement." * * * "Je coupai d'abord, par quatre petites incisions faites avec les ciseaux 6vid6s, le collet de I'intestin 6trangl6, que je remis dans son 6tat ordinaire. Je passai une anse de fil dans la portion du mesentere, correspondant aux deux bouts de I'intestin; je les fis rentrer jusqu'au bord de l'ouverture, que j'avais eu soin de debrider, et, le pansement fait, j'attendis les 6v6nemens. Les premiers jours furent orageux; ensuite les accidens se dissipfirent; ceux qui dgpendaient de la perte des matieres alimentaires s'appaiserent successivement; et, apr§s deux mois de soins et de traitement, les deux bouts de l'ileon 6taient en rapport et pres a contracter adherence. Je secondai le travail de la nature, et fis panser le malade avec l'ingenieux moyen de Af. Desault, c'est-£L-dire le tampon, qui fut employ^ pendant deux inois a differentes reprises. Ce militaire est sorti de l'hopital, parfaitement gueri." 3Dr. P. II- Hamilton' (A Treatise on Mil. Surg, and Hygiene, 186.5, p. 354) says : " Be assured the patient will have a better chance for life, if we let him entirely alone; and it surprises us that any good surgeon would think otherwise." 10 71 PENETRATING WOUNDS OF THE AEDOMEX. [cii.\r. VI. favorable to this view.1 It must be conceded to be far from conclusive. The evidence in the same direction, afforded by pathological anatomy, is limited, I believe, to a single observation. Mr. Williamson regards the preparation from the case of Paul Massey, which is preserved at Netley, and is figured in the wood-cut (Fig. 52), as "unique." This man survived a penetrating shot wound of the abdo- men five and a half years. The symptoms consequent upon the injury were so inconsider- able that it was the opinion of the regimental surgeon, Dr. MacDonald, that the ball had coursed around the abdomen without penetra- ting it. The patient stated, however, that he had passed blood by stool, soon after the recep- tion of the injury. He became subject to bowel complaint, and for the last twelve months of his life was nearly constantly under treatment for scorbutic dysentery. Surgeon J. H. Taylor, who made the autopsy, and Dr. Williamson, regarded the constrictions as the results of shot perforations. Yet there were no adhesions of the intestines at any point; and Professor Longmore argues, very plausibly, that it seems more likely that the gut was contused than perforated, and that the constrictions gradu-, i„X^Th^r™te aRy supervened. Guthrie (Inj. of Abd., p. ^.1071, Netiey (after wiluamson, pi. v). 3^ regarcie(i tae proper management of shot wounds of the intestines as an important point undetermined by his contemporaries, to which the best attention of their successors should be drawn. The observations made in later European wars have not greatly augmented our knowledge of the subject, and it is therefore the more desirable that the experience of the American War, on this point, should be exhaustively discussed. In the majority of the cases sufficiently well defined to be classified in this group, the subdivision of the small intestine implicated was not indicated. Manv, perhaps the larger proportion, appear to have been complicated by other 1 See Cases 207-211 inclusive. Gutiiuie's Case 46 (Wounds and Inj. of the Abd., p. 33) is one of the very few recoveries from a musket-ball wound supposed to interest the small intestine. The missile, entering in the right iliac, came out a little below the umbilicus on the opposite side. "A faecal bilious discharge, evidently from the small intestines," took place. The soldier was sent to England from Waterloo, well but weak. JOHN Thompson (Report after Waterloo, already cited, p. 105) notices this case and one other: "We saw another patient, also considerably advanced in recovery, who had received a wound by a ball which had entered about three inches above the posterior spinous process of the ilium, on the left side, and had passed out of the right hypochondriac region, near to its middle. A part of the food which he took was said to have come, for fifteen days, by the pt sicrior orifice, through which two lumbrici were also discharged. This man never had any vomiting." From the old authors, I can recall only one example of recovery from a shot wound of the small intestines; that related by Bordenave (Mem. de I'Acad. Roy. de Chir., T. II, p. 51!), Obs. XIV): A Dutch suldier, shot through the right iliac region at Raucoux, was treated by M. T*. ncy6s. There was protrusion of a wounded loop of the ileum. The patient recovered with a stercoral fistula, which ultimately closed. Modern wars have furnished few instances. Tbe single case observed by LARREY has been cited on the preceding page. The case of Massev was the solitary instance observed in India. None were reported from the Crimea. From the Italian War of le'5:', the unreliable Demme (Militdr-Chirurgische Studien, Wurzburg, 1861, B. II, S. 143) describes the recovery of an Austrian infantry soldier struck, at Solferino, by a musket ball, which was voided at stool, the direction of the wound indicating a lesion of the small iutestiues (Dttnndanns); but he notes that the faecal exodus was very copious; and, if the facts are correctly reported, the most probable inference is that the faecal fistula followed sloughing of the wall of the caecum. In the Bohemian War, Professor RICHARD VOLKMAnn. of Halle (Eintge Fdlle ron geheilten penetrirenden Schusswunden des Abdomens aus dem Feldzuge von 19C6, in Deutsche Klinik, 1868, B. I), observed two cases of recovery from penetrating shot wounds, in which he believed that the small intestines were interested. In a carefully reported case of a recovery after faecal fistula from a wound of the abdomen by bird-shot, Dr. MICHAELIS, an Austrian regimental surgeon ( Wiener Medizinische Presse, 1868, B. IX, S. 920), concludes that the alimentary canal was wounded in two places, one of the lesions being in the small intestine: '" Nacb dem Mitgetheilten ist es ausser Frage, dass mindcstens zwei verschiedene Darmtheile durch die Sehrolkorner zerrissen \vunion, und zwar dass eiucs davon dem Diinndarm, ein anderes dem Dickdarm entsprieht." SECT. m.| WOUNDS 0E THE LARUE INTESTINES. 75 visceral lesions, of which examples will be adduced hereafter. There are but few good accounts of autopsies. In the following instance, explanation of the obscure attendant phenomena is left to conjecture : Cask 230.—Private Jacob Krausa, Co. I, 9tli New Hampshire, aged 36 years, received a wound of the abdomen and of the left, wrist at Petersburg, June 20, 18(>4. He was taken to the field hospital of the 2d division, Ninth Corps, where simple dressings were applied to the wounds. He was conveyed by hospital transport to Washington, and, on the 24th, admitted into Emory Hospital, and committed to the care of Acting Assistant Surgeon E. W. Thompson, who notes on the medical descriptive list: " Gunshot wound of the abdomen, penetrating the small intestines just below the umbilicus; wound of left wrist, superficial." At the time of admission the wound of the abdomen was highly inflamed and sloughing; ftecal matter, mixed with considerable pus, was discharged from the wound. The patient was unable to retain his urine. Stimulants were administered and low diet ordered. Pressings of cold water and kerosene oil were applied to the wound of the abdomen ; that of the wrist was dressed simply. On the 29th, the right leg began to swell and become ccdematous. Cold-water applications were made to the lej_r, which reduced the inflammation. On July 2d, Dr. Thompson notes that "mortification has commenced on the leg; the wound is becoming gangrenous;" a wash of eilute nitric acid and water was employed. On the 7th, the patient bled about one ounce from the wound. Death resulted July 8, 18li4. Diarrhoea was present throughout the whole time. If an autopsy was made the record was not forwarded to this office. Protrusion of the unwounded or wounded bowel is well known to be rare in shot wounds. The following instance has been reported by Surgeon W. 0'Meagher, 37th New York: Case 231.—Private J. McLellan^Co. II, 1st New Jersey Cavalry, was wounded, February 24, 1802, near Pohick, by a musket ball, which entered the right lumbar region and emerged half an inch below the navel, severing the small intestine, the wounded gut being protruded and the extent of the injury revealed. There was profuse bleeding from the divided mesenteric arteries, vomiting, and rapid collapse. The patient sank and died, nine hours after the reception of the wound, February 24,18G2. The complications and treatment wf wounds of the small intestines will he more conveniently considered at the close of the next subsection. Wounds of the Large Intestines.—It has long been known that injuries of this group were less fatal than wounds of the small intestines.1 The position and structure of the colon account for the less liability in wounds of this portion of the intestinal canal to extravasation of the faecal contents into the peritoneal cavity. The disposition of the muscular coat, and the firm attachments by which the gut is secured, tend to preserve that parallelism between the wounds in the parietes and in the bowel, and that apposition of the intestinal and parietal surfaces that are such important safeguards; and further favorable conditions are found in the facts that the colon is only partially invested by the peritoneum, and that injuries of its ascending and descending portions, especially, do not necessarily jeopardize other organs. In the preliminary report in Circular 6, S. CI. 0., 1865, p. 26, I stated that " recoveries after wounds of the large intestines have been much more numerous than after wounds of the ileum or jejunum." A closer study of the facts, justifies the assertion that the difference in fatality, in injuries of these two groups, is very great; the lesser mortality of wounds of the large intestine having been abundantly exemplified. Adverting briefly to the miscellaneous injuries of the large intestines, I will adduce a long series of remarkable recoveries from shot wounds, many of which have been kept under observation for several years. 1 BENJAMIN Bell (A System of Surgery, 2d ed., Edinb., 1785, Vol. V, p. 289) is one of the few authors who deny that wounds of the large are less dangerous than those of the small intestines. He says that he has not observed that this is confirmed by experience, though the proofs experience affords are abundant. It has been seen, in the notes to page 63, how few authentic recoveries from wounds of the small intestines were known to the ancients; of wounds of the large intestines, they adduced a considerable number. In the translation of ALBUCASIS (De Chirurgia, Oxonii, 1778, Lib. II, Sect. 85, p. 393) is recorded a recovery from a lance wound of the great intestine. Nidus VlDIUs (Comment in lib. HIPI'OCRATIS, de vuln. cap., 1544) records a recovery from a punctured wound of the large intestine. Pake (Traite des playes d'hacquebutes, 1552, fol. 79) records the recovery of the silversmith of the ambassador of Portugal from a sword thrust in the colon. MuitGELIUS (in Schenckius, I. c, p. 368) relates a recovery from a punc- tured wound of the colon. A. DE HAKTWISS (Eph Nat. Cur., Cent. 1, Francofurti, 1712, Obs. VI, p. 43) relates a case in which a portion of the colon had been cut off by a knife, and a preternatural anus had formed, with ultimate recovery. Tulpius (Obs. medicse, Lugduni, Bat., 1716, Lib. Ill, Cap. XX, p. 2)8) notes a stab wound of the large intestine, with recovery. TIFFENBACH ( Vulnerum in intestinis lethalitas, Wittemberg, 1720, in Hallek'S Disp. chir., Lausannas, 1756, Vol. V, p. 63) records a recovery from a bayonet wound in the left hypochondriac region, with injury of the colon. NOURSE, C. (Philosoph. Trans., 1776, p. 427), relates a recovery from a stab wound of the colon. IlON'ALDSON (Medical Comment., 1780, Vol. VII, p. 372) notes a stab wound of colon; completely cured in five weeks. TUDECIUS (De intestino colo vulnerato cum hypogastrio vulnerato coalescente, in Eph. Med. Phjs. Cur., Norimbergse, 1G93, Ann. IX, Obs. CXXI, p. 293) cites a case of sword wound of the colon ; fatal in sixteen days. At the autopsy the edges of the wound of the colon were found united with those of the abdominal wall. 76 rENETEATING WOUNDS OF THE ABDOMEN. [CHAP. VI. Punctured and Incised Wounds.—Comparatively few examples of these lesions were reported. Surgeon S. W. Gross, U. S. V., has printed1 an interesting case of recovery, from a sabre wound of the descending colon. Pension Examiner J. R Bailey, in March, 1866, reported the same case with some additional details :2 CI/si: 232.—Private C. A. McCullocli, 3d Kentucky Cavalry, aged 19 years, was shot through the chest, in the skirmish at Sacramento on December 28, 1831, a pistol ball perforating the right lung. In retreating he received also a sword thrust in the left flank, penetrating the abdomen. He rode about a mile after this, and ihen was too faint to sit upon his horse, and was left at a farm-house. Here he was attended by a practitioner of the neighborhood, who administered purgatives. There could be no doubt that the sabre penetrated the bowels, for there was a very copious discharge of fecal matter by the wound for several days. He was seen, however, occasionally, by Union surgeons, when they could visit the farm-house, which was situated between the lines. After protracted suffering, he recovered and performed some little service. Surgeon Singleton was in charge of the regimental hospital at that time. He reported that McCullocli was discharged in October, 18:52, and then enjoyed better health than could be expected. [McCulloch's name is not upon the Pension Roll.] In the next case, the diaphragm, and the thoracic as well as the abdominal cavity, were implicated; but the fatal termination resulted immediately from the faecal extrava- sation, due to the wound in the colon : Case 233.—Private Stephen Moel, Co. K, 10th Tennessee Cavalry, was admitted to general hospital at Natchez, Mississippi, a half hour after midnight, April 8, 18G5, having received, at seven o'clock the previous morning, a punctured wound, from a pocket-knife, in the seventh intercostal space, posteriorly. His pulse was small and rapid, countenance anxious, respiration short and hurried, tongue furred, and abdomen greatly distended. He complained of very severe pain in the diaphragmatic region. A mass, having much the appearance of highly congested adipose tissue, protruded one and a half inches through the external opening. Assistant Surgeon A. E. Carothers, U. S. V., excised the protruding mass, and endeavored to induce haemorrhage externally by placing the patient on the affected side, but little bleeding occurred. The patient became comatose, and died on April 8, 18(55, thirty-eight and one-half hours after the reception of the injury. At the autopsy, a large quantity of bloody serum was found. The diaphragm had been punctured, and the omentum forced upward through the wound in the diaphragm and out of the external wound. There was intense and general inflammation throughout the peritoneum and the pleura of the injured side. The lungs and liver were normal. The colon was found punctured at the left end of the transverse portion, and had permitted the abundant escape of feces into the abdominal cavity. The whole intestinal canal was highly congested. The case is reported by the operator. In a case of incised wound of the descending colon, without protrusion, enteroraphy was unsuccessfully practised :3 Case 234.—Corporal M. Moran, Co. II, 111th Pennsylvania, aged 22 years, was stabbed July 6, 1865, in an affray in camp, near Washington, and was taken to the regimental hospital. It was ascertained that a dirk knife had penetrated the abdominal cavity, in the left iliac region. The following day the patient was taken to Lincoln Hospital. The wound in the abdomen was inflamed, the lips red and swollen. A general inflammatory reaction had set in, the patient having been in perfect health at the time of receiving the wound. Chloroform was administered, and Acting Assistant Surgeon W. E. Roberts enlarged the wound in the parietes by an incision one and a half inches long. This fully exposed an oblique wound of the walls of the descending colon. The intestine was drawn down, and the division of its tunics was closed by six points of interrupted suture. Symptoms of peritonitis were combated by a small bleeding from the arm, and by full doses of opium, with cold applications and poultices to the abdomen. The progress of the case was not favorably modified, and death resulted, July 19, 18ii5, thirteen days from the reception of the wound. Gunshot Wounds.—While few instances were observed of recovery from shot wounds of the transverse colon, many were seen of survival after perforations of the caecum and ascending portion of the bowel, and a still larger proportion of recoveries was observed in wounds of the sigmoid flexure and other parts of the descending colon. iNot a few of 1 GROSS, S. W. (Am. Med. Times, March 19, 1864, Vol. VII, p. 136), and HAMILTON (A Treatise on Mil. Surg., p. 384). Dr. Gross gives the youth's name as William Lowry, and states that he last saw him on February 18, 1862, eight weeks after the reception of the injury. 2 The American medical periodicals record but few recoveries from stabs in the large intestines treated on the expectant plan: Dr. C. II. RaWSON (Am. Med. Times, 1864, Vol. VIII, p. 16) records a case of recovery after fascal fistula, following a stab wound of the descending colon. He infers that the serous and muscular tunics only were divided by the knife, and that the cellular and mucous coats gave way on the ninth day. Dr. AV. N. FOUISES (The College [Cincinnati] Jour. Med. Sci., 1859, Vol. IV, p. 441) describes a recovery from a stab in the left iliac region, bloody stools indicating that the descending colon was injured; there was no fascal extravasation, and, under an opiate treatment, the patient was well in three weeks. *]. Dr. A. POST has, in the reports of the New York Hospital (The Annalist, 1846, Vol. I, p. 26), a case cf a stab wound with protrusion of the descending colon, iD which a longitudinal incision an inch long was successfully united by two sutures, and the bowel returned. A prophylactic blister was applied, a practice originating, according to Dr. POST, with the late Dr. BoitROWE, to which the happiest effects were ascribed. 2. Drs. MASON and WlllTXr.v, of Prairie du Chien, describe (Chicago Med. Exam., 1867, Vol. VIII. p. 21) a dirk wound of the transverse colon, with protrusion, and division of a large branch of the colica media. Two ligatures were placed on the divided artery, and the intestinal wound was united by the glovers' suture, the serous surfaces being carefully approximated. Complete recovery in four weeks. 3. Dr. J. P. Ciiesxey (Cincinnati Med. Repertory, 1869, Vol. II, p. 335) records a successful case of enteroraphy in a stab in the descending colon, with protrusion; the intestinal wound, an inch long, was closed by the glovers' suture. sun?. His . of Ui« •War of the Rchrllion Vol.11 I'ha y\1 I i3& &■%. mf $ Up pag>.77 ■MS* if. Sla.H-li del. T. Sim lair i S and had nearly recovered. August 19,1864, Surgeon M. J. Borland, 8th Ohio Cavalry, relieving Surgeon A. H. Thayer, Cth West Virginia Cavalry, reports that he found no hospital records on file there. January 11, 1865, the post of Beverly was captured by General Rosser, and all official records there were reported to have been destroyed. Hence it has been impossible to glean any fuller details of the case of Wease. The explicit and careful statement of Surgeon C. E. Denig supplies the essential facts. Examining Surgeon Thomas Kennedy, of Grafton, West Virginia, reports, January 9, 1872, that the "ball entered the right side of the abdomen, between the umbilicus and upper crest of the ilium, four inches from the umbilicus, and came out between the ilium and the spine, four inches from the spine, passing through the large intestine and upper part of the ilium. The contents of the bowels passed out of the posterior wound for some months, and portions of bone were also eliminated. The cicatrices of entrance and exit were depressed and about an inch in diameter. The abdominal muscles around the anterior cicatrix were contracted. Locomotion was difficult, and the physical disability total and temporary. Weight, 135 pounds; age, 30 years; pulse, 68; respiration, 18." In short, this pensioner appears to enjoy tolerable health. Case 247.—Private Frank Saville, Co. I, 2d Delaware, aged 21 years, was wounded at Gettysburg, July 2. 1863, by a conical ball. He was admitted to Seminary Hospital from the field, and subsequently transferred to Wilmington, where he entered the Tilton Hospital, July 10th; he was furloughed on April 25, 1864, and returned May 5th, and, on the 10th, was transferred to Summit House Hospital, Philadelphia. On August 18th, he was transferred to Satterlee Hospital, and Surgeon Isaac I. Hayes, U. S. V., in charge, reports: "Ball entered one inch from umbilicus, left side, and passed out near crest of ilium; faeces passed from wound of exit for about three months; when admitted here, both wounds were entirely closed and the general health of the patient good." On August20th, he was detailed as nurse in the ward, and on November 1st was transferred to Wilmington, where he was admitted to Tilton Hospital. The wounds were healed at the time of his admission, and, on November 7th, he was furloughed, and was discharged the service December 19, 1864, on account of "gunshot wound of abdomen injuring intes- tines and causing artificial anus." Pension Examiner William Corson, of Norristown, reported, November 27, 1869: "Ball entered abdomen four inches from umbilicus, right side, passed out at crest of ilium, posteriorly—wound of colon—faecal matter passed from wounds for two months—tending to diarrhoea without control. Fatigue and pain from exertion or standing. Disability three-fourths, mainly permanent." Case 248.—Private J. Labar, Co. E, 28th Pennsylvania, was accidentally wounded by the discharge of the musket of a falling comrade, at Leesburg, March 12, 1862. He was taken to the regimental hospital on the same day, and, on May 22d, was transferred to hospital No. 1, Frederick; thence, on June 3d, to Harrisburg, to hospital at Camp Curtin, where the injury is recorded as a "gunshot wound of the right side, the ball passiiig through the liver." There is no further hospital record of the case, save that the patient was discharged from service September 29, 1882, and pensioned. Pension Examining Surgeon E. Swift, of Easton, Pennsylvania, reports, August 24, 1886: "Ball entered the right side, six inches from the spine, and three inches above the spine of the ilium, and passed out one and a half inches to the right of the linea alba, and two inches below the end of the sternum. The ball passed through a portion of the liver, lung, and intestine—colon, probably. The anterior orifice is closed; faecal matter was discharged from the wound, which discharge still continues in diminished quantity. His general health has improved, and he can now walk out, or even ride a few miles; still he is very feeble, and utterly unable to do«any kind of work, and with little prospect of ever being much better; disability total and permanent." In June, 1883, his pension was increased from eight to twenty dollars a month. He died June 12, 1887. There is no record of an autopsy. Case 249.—Private Michael Hickey, 1st Maine Battery, aged 18 years, was wounded at Cedar Creek, October 19, 1834, by a conoidal ball. He was received into the division field hospital on the same day, and on October 21st was admitted to the Nineteenth Corps hospital, at Winchester, where the case was diagnosticated as "gunshot wound of the back." He remained in this hospital until December 5th, but the records furnish no evidence of the symptoms or treatment at that time He was next transferred to Frederick, doing well. The case is thus described: "Gunshot perforating wound of the intestines on the right side, ball entering over fourth lumbar vertebra, passed through the abdominal cavity, wounding the intestines, and emerging one and a half inches above the crest of the right ilium." Assistant Surgeon R. F. Weir, U. S. A., in charge, says: "Patient states that the contents of the bowels came out through the wound in the back for two days, and through that in the side for twenty-five days, after the injury." On March 22, 1865, the patient was transferred to Augusta, and, on the 23th, to Cony Hospital, and was discharged the service June 22, 1835. Pension Examiner Josiah F. Day reported, September 12, 1837: "For about three weeks he had faecal discharges from the wounds of entrance and exit. In six months the wound was entirely healed. About three months ago, at the point of exit, there was discharged a small quantity of pus for three or four days; since that time it has remained well; general health good; he works in a cotton-mill and attends four looms, and has done so for eight months, during which time he has lost one-half of the time. Disability three-fourths." Case 250.—Private J. L. McLane, Co. B, 76th New York, aged 24 years, was wounded at Gettysburg, July 2, 1833, by a conoidal ball. He was admitted to the Seminary Hospital on the following day with "gunshot wounds of hip and bowels," and, on July 28th, was admitted to Camp Letterman Hospital, where Acting Assistant Surgeon H. Leaman reported as follows: "Wounded by a minie ball, entering the right groin and making its exit through the buttocks, four inches behind and a little above the level of the trochanter major. He suffered from the passage of faeces through the wound of exit for fifteen days; since SKt"1'1"1 WOUNDS OF THE LARGE INTESTINES. 83 that he has not had any unpleasant symptoms. When I took the case, August 15th, the wounds were nearly healed; the general health excellent; at present, August 20th, the wounds are closed. August 2lst, furloughed for twenty days." He was discharged the service October 11, 1864. Pension Examiner (i. W. Avery, of Norwich, New York, reported, March 9, 1869: "A musket ball entered the left buttock, passing through its centre, lacerating the gluteus maximus; also, a buckshot entered the left groin, where it still remains; disability probably permanent," Pension last paid February, 1873. Case 251.—Corporal Simon J. Fought, Co. D, 46th Ohio, aged 25 years, was admitted to the General Hospital at Mound City on July 25th, from Haynes's Bluff, and Surgeon 11. Wardner, IT. S. V., reports as follows on the hospital case-book: "Was wounded in a skirmish at Black River, Mississippi, on .July 5, ]H63, by a rifle ball striking the anterior wall of the abdomen, in a line between the anterior superior processes of the ilii, and about half an inch from the angle of the right ilium, and emerging about one and a half inches from the angle of the left ilium; the wound was dressed with simple dressings, cold water, poultices, etc. About two weeks after the wound was received, the contents of the bowels commenced passing out at the point of the entrance of the ball; this continued for some ten days, when it entirely ceased; wound discharging freely, and the discharge very healthy in color and consistence: patient's spirits good; appetite good; general health excellent. August 10th, wound discharging more than for some days; discharge not healthy, having the odor of fasces; patient attributes the change to sitting up too long; wound discharges more while the patient is eating than at other times; general health good. August 13th, wound doing well; some fa-ees passed out this morning; since then the discharge has been healthy. August 14th, patient feeling well; wounds doing well; the wound at point of entrance discharging more than at point of exit; granulation going on finely; appetite good. August 15th, wounds granulating finely ; in every way a steady and visible improvement. August 16th, patient feels well; the discharge this morning was mixed with the food he ate for supper last evening almost unchanged (he ate mush); the wound granulating around the borders finely. August 17th, the patient has been sitting up for a while to-day; is in the best of spirits; appetite good. August 18th, patient says his bowels have been costive to-day, and that some faeces passed through the wound; otherwise, same as yesterday. 19th, wound looks well, discharge clear; bowels loose; appetite good; his bowels have to be kept lax in order to allow them to act without irritating the wound; it having been noticed that whenever he becomes costive a portion of the faecal matter passes out through the wounds. 20th, wounds doing well, patient able to sit up; discharge light; health good; granulation going on finely. 21st, patient walked a little more than usual to-day; discharge a little mixed with faecal matter. 22d, wound doing well; still walking around; discharge perfectly healthy. 23d, he is walking around more and more every day; wounds rapidly healing; discharge healthy, and the patient in the finest spirits. 24th, doing well; discharge not so great, and unmixed; able to sit up most of the day. 25th, discharge this morning healthy, but at noon was thin, watery, and mixed with a small portion of fluid faeces; health good; treatment, cerate dressings. 27th, some unhealthy granulations; when the patient eats heartily it is found that the discharge from the wound is mixed with faecal matter; treatment, cerate dressings; caustic to unhealthy granulation, and patient forbidden to indulge his appetite to excess. 29th, doing well; wounds healthy; discharge at noon almost always mixed with faeces. August 30th and 31st, much the same. September 11th,-doing tolerably well; some faecal matter comes out at the wound of entrance; discharge light, thin, and watery; health good; appetite good; wound of exit almost healed. For the next four days he was much the same. 16th, wound discharging considerably, discharge thin and mixed; had diarrhoea yesterday, but has had no passage to-day. 19th, discharge mixed with a small quantity of faecal matter. 20th, patient affected with diarrhoea. 22d, some faecal discharge. October 1st and 2d, wound looking tolerably well, discharging some in the afternoon, but none in the forenoon. 3d and 4th, wound still looking well, but discharging some faecal matter; discharge of pus small; treatment, cerate and adhesive strips. 5th, patient affected with diarrhoea, which caused more^fascal matter to pass through the wound. 9th, wound of exit entirely closed; that of entrance discharging considerably; no faecal matter as long as patient lies quietly. On the 17th, the wound was still contracting; the patient was affected with violent headache and fever, and, on the 21st. the wound of exit again opened, and from this time until October 29th, the wound had gradually healed and was then again closed. November 4th, discharge thin and watery and colored by faecal discharge; general health good; treatment, cerate and plasters. November 7th, much the same as at last report; discharged from service to-day, and started for his home in Columbus, Ohio." . At the time of discharge his general health was good, but the wound of right side had not healed. On September 21, 1867, Pension Examiner E. B. Fullerton, of Columbus, reports: "Evident adhesions of bowel to abdominal walls, the sense of weakness being so great that sleep is onlv obtained by lying on the back or face; has great difficulty in digesting; at times, accumulations just above wound, amounting to partial obstruction of bowels; in walking, and during digestion, he keeps his hand constantly on the wound as a support; he is liable to have the trouble renewed by any fall or sudden movement; disability permanent, and equivalent to the loss of a limb." On July 3, 1868, Pension Examiner A. L. Lowell, of Columbus, reports: "Ball entered abdominal parietes in right inguinal region, and at that point opened the peritoneum and ascending colon, causing a faecal fistula; it then traversed the muscles of the hypogastric region and emerged from the left inguinal region. The fistula is now entirely and permanently healed- the muscles divided by the ball have become partially restored in efficiency, and a healthy cicatrix, extending across the abdominal walls, shows that permanent reparation has taken place; he is a strong, healthy man, and physical signs demonstrate no grave intra-abdominal lesion." An Examining Board of Surgeons, Drs. S. Smith and E. B. Fullerton, of Columbus, reported, March 1, 1871: "Ball struck the abdomen on the right lower side, just above the groin, passing across through the abdominal cavity, and out on left side; passed faecal matter through the openings for five or six months; both now closed, but evidences of contraction of the gut and adhesions to the abdominal walls and of partial obstruction remain, and mechanical means are necessarv sometimes to press forward the contents of the bowels. The great danger in this case is from the permanent obstruction of the bowels and the laceration of the walls. If dependent on manual labor, he would, in our opinion, be in constant danger of fatal injury." Fought was last paid to include December 4, 1872. Case 252.—Private II. P. Dugan, Co. I, 121st Pennsylvania, aged 26 years, was wounded at Gettysburg, July 3, 1863 by a conoidal ball, which entered one inch below the crest of the right ilium. He was taken to the field hospital, where the missile was removed through a counter-opening two inches posterior to the point of entrance; simple dressings were applied to the wound. On July 22d. he was transferred to the Chestnut Street Hospital, Harrisburg. Here the fracture of the right, ilium Ss-1 PENETRATING WOUNDS OF THE ABDOMEN. |('HAP. VI. was noted bv the ward surgeon, who also states that "since the day he was wounded some fa-cal matter has escaped with the discharge of pus through the wound. Water dressings and nourishing diet. August 12th, general health improving; faecal discharge much less. August 20th, general health good. Small pieces of necrosed bone have been removed through the opening; there is still a very slight discharge of faecal matter." On September 16th, he was transferred to South Street Hospital, Philadelphia, and placed in Ward I, under the charge of Acting Assistant Surgeon Knorr, who states that "since his admission the wound has been dressed simply. The external opening communicates with the colon, and wind and faeces make their exit through the fistulous opening. On September 20th, he complained of great pain in the lower right side of the pelvis, which was relieved by enemata and the application of warm cloths externally. This trouble occurred again on the 23d, but disappeared under the same treatment." On July 7, 1864, he was transferred to Beverly, New Jersey, at which time the fistulous opening still remained. At Beverly he was reported as "convalescent," and was returned to duty February 21,1865; but, on the 27th, was admitted into the 2d division hospital at Alexandria, was transferred on May 21st to McClellan Hospital, Philadelphia, and was discharged from service July 8, 1865. Pension Examiner John Neill reports, July 16, 1868, that "the entrance wound is depressed and discharging, with evidence of necrosed bone. The ilium was comminuted, and numerous small pieces of bone have escaped. There is probably more to be discharged. The man is ruddy and in perfect health, and can pursue his trade except when a fresh suppuration takes place. He has entire use of all of his limbs." The Pension Examining Board at Phila- delphia reports, March 23, 1870. that the inconvenience and disgusting nature of the disability has not improved, and debars him from obtaining employment, and recommends him for an increase of pension, which was granted. He was last paid on December 4, 1872. Case 253.—Corporal C. F. Ballou, Co. I, 44th New York, aged 23 years, was wounded at Gettysburg, July 2, 1863, by a conoidal ball. He was admitted to the Seminary Hospital on the 4th, and, on the 17th, was transferred to the Cotton Factory Hospital at Harrisburg. Acting Assistant Surgeon L. Post, who had charge of the case, made the following report: "Ball entered the right thigh two inches below Poupart's ligament, and a fragment of ball was taken out near the crest of the ilium. A fragment of the same is supposed to have entered the bowels from the same source. For several days there has been a fistulous opening, and from it gas and thin excrement has passed; there is some soreness in the right side. The discharge of pus from the wound has been excessive; pus has also been discharged from the bowels. To-day, August 15th, the wound appears better. A light, generous diet is allowed; appetite good; pulse soft and natural; the wound has been dressed twice each day, and the symptoms are evidently much improved. August 24th, continues to improve; fistulous opening gradually closing. September 16th, patient is considered to be doing well, and is able to walk out." On December 25, 1863, he was discharged the service. The records of the Pension Office show the following report of the case by W. L. Wood, Acting Assistant Surgeon in charge of hospital at Harrisburg: "Ball entering the pelvis, producing vesical fistula." Pension Examiner C. S. Hurlbut, of Olean, New York, reported, November 12, 1856: "Ball entered the left leg or thigh, near the hip, passing along the ala of left hip and emerging near the dorsal vertebrae; disability three-fourths." Paid to December 4, 1872. Case 254.—Private Alex. Day, Lee Battery, Braxton's Artillery, aged 23 years, was wounded at Winchester, September 19, 1864, by a conoidal ball. He was admitted to the depot field hospital for prisoners of war at Winchester on the same day, and Surgeon L. P. Wagner, 114th New York, reported as follows: "Gunshot wound of abdomen, penetrating the large intestine; faeces passed through both orifices during four weeks from date of wound." The treatment consisted of applications of simple dressings, and the administration of anodynes. December 10th, the patient was transferred, convalescent, to West's Buildings Hospital, Baltimore, and the case reported as "gunshot wound of right side of abdomen, striking the ilium." On January 5, 1865, he was transferred to Fort McHenry for exchange. Case 255.—Private Robert Brierly, Co. A, 1st Delaware, aged 22 years, was wounded, at the battle of Antietam, by a conoidal musket ball, which entered a little to the left of the umbilicus, aud lodged under the muscles near the anterior superior spinous process of the right ilium. There was great prostration, with nausea and vomiting, which were treated at the field hospital by the administration of opiates. Three weeks subsequently, the patient was transferred to Frederick, Maryland, under the care of Acting Assistant Surgeon A. V. Cherbonnier, who has furnished a detailed clinical history of the case (Bd. MSS., Div. Surg. Pec. S. G. O., 33): "On October 25th, faeces escaped through the lower wound, which had been for several days in a sloughing state. The artificial anus continued open until November 15th. On November 25th and December 11th, there were attacks of colic, followed by reopening of the faecal fistula. By the end of December, the wounds appeared sound and permanently healed, and the patient was transferred to Baltimore, and was discharged the service December 31, 1862." His name does not appear on the Pension Roll. [See Circular 6, S. G. O., 1865, p. 26.] Case 256.—Surgeon Edward Batwell, 14th Michigan, reports that "Sergeant William Vannalta, Co. K, 14th Michigan, was shot through the bowels, at Lavergne, Tennessee, October 7, 1862. The ball entered at a point about equidistant from the anterior superior spinous process of the ilium, the umbilicus, and the symphysis pubis. I did not attempt to trace its course. When first seen, he lay upon his back, his legs drawn up, his countenance anxious and pale; a cold clammy perspiration covered his face and limbs; pulse 90, small and weak. Stimulants were carefully administered, and, toward evening, reaction had set in to a considerable extent, accompanied by some pain and tenderness over the right side of the abdomen. A grain each of calomel and opium were ordered every third hour, and tepid-water dressings were applied to the wound. October 8th, on removing the dressings, the wounded intestine was seen lying at the bottom of the wound, and a discharge of faeces occurred on the slightest movement. The idea of an artificial anus suggested itself as affording the best or only chance of saving his life, and, with this object in view, the intestine was seized and held to the abdominal parietes with four serres-fines. Two grains of opium were administered every third hour, and cold-water applications made. In the evening, the abdominal tenderness had lessened; about two pints of straw-colored urine were drawn oft' with the catheter. October 9th, the wound looked healthy, and, toward evening, a warm-water enema was given for the removal of any accumulated faeces in the lower bowels; the opium was still continued to semi-narcotism. The abdominal tenderness decreased, although some tympanitis was present. Pulse 75 to 80, and rather hard. October 10th, stercoraceous matter escaped freely from the wound; the surfaces were cleansed thoroughly, sect, m.) WOUNDS OF THE LARGE INTKSTINES. 85 and, in the evening, the serres-fines were removed. The formation of an artificial anus was then abandoned for the more desirable objects of endeavoring to close the intestinal aperture (which was now firmly adherent, to the surrounding edges of the wound), and to make the bowel permeable. October 11th, the edges of the wound were drawn together with adhesive straps; the dose of opium was increased to three grains every fourth hour; the patient felt very comfortable. On October 15th, the dressings were removed; there was no appearance of faecal discharge, and the tympanitis had entirely disappeared. On the 17th, a large dose of castor oil was given, which operated thoroughly four times without pain or trouble to the patient. On October 21st, he was able to go out of doors, but the pain caused by walking was very great, and was referred to the promontory of the sacrum. This gradually lessened, and toward the end of December he felt very comfortable." On January 5, 1863, he was discharged from service and pensioned. Pension Examiner William F. Breakey reported, June 27. 1866, that "the bullet entered the right side of the abdomen, two inches from the median line and four inches below the umbilicus, and lodged, and has not been extracted. He suffers constant pain in the region of the wound and in the hip and back, which is greatly aggravated by labor or exposure; great general disability." [See Michigan A. G. E., 1803, p. 319.] Case 257.—Private Philip Hill, Co. C, Kith Pennsylvania, was wounded at Cedar Mountain, August 9, 1862. He was admitted to Mansion House Hospital. Alexandria, August 15th, and, on August 30th, was transferred to York, Pennsylvania. Surgeon H. Palmer, U. S. V., reported that the ball entered the right natis and passed into the abdominal cavity, wounding the great intestines. I Veal matter escaped from the wound for several days. Hill was discharged the service, November 14, 1862, for total physical disability. His name is not upon the Pension List. Case 258.—Private G. W. Smith, Co. K, 8th Alabama, aged 18 years, was wounded in the abdomen at Gettysburg, July 2. 1863. There is no record of the case prior to his admission to hospital at Camp Letterman, August 7. 1863. Assistant Surgeon W. F. Richardson, C. S. A., reports: "Wounded by a mini6 ball entering the median line one inch below the ensiform cartilage, and passing obliquely downward and outward emerged from the right hip, after passing through the ilium. The patient passed faeces through the opening made by the exit of the ball for three weeks. August 7th, the discharge of faeces through the wound of exit has ceased; wound suppurating and discharging healthy pus; several spiculae have been removed from the wound. September 20th, general health good; the anterior wound is healed; wound of exit still discharging. October 6th, transferred convalescent." He was admitted to West's Buildings Hospital on the same day, and, on November 12th, was transferred to City Point for exchange. Surgeon George Eex, U. S. V., stated that he was "improving, and probably would recover." Case 259.—Private G. W. Crabtree, Co. C, 11th Illinois, was wounded at Pittsburg Landing, April 7, 1862, by a musket • ball. He was admitted to Mound City Hospital, from the field, on April 11th, and the following history of the case is given by Surgeon E. C. Franklin, U. S. V.: "Ball entered left side of the abdomen, three inches to the left of the umbilicus, passing through the body, and made its exit one inch from the spine, on the same side. Three days after the injury was received, there was a discharge of faecal matter from both wounds, which continued, at intervals, until May 2d, when the bowels were inclined to be constipated, the discharges through the wounds became profuse, and the patient much distressed; but when the lower bowels were relaxed by mild cathartics, the discharge became slight and the patient comfortable. By May 10th, he was able to sit up and walk about, there having been no discharge of faecal matter since May 3d, the dejections taking place regularly, by the rectum, and the wounds rapidly healing. June 3d, patient entirely convalescent; both wounds healed; quite free from pain; appetite good; bowels regular. When the above case was admitted, the wound was considered fatal; the treatment consisted in keeping the body in an upright position, employing cold-water dressings, and keeping the bowels soluble with saline cathartics. On June 11, 1862, he was returned to duty, perfectly cured." He was discharged the service November 20, 1862. Pension Examiner J. Eavold, of Greenville, Illinois, reported, March 29, 1870: "Gunshot wound of left abdomen; ball taking effect about six inches to the left of navel, passing inward and backward, and issued about two inches higher from a line of the point of entrance, near the spine. From the constant drawing pain in the wounded parts, I am led to believe that there must be some intestinal adhesions to the walls of the abdomen. The pain and cramp-like drawing has of late increased, so as to entirely forbid manual labor. When the weather changes, the pain is accompanied by bloating and fever, which renders his condition very painful. Disability total." This pensioner was last paid to December 4, 1872.' Case 260.—Private Eobert Smith, Co. D, 1st Indiana Cavalry, aged 20 years, was wounded at Helena, Arkansas. July 4, 1863, by a conoidal ball. He was admitted to the regimental hospital on the same day, and, on the next, transferred, on the hospital steamer R. C. Wood, to Memphis. He entered Gayoso Hospital on the 7th, under the charge of Surgeon D. W. Hartshorn, U. S. V., who furnishes the following notes: "This man was struck by a minie" ball about two inches above the crest of the ilium; it penetrated the abdomen, passing backward and outward, and lodged near the spiue, in the right loin, from which place it was cut out. July 7th, rest and water dressings. July 16th, a grain pill of opium at bedtime. July 19th, wound upon back becoming grangrenous; nitric acid is applied; afterward, resin cerate on lint was applied, and covered by poultices of yeast, flaxseed, and charcoal. A mixture of brandy, sulphate of quinine, and dilute sulphuric acid was ordered; also, one grain of opium at bedtime. July 20th and 22d, same prescription. July 25th, a large slough came off, leaving a healthy ulcer- ating surface. July 26th, same dressings continued; healthy granulations continue to appear; more or less faecal matter, mixed with pus, has been discharged from the wound near the crest of the ilium, since admission. July 30th, no faecal matter has been discharged from the wound for the last four days, although the pus has still a bad odor. August 8th, no odor in pus. August 22d, both sores doing well, but discharging pus. August 23d, furloughed for thirty days." On October 15, 1863, he was admitted to hospital No. 2, Evansville, Indiana; the wound was still suppurating. The patient was discharged the service March 29, 1863. A transcript from the Pension Office records reports as follows: " Gunshot wound received at Helena, Arkansas, July 4, 1863; ball passing through the left ilium and lodging on the right side of the lumbar vertebra?, in its course wounding intestines, and resulting in artificial anus at the wound of entrance of ball." Examining surgeon's certificate, July 13, 1866, states: "Ball passed through the superior portion of the left hip-bone and came out about two inches to the right of 1 A history of this case, by E. Andrews, M. I)., taken from the records of the Mound City Hospital, was published in the Chicago Medical Examiner, Vol. V. 1864. p. 551. It is stated in this account that the descending colon was wounded. s<; PENETRATING WOUNDS OF THE ABDOMEN. [CHAT. VI. the spinal column. It penetrated the bowels in its passage, causing a discharge of faecal matter from the wound for months. So complete a recovery as he has attained is almost without a precedent. The bowels adhere to the cicatrix, which is still some- times painful, and a slight cause, at any time, might totally disable him. His chief disability now consists in the difficulty of bending forward, because of the wounding of the spinal muscles." Examining surgeon's certificate, August 29. 1867, states: •<*'** causing discharge of faecal matter through wound of exit. An artificial anus is thus formed, which omits wind and occasionally faecal matter at this time, * * ." Examining surgeon's certificate, November 1, 1871. states: "Height. 5 feet 11 inches; weight, 160 pounds; dark complexion; aged 28 years ; respiration 18; pulse 09. Ball evidently passed through the doscendiug colon and out near the last lumbar vertebra, just to the right of spinal column. There is evidently adhesion and stricture of the intestinal canal, the bowels being either costive or troubled with diarrhoea. Complains of constant pain and weakness through the lumbar region." Case 261.—Lieutenant O. W. Williams, Co. C, 25th Ohio, aged 32 years, was wounded at Devaux Neck, S. C, December 6, 1864. He was admitted to the officers' hospital at Beaufort, on December 8th, from the field, and Surgeon A. P. Dalrymple, U. S. V., in charge, thus reported the case: "Gunshot wound of right side of abdomen, ball entering about one inch from the superior anterior angle of the ilium and penetrating the intestines; ball not extracted; wound severe. He was returned to duty February 8, 1865, and on April 26, 1865, he was discharged the service." Pension Examiner W^m. Loughridge, of Mansfield, Ohio, reported, November 28, 1865: "Musket ball struck and entered the right side of the abdomen, two inches inside and a little below the anterior superior spinous process of the ilium. The bowel was penetrated; the woundjs still open and discharg- ing pus—sometimes faecal matter and sometimes flatus; the ball is still lodged somewhere in the body. The right lower limb is almost completely paralyzed; disability total, and permanent." On November 19, 1865, he reports: "There is still an opening, through which gas occasionally passes. As soon as he became conscious after receiving the injury, he felt a severe pain in the back, in the region of the sacro-iliac junction, and has suffered from it ever since. Three years after receiving the injury, he suffered from the formation of an abscess on the back of the sacrum, in the region where he complains of the pain. Soon after he received the injury he experienced loss of power in the lower right limb, which has continued more or less ever since; and about two months afterward a small piece of bone, composed almost literally of cancellated structure, passed from the opening in the abdomen. From its appearance, I am inclined to the opinion that there has been caries of the promontory of the sacrum, or perhaps of the posterior superior spinous process of the ilium; from the appearance of wound and history of case, I believe that the ball passed directly through the abdomen and lodged near the sacro-iliac junction. The opening in the front part of abdomen is now nearly closed, and the paralysis is almost entirely gone. He occasionally experiences some little loss of power during inclement weather, but, according to his oAvn statement, is decidedly improved, and his general health is good, but is still feeble in general strength; ball still lodged in his person." Height, 5 feet 7-J inches; weight, 115 pounds; respiration 18; pulse 80. No increase. He was last paid to December 4, 1872. Case 262.—Corporal J. Clemence, Co. F, 14th United States Infantry, aged 21 years, was wounded in the abdomen at Gettysburg, July 2, 1863, by a conoidal ball. He was admitted to Seminary Hospital on the following day, and remained until July 31st, when he was transferred to Camp Letterman Hospital. Acting Assistant Surgeon W. II. Hays, who had charge of the case, reports: Wounded by a minie ball entering the right lumbar region, midway between the crest of the ilium and the fourth lumbar vertebra, and passing obliquely upward. The missile Avas removed, on July 10th, from the anterior Avail of the belly, tAvo inches above and to the right of the anterior superior spinous process of the ilium. Faecal matter discharged from the wound of entrance up to August 17th. On September 28th, this man Avas discharged, cured." He Avas admitted to the Filbert Street Hospital on the same day, and transferred to Broad and Cherry Streets Hospital December 7, 1863. He Avas admitted to Fairfax Seminary Hospital April 21, 1864. and registered as a "flesh Avound of abdominal parietes," and Avas transferred, June 21st, to Ward Hospital, at NeAvark. He Avas discharged the service December 23, 1864. Examining Surgeon Geo. W. Cook, of Syracuse, reported, March 20, 1866: "Ball entered the back, near the sacrum, and passed out just above the anterior spinous process of the ilium of the right side—a track of about eight inches. The disability is from pain upon change of position, Avalking, lifting, etc. Disability three-fourths, and of indefinite duration." Last paid to December 4, 1872. Case 263.—Private G. B. Burt. Co. F, 7th Maine, received a gunshot Avound of the abdomen at Chancellorsville, May 3, 1863. He Avas admitted to the field hospital of the Sixth Corps, at Potomac Creek, on the folloAving day, Avith "gunshot wound of the left iliac region, involving intestines," and sent, on June 14th, to Point Lookout. Here the Avound Avas ascertained to interest the caput coli; the treatment consisted of strict attention to cleanliness, Avith simple dressings. On October 26th, the patient Avas furloughed; he Avas readmitted, and registered as a deserter March 31, 1864. He, hoAvever, rejoined, and Avas mustered out Avith his regiment on June 27, 1864. Pension Examiner H. B. Hubbard, of Taunton, Massachusetts, reports, July 20, 1864 : "Entrance of ball lower part of abdomen, left side; exit through the ilium of same side; intestine perforated; liquid faeces still discharged from anterior opening. Disability total, probably permanent." Examining Board of Surgeons J. B. TreadAvell, Horace Chase, and John W. Foye, of Boston, reported, November 2, 1870: "Ball entered about two and a half inches above right anterior superior spinous process of ilium, passed backAvard, and emerged four inches from median line of back and on a level Avith top of sacrum. States that wounds discharged faecal matter for twenty months. Wounds are noAV fuundly healed. Complains of dragging sensation and pain in region of anterior Avound. There can be very little disability in the case, as he states that he Avorks constantly and carries a magnificent pile of flesh. Disability rated, nevertheless, at five- eighths; height, five feet eight and one-half inches; Aveight, 192 pounds; aged 30 years; respiration 18; pulse 70." Case 264.—Sergeant Thomas Murphy, Co. A, 63d NeAV York, aged 18 years, Avas Avounded at Gettysburg, July 3, 186:!, by a conoidal ball, AA-hich entered the left iliac region, passed directly through the abdominal cavity, and emerged above the crest of the right ilium, about three inches from the spinal column. Surgeon C. S. Wood, 66th NeAV York, reports' that he "saw him twenty-four hours after receiving the injury and found him very prostrate, Avith feeble pulse, cold clammy skin, vomiting, etc. Faecal matter Avas escaping from both orifices. He Avas placed in a comfortable position and cold Avater applied to the openings, 1 WOOD (C. *.), Three cases of Gunshot Wounds, in Am. Mad. Times. ]y64. by a conoidal ball. He Avas taken prisoner, and, on August 24th, avus brought, by steamer NeAV York, to Annapolis, and admitted to No. 1 hospital, Avhere the injury Avas recorded .as a "gunshot Avound through the abdomen." On August 24th, he was transferred to Camp Parole, Avhence he Avas returned to duty, September CO, 1864. On March 19, 1865, he was discharged the service. Pension Examiner Ira W. BelloAvs, Knoxville, Pennsylvania, reports, May 7, 1866: " Ball entered the left side. over the descending colon, came out through the posterior superior spinous process of the left ilium; faecal mat';er is now discharging from the wound in the back; general emaciation; is unable to leave his room. Disability total; will probably prove fatal." H. A. Phillips, M. D., of Knoxville, reported that the pensioner died April 19, 1869. at Westfield, Pennsylvania and states: " I attended Charles L. Odell for about a month prior to his death ; when I first saw him, I found him suffering from a fistulous opening, communicating Avith the bowels, Avith profuse discharge of faecal and purulent matter, resulting from aAVound received in the United States service, from Avhich injury he died, very much emaciated, April 19, I860."' SECT. Ill] WOUNDS OF THE LARGE INTESTINES. 89 Case 271 .—Sergeant LeAvis E. Morley, Co. E, 61st New York, Avas Avounded at Gettysburg, July 1, 1863, by a conoidal musket ball, Avhich entered a little beloAv the umbilicus and to the left of the linea alba, and passed obliquely through the body, penetrating the sigmoid flexure of the colon and the Aving of the left ilium in its passage. When brought to the field hospital he was in a state of collapse. Freces escaped from the wound. There was excessive tenderness and pain. Opiates were freely administered, and the symptoms of peritonitis gradually abated. On July 10th, the patient was in a condition to be removed to Baltimore. The discharge of fasces from the Avounds continued until September 28th, when there Avas an evacuation by the rectum. The Avounds soon aftenvard closed, and, on October 27th, the patient Avas sent home on furlough. On November 15, 186:?, he returned, and remained an inmate of Jarvis Hospital until October 14, 1864, Avhen he was discharged from service for total disability resulting from his Avounds, and sent to his home in Hinsdale, Illinois. He Avas pensioned, and, on March 18, 186."), Pension Examiner J. C. W. Keenon reported that " the ball entered an inch and a half below the umbilicus, a little to the left of the median line, and passed out through the ilium, leaving an adhesion of the boAvels, probably, to the abdominal Avail." Morley Avas in tolerable health Avhen his pension was last paid, December, 1872. Case 272.—Private John Haun, Co. I, 20th Indiana, aged 30 years, Avas shot through the body in an engagement at Oak Grove, June 25, 1862, > by a musket ball passing from the right lumbar to the left hypochondriac region. No record of the early symptoms or progress of the case can be found, for the patient Avas made a prisoner and remained in Richmond until July 25th, when he Avas paroled and sent to the hospital at Fort Monroe, and thence on the hospital transport State of Maine to Philadel- phia, Avhere he Avas admitted to Broad and Cherry Streets Hospital on July 29, 1862. Surgeon John Neill, U. S. V., reports that "a mini6 ball penetrated the lumbar region about three inches to the right of tbe spinal column, and one inch above the iliac bone, and, passing obliquely across in front of the vertebra and slightly upward, made its exit in the left side, immediately below the last rib. Considerable haemorrhage folloAved from the Avound of exit, and four days after the injury faeces and wind passed from the same opening. At the time of admission, his health was very much broken down, and he suffered from a severe cough and from pain in the left chest, resulting from pleurisy contracted before the wound Avas received. The Avound of entrance had healed; that of exit Avas still open and discharging a small amount of pus, occasionally mixed with faecal matter and fetid gas. The descending colon Avas supposed to be the part involved, and appeared to be adherent to the abdominal walls at the opening. The wound Avas dressed Avith a flaxseed cataplasm ; the patient was ordered a good diet, Avith milk-punch and beef-tea, and stimulating expectorants, with opium at night. Under this treatment his health improved rapidly; the Avound granulated slowly, and by October 25th had entirely closed. For four weeks previous to that date, no faeces or wind had passed by the wound, and the patient Avas convalescent without any bad results." A subsequent report says: "John Haun, reported as cured in January, 1863, had a relapse, the Avound again opening and discharging faeces for a few days, and a small piece of flannel shirt. The faecal fistula then again closed." Haun was discharged from service on April 4, 1863. Pension Examiner G. W. Mears, of Indianapolis, furnishes a certificate, dated April 14, 1863, rehearsing the above facts, but stating that the anterior wound Avas still open. In December, 1863, Haun drew his pension, since which date the Pension Office has received no commu- nication from him or his heirs. Postmaster Hoback, of Francesville, Indiana, informs the editor, April 19,1873, that Mr. Haun died, from a Avound of his abdomen, some six or eight years ago, Case 273.—Dr. J. T. Taylor records2 that Captain W------, C. S. A., was Avounded near Mansfield, Louisiana, April 8, 1864, by a minte ball, that entered midAvay between the umbilicus and the anterior superior spinous process of the left ilium, ami passing backAvard emerged near the sacral articulation of that bone. For eight days he lay among those regarded as fatally wounded, taking morphia and such stimulants and nourishment as he desired. The abdomen was tympanitic and tender. There was a constant discharge of thin faecal matter from the Avound of exit. He Avas noAv instructed to lie toAvard the wounded side. The diet was restricted to animal broth, the medicine to three grains of opium daily, and the Avounds Avere scrupulously cleansed, and covered by cold cataplasms of slippery elm, which Avere made to extend over the abdomen. Portions of clothing and sloughs of cellular tissue Avere removed from the entrance Avound, which soon aftei'Avard healed. Pressure Avas applied to the preternatural anus, and dejections by the rectum were facilitated by enemata. The officer Avas discharged from hospital in a fair Avay of recovery. Case 274.—Lieutenant J. H. Cook, Co. E, r>7th Massachusetts, aged 23 years, Avas Avounded at Petersburg, July 21, 1864, by a conoidal ball. He Avas admitted to the field hospital of the 1st division, Ninth Corps, on the same day, and the case reported as "gunshot penetrating wound of the left hypochondriac region." He Avas furloughed on July 25th, and, on October 31st, was admitted to hospital at Readville, Massachusetts, Avith "gunshot Avound of side." He was discharged the service December 27, 1864. Pension Examiner S. L. Sprague, of Boston, May 2,1866, stated that he examined Lieutenant Cook on February 2, 1865, and that "a minie ball, entering the left side beneath the tAvelfth rib, Avas cut out from over the spine of the lowest lumbar vertebra. The ball passed through the abdomen, Avounding the intestine. Fa'cal discharge is now constant at the Avound. There is numbness of the hip and thigh at the right side; he can walk one-half a mile Avith a cane; he is debilitated, and has constant pain in the hip." Pension Examiner W. H. Page, of Boston, reported, January 26, 1866: "Ball entered at edge of left lower rib, centre of left side, about four inches above the superior process of ilium, and came out on right side of spine, about one inch to right and on a level Avith the top of crest of ilium He alleges that there Avere faecal discharges from the posterior wound for about four Aveeks ; Avhen it healed, but has broken out twice since—the last time being last July; it is hoav entirely healed; has trouble in passing urine Avhen he gets cold ; the urine is very offensive, and he has more or less pain in the kidneys; cannot lift any heavy thing, nor Avalk any great distance, without having very severe pain in the back. The left leg is also enfeebled by the cutting off of some of the nerves; disability three-fourths, and permanent." Pension last paid to December 4,1872. 1 One report says: "Fair Oaks, May 31, which date is given in Circular 6, S. G. 0., 1865, p. 25; but the 20th Indiana did not join the Army of the Potomac until June 8, 1862; on June 25th, it was heavily engaged, in Kearney's Division of the Third Corps, at the ' Orchards' or Oak Grove, losing 120 in men and officers." See Report of General George B. McClellan, Ex. Doc, 38th Congress, 1st Session, p. 120, and Report of the Adjutant General of Indiana, 1865, ATol. II, p. 191. ' TAYLOE (J. Theus). Surgical Observations, in the Southern Jour. Med. Sci., 1867. Vol. II, p. 18. 12 90 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. Case 27.").—Lieutenant J. E. Mallet, Adjutant 81st New York, aged 21 years. Avas Avounded at the battle of Cold Harbor, .Line 3, 1864, bv a musket ball, Avhich entered three inches to the left of the umbilicus and made its exit a little to the right of the spinal column. The direction of the ball is indicated in the accompanying Avood-cut (FlG. 57), engraved from a photograph on the wood block made at the Museum several years ago. This officer, Avho still survives and holds an important civil office under the Government, has kindly prepared an account of his case, which is peculiarly valuable because of the rarity Avith Avhich reliable information of the immediate symptoms produced by severe wounds can be obtained. The authenticity of the facts is unquestionable, and, independently of the officer's own statement, is affirmed by the testimony of the medical attendants: "I was Avounded," says this brave officer, " at the battle of Cold Harbor, Avhile serving as adjutant of the 81st NeAV York Infantry, or 2d Oswego Regiment, then Avith the Army of the Potomac, and attached to the first (Marston's) brigade, first (Brooks's) division, Eighteenth (Smith's) Army Corps. It was about five o'clock in the morning, and in the assault on the enemy's entrenched lines, I was struck. I fell at the distance of about fifteen paces from the works Avhich our men were charging with uncapped pieces. The missile entered my left side. I distinctly remember the sensations experienced upon being hit. I imagined that a cannon-ball had struck me on the left hip-bone, that it took a doAvmvard course, tearing the intestines in its course, and lodged against the marrow of the right thigh-bone. I fancied I saw sparks of fire, and curtains of cobAvebs Avet with dew, Bparkling in the sun. I heard a monotonous roar as of distant cataracts. I felt my teeth chatter, a rush of blood to my eyes, ears, nose, and to the ends of my fingers and toes. These sensations croAvded themselves in the instants in Avhich I struggled to stand, and actually fell forAvard on my face. As I fell, I experienced another sensation as of a sudden and violent bloAv on the nape of the neck, and then became completely insensible. I Avas awakened to consciousness by cheering, and fearing to be trampled by the advancing lines, I made a desperate effort to regain my feet; and, doubled up as one Avith a broken back, Avith my sword strapped to my right Avrist, and the scabbard in the other hand, I dragged myself about forty paces to the right and rear, and entered the skirt of a Avood, Avhere I saw men hiding behind trees, which angered me, and I again fell insensible. Later, I remember being put on a stretcher by some men of a Massachusetts regiment, and carried some distance to an ambulance. During the day, some one had given me a piece of sponge cake dipped in wine ; but it Avas at once rejected. It rained during the day, and some one covered me with a rubber blanket, which a passer-by presently carried off, and I had the will but not the poAver to protest. The pain in the Avound in the back was intense. I do not recollect distinctly my arrival at the corps hospital; but I recall the visit of Surgeon W. II. Rice, and his exploration of my Avound, and his instructions to a friend to take my watch and valuables, and my inference that he considered my case hopeless, and that these mementoes vvere to be sent home. On the afternoon of June 3d, I Avas put in an ambulance Avagon Avith Lieutenant McKinuey, and taken as far as Bethesda Church, where Ave stopped over night. We proceeded on our journey next morning, over very rugged ground. I remember the wounded who could" Avalk often put their shoulders to the Avagon to keep it from upsetting. We arrived at White House Landing, on the York River, late on the afternoon of June 4th. I had suffered much pain from shortness of breath, but was relieved by draughts of Avater. I Avas put on a hospital transport, and Avas laid by the side of the deck, where the breeze could reach me; but it seemed to take aAvay my breath instead of restoring it. I Avas very faint, and Captain Tyler, of my regiment, and others, have since told me that I Avas regarded as a dead man. I remember nothing further until Ave reached Alexandria, and finally Washington, where I asked to be taken to Douglas Hospital; but nearly all the Avounded were carried off in ambulance wagons, and I thought I was deserted; but finally they brought a stretcher and carried me to Armory Square, Avhich was nearer the steamboat Avharf. I Avas placed in Ward I about midnight. On the morning of June 6th, Medical Inspector Coolidge examined me. From memoranda, made soon afterward, I find that I Avas frequently unconscious during the next week; but that, on June 12th, I could read the leaded headings of neAvspapers. On June 15th, I had a distressing pain in the boAvels. Gradually my vision improved, and, on June 22d, I began to keep my diary. Acting Assistant Surgeon Bowen Avas attending me. On June 27th, I ate some blackberries, Avhich made me sick, and for the next tAvo days I Avas feverish and drowsy. On July 1st, I had severe colic. On July 3d, Surgeon Bliss examined me. On the 5th, I Avas better, and asked to be sent home. On July 6th, I sat up in an arm-chair. On the 12th, some blackberry seeds were found in the lint removed from the Avound in the side. On July 17th, I drank a glass of soda-Avater, Avhich, in about fifteen minutes, began to Tig. 57.—cicatricesiiiacaseofshotper- bubble out at the orifice in the side, forcing off the adhesive plaster and compresses, foration of the descending colon. [1'roni . . ° ,, • , n A t i a photograph.] and soiling my clothing with a copious fetid discharge ot a yellowish color. On July 27th, I Avas taken on a stretcher to the cars, and rode to Ncav York, and thence on a steamer to Albany, and thence by rail to Oswego, where I arrived on the 29th, and Avas attended by Dr. C. P. P. Clark, of Fort Ontario. My hospital diet nearly starved me, and I suffered greatly during the dressings. Pieces of shirt and trowsers and braces Avere extracted from the wounds at different times. There Avas a swelling below the Avound, which Avas very sensitive. Some of the surgeons thought it contained the ball; others that a fragment of the eleventh rib Avas lodged there. On August 11th, I Avalked for the first time. On August 26th, there Avas so much pain in the SAvelling referred to that a surgical consultation Avas held, and, on the 28th, Dr. Clark incised the SAvelling and removed a large button that had been driven in by the ball. On October 1st, I reported at the hospital at Annapolis, and on October 31, 1834, Avas honorably discharged for Avounds received in action, on the recommendation of the board of Avhich General Graham Avas president. In 18C5 my health improved, so that I Avas able to do clerical duty, and from that time to this (1873) ray health has been comparatively good. I am nevertheless subject to pain in the spine at damp seasons. My left side and arm are Aveak, and, in walking a considerable distance, my left leg becomes lame. It may be proper to add that at the time of receiving the Avound I had been fasting for sect, ni.l WOUNDS OF THE LARGE INTESTINES. 91 Eig. 58.—Conoidal ball, battered by contact with the ninth riband the trans- verse processes of the lum- bar vertebrae. Spec. 6248. nearly forty-eight hours." The principal facts above recited in a connected form, appear, separately, in the reports of Surgeons W. II. Rice, 81st Now York, II. P. Porter, 10th Connecticut, Acting Assistant Surgeon C. II. BoAven, and Surgeon B. A. Vanderkieft, U. S. V. Dr. BoAven remarks that the evidence of extensive destruction of the Avail of the decending colon Avas conclusive, and that a spinous process of a vertebra Avas probably fractured. The evidence of the intestinal lesion consisted in a copious faecal discharge from the Avound, Avhich persisted for several weeks, while the patient Avas at Armory Square. Mr. Mallet received the brevet of Major of United States Volunteers for gallantry. Case 276.— Private Allen J. Marker, Co. I. 4th Maine, aged 18 years, was Avounded near Centreville, at the battle of Chantilly, September 1, 1862,' and Avas taken to the regimental hospital, where Assistant Surgeon G. II. Martin, 4th Maine, recorded his injury as a " gunshot Avound of the side and arm." The Avounded man was conveyed to Washington, and entered Kpiphany Hospital on September 2d. Dr. N. P. Monroe states, Avithout describing the Avound of the arm, that "the ball passed through the left side betAveen the ninth and tenth ribs, fracturing the latter, and lodged between the transverse processes of the third and fourth lumbar vertebrae, Avhenee it was extracted, as I was informed, on the previgus day." Surgeon J. II. Brinton, U. S. V., saw the patient, and notes the entrance Avound as in the eighth left intercostal space, and the lodgement as between the apophyses of the second and third lumbar vertebrae, and the ninth rib as fractured. The missile Avas placed in the Museum by Dr. Brinton, and is represented in the Avood-cut (FlG. 58). The missile is said to have lain subcuta- neously, and as soon as a counter-incision Avas made for its extraction faecal matter Avas discharged by this Avound. From the anterior opening a number of bone splinters were extracted. A slight escape of faecal matter from this opening lasted for fourteen days. From the preternatural anus in the loin a free discharge of faeces persisted for nearly seven months. On September 5th, a portion of sphacelated colon presented at the posterior orifice, and Avas removed with scissors by the Avard surgeon. On September 10th, a piece of omentum, "tAvelve inches long and two inches Avide" (sic), is said to have been removed. Notwithstanding the free suppuration from the wound in the arm and hypochondrium, the general condition of the patient was encouraging. He Avas sustained by a nourishing diet, with porter and tonic medicines. Late in October, Hospital SteAvard Stauch prepared, under Dr. Brinton's supervision, an excellent water-color drawing of the subject. This is preserved in the Surgical Seiies of Drawings, A. M. M., as No. 15. A reduced copy of the draAving is presented in the accompanying Avood-cut (Fig. 59). On November 1st, it is noted that the boy had a steady, hearty appetite, and main- tained tolerable health, and that the dejections had taken place by the natural channel, on that day, for the first time since the reception of the injury. The lad Avas preparing to go to his home. On November 21st, though stercoraceous matter still escaped from the lumbar Avound, the patient, at his OAvn desire, was discharged from service by Surgeon James Bryan, U. S. V. The faecal fistula persisted until May, 1863, AA-hen the discharge from the Avounds became sero-purulent. A month afterward, both Avounds healed up soundly, and the patient Avent to his home at Belfast, Maine." He Avas pensioned. On September 15, 18,34, his condition Avas so satisfactory that his pension Avas reduced. He applied for an increase, and, on August 27, 1870, Pension Examiner Charles N. Germaine, of Rockland, Maine, made the following report in the case : "A musket ball pene- trated the loAver third of the left arm, fracturing the humerus, as indicated by cicatrices and by irregularity of the surface of the bone. Arm Aveakened thereby, so that it is with difficulty be can raise more than thirty pounds. The natural dexterity of the arm is injured, and the hand weakened in its poAver of grasping. Disability one-half. Secondly, there exists a large depressed cicatrix on his left side, between the ninth and tenth ribs, where a musket ball entered; another large (two by four inches) calloused cicatrix between the third and fourth lumbar vertebrae, Avhere a ball was cut out. In the Avound of his side, a false passage existed for three or four months after receiving tbe Avound, from Avhich the excrements of his body escaped. The seat of the Avound is now subject to periodical attacks of soreness and pain. By reason of injury to the spine, his back is Aveak, and his side is slightly paralyzed. If he attempts to perform manual labor his back becomes so weak and lame that he cannot stand erect; his side also becomes weak and painful, producing general exhaustion. If he inclines fonvard his back becomes painful and Aveak; his boAvels are constipated, requiring the constant use of purgatives; he is reduced in general strength; loss of Aveight, twenty-five pounds. For this disability, I rate him one-half; for both disabilities, total." Case 277.—Sergeant Daniel B. Deyo, Co. C, 156th New York, aged 32 years, was wounded in the bowels at Winchester, September 19,1864. His admission to the regimental hospital, and transfer to the Nineteenth Corps hospital, is noted by Surgeon George C. Smith, 156th New York; but no details are recorded until December 14th, Avhen the patient Avas sent to Frederick. Here, Acting Assistant Surgeon F. A. Grove states that "the ball entered midway betAveen the spinous process of the ilium and the last rib of the left side, and emerged near the last dorsal vertebra, Avounding the descending colon. The patient states that 1 Sec Annual Report of the Adjutant General of the State of Maine for the year 1862, p. 51, for particulars of the part the regiment bore in this engagement. Fig. 59.—Preternatural anus in the lumbar region, from a shot perfora- tion of. the colon. Surg. Drawings, A. M. M., No. 15. 02 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. lie had f;rcal discharge from both anterior and posterior Avounds for three weeks, and also had profuse haemorrhage, from the same source, during that time. The stercoral discharge from the Avounds then ceased, and the fieces resumed their natural channel. Tlie appetite Avas good, but the patient suffered occasional slight attacks of diarrhoea, which were controlled by opium. The wounds still discharged small quantities of pus, and, occasionally, air escaped from the anterior opening; a compress and bandage were applied.'' On January 19, 1865, Devo Avas transferred to McDougall Hospital, in charge of Assistant Surgeon Samuel H. (>rton, IT. S. A., Avho notes a fracture of the last rib. The patient was discharged from service on February 27, 1865, and pensioned, and Avas last paid to December 4, 1872. Case 278. —Private Warren Miller, Co B, 73d Ohio, aged 19 years, Avas Avounded at Gettysburg, July 2, 1863. He Avas admitted to Seminary Hospital on the same day, Avith "gunshot compound fracture of right shoulder, Avound of left arm, and of left side," and Avas transferred to Camp Letterman Hospital on July 25th, Avhere the folloAving report of the case is made by Acting Assistant Surgeon E. A. Koerper: "Wounded July 2d, by a mini6 ball, entering near the crest of the left ilium, six inches to the left of the last lumbar vertebra, and lodging; the ball cannot be found. August 9th, the Avound Avas discharging considerable pus mixed with faecal matter. August 10th to 20th, general health good; his boAvels move regularly. September 10th, faecal passages still continue from Avound. October 20th to November 8th, health good; still discharging faecal matter from Avound." On November 17th, he Avas transferred to Camp Chase, Avhere he was admitted on the 19th, and the Avound reported as "gunshot wound of the left hypochondriac region, perforating the colon, resulting in an artificial anus." He Avas discharged the service on January 5, 1864; disability, three-fourths. Pension Examiner O. J. Phelps, Pickton, Ohio, under date of February 23, 18G4, states: "One Avound Avas in the left forearm, taking out a section of the ulna; another in the left side; ball entered just above the ilium; ball probably remaining in. The third Avound Avas in the flesh on the top of the right shoulder. Disability total; in part permanent." Case 279.—Private M. Meyer, Co. G, 145th Pennsylvania, aged 32 years, Avas Avounded at Spottsylvania, May 10, 1864, by a conoidal ball. He was received into the field hospital of the Second Corps on May 12th, and, on the 13th, he Avas admitted to the 3d division hospital at Alexandria. Surgeon E. Bentley, U. S. V., reports the case as folloAVs: "Ball entered near the terminal extremity of the eleventh rib, passing backAvard and slightly upward, and one and one-fourth inches to the left of the spinal column. On admission, fascal matter Avas passing from both entrance and exit Avounds; the boAvels Avere constipated, and there was considerable pain in the regions of injury; anodynes Avere administered; the appetite Avas poor; liquid diet Avas prescribed, and detergent dressings Avere applied to the Avound. On May 19th, an enema of Avarm water and oil Avas given, and the bowels moved several times; anodynes Avere continued, with liquid diet; dressings the same. No further movement of the boAvels occurred till May 23d; boAvels then quite relaxed; lead and opium pill given May 24th; bowels checked, and no more movement until May 27th; an enema Avas administered, and the boAvels moved freely; anodynes Avere continued, Avith liquid diet; bowels then moved nearly every day. May 28th, several small pieces of bone came out at the posterior opening of the wound. June 1st, no discharge of faecal matter from Avound. June 3d, boAvels relaxed; lead and opium pills given, one every four hours, until the diarrhoea was checked. June 5th, bowels regular; patient suffering less pain; appetite quite good. June 10th, a little gas escaped from the boAvels through the external Avound; same treatment continued. June 15th, a A-ery little faecal matter came out at the Avound; anodynes and liquid diet continued; boAvels regular. July 1st, up to this time no more faecal matter or gas had escaped from the boAvels; patient feeling pretty well, and appetite good, requiring little opiate medicine. July 11th, a piece of bone made its appearance at the anterior opening, and Avas taken out, one-half inch in length, one-fourth in breadth, and of the thickness of the rib. July 20th, the patient was doing Avell, appetite good, and some solid food Avas allowed; boAvels regular; slight suppuration from Avound. The patient Avas able to go about the house and yard. September 1st, continued to improve." September 9th, furloughed for thirty days, and, not returning, Avas recorded as a deserter October 20, 1864. He is not a pensioner. Case 280.—Private E. Proctor, 6th Maine Battery, aged 24 years, was Avounded at Gettysburg, July 2, 1863. He was admitted into the field hospital, Avhere the injury Avas registered as "a gunshot wound of hip." On July 23d, he Avas transferred to Camp Letterman Hospital, Avhere the folloAving report Avas made by Acting Assistant Surgeon Charles S. Gauntt: "Wounded by a mini6 ball entering the back, three inches to the left of the first lumbar vertebra, and making its exit one inch above the anterior superior spinous process of the left ilium. Transferred September 15th, cured." On the next day he Avas admitted to MoAver Hospital, and Assistant Surgeon C. Wagner, U. S. A., reports as follows: "September 16th, admitted with gunshot Avound in left side; Avound healing; simple cerate applied. September 28th, Avound inclined to slough; dressed with nitric acid and yeast poultice. Same treatment continued, and patient improving until November 13th, Avhen the Avound Avas nearly healed. November 30th, a small piece of bone Avas removed to-day, which had been keeping up a discharge; it will now probably heal up. December 6th, he complains of pain in hip; wound discharging; cold-Avater dressings continued; patient asthenic. May 1st. Avound still discharges faecal matter occasionally. Up to June 1, 1884, there was no improvement in the wound. July 1st, Avound remains about the same, discharging gas and pus occasionally. July 10th to 20th, wound still discharging, and no change in appearance; health otherwise good. July 30th, made an incision down to the bone to remove any loose fragments of bone, but found the orifice perfectly free from necrosis, and introduced a tent to make the Avound heal from the bottom. At the same time, gave an anodyne to lock up the boAvels. August 7th, the patient again passed faeces through the Avound. August 28th. has not passed any faecal matter for ten days; has had several natural passages by the rectum, and the track has closed up. September Cth, doing very Avell; some prospect of a cure. October 15th, wound in abdomen healed; Avound of hip still open. He Avas finally discharged the service June 16, 1835." Examining Surgeon J. B. Walker, of Union, Maine, reported, April 17, 1867: "Wounded by a ball, Avhich entered his back near the posterior part of the crest of left ilium, passed forward and upward, cutting through the bowels, and came out in front of the abdomen, two inches internal from the anterior superior spinous process of the left ilium, leaving a permanent opening from the boAvels to the surface on the back, through Avhich gas and faecal matter are constantly oozing Avithout control. Disability total and permanent." April 21, 1873. application for increased pension was pending. WOUNDS OF THE LARGE INTESTINES. 93 Case 281.—Private Franz Escher, Co. K, 3d NeAV Jersey Cavalry, aged 41 years, received a wound of the left side of the abdomen at Winchester, August 10, 1864. Diligent search failed to obtain the history of the case previous to his admission, on November 29th, into the field hospital at Winchester, under the charge of Assistant Surgeon H. B. Noble, 2d Ohio Cavalry. Here the injury is recorded as "a gunshot Avound of the left ilium." On December 11th, he Avas transferred to the Filbert Street Hospital. Philadelphia, Avhere Surgeon Thomas B. Reed, U. S. V., notes "gunshot Avound of crest of ilium and intestine; the entrance A\-ound Avas a little anterior to the posterior superior spine of the ilium; that of exit Avas just behind the anterior superior spine. There Avas artificial anus and loss of bone. Simple dressings." On May 11, 1865, he Avas transferred to Satterlee Hospital. Here the ward surgeon makes the following minute upon the prescription book: "Gunshot Avound; ball passing through about two inches above the superior border of the ilium, near the anterior superior spinous process of the same, fracturing the hip-bone, and, doubtless, making an opening into the descending colon near its junction Avith the transverse colon. Occasionally his faeces pass out in large quantities through the opening, especially Avhen the bandage is loose, though a small quantity continually remains at the opening. The patient is doing well and the openings are clean and healthy." Bandaging of the abdomen Avas the only treatment resorted to. On July 25th, he was transferred to the Ward Hospital, Newark, and on September 14th, to DeCamp Hospital, New York, Avhence he Avas discharged from service on June 22, 1866, on account of "gunshot Avound of the intestine above the crest of the left ilium, resulting in a permanent artificial anus." Pension Examiner J. Henry Clark, of Newark, New Jersey, reports, December 16, 1858: "The pensioner has an artificial anus in the left side of the abdomen, above the sacrum, from Avhich considerable bone has been discharged. He has not defecated, I believe, for two years by the anus, and requires constant attendance. Disability total and undoubtedly permanent." Escher applied for an increase of pension, and, on November 6, 1872, appeared before the Examining Board of Surgeons at NeAvark, who report as follows: "Wound of sacrum, spine, and abdomen, leaving an artificial anus, Avhich still exists. Is permanent in degree, and not caused by vicious habits. We do not find any cause for increasing the rating. Disability total, second grade. Weight, 160; height, five feet eight inches; age, 50; respiration 18; pulse 70." Report signed by Drs. J. D. Osborne and A. W. Woodhull. Case 282.—Corporal John N. Payne, 5th Vermont, aged 34 years, In the general assault on Petersburg, April 2, 1865, near Fort Welch, received a shot Avound of the abdomen, and was taken to the 2d division hospital of the Sixth Corps, under charge of Surgeon S. F. Chapin, 139th Pennsylvania, Avhen the injury Avas registered as a "gunshot flesh wound of the abdo- men." Ou April 11th, the patieut Avas transferred to the depot field hospital of the Sixth Corps, under Assistant Surgeon J. S. Ely, U. S. V., who recorded the injury as a "gunshot flesh Avound of the left side." On April 12th, the wounded man Avas sent to Washington and placed in HareAvood Hospital. SurgeonR. B. Bontecou, U. S. V., reports that "amusket ball entered over the left hypochondriac region, passed obliquely downward and backAvard, and emerged near the spine, injuring, in its course, the descend- ing colon; faeces passed artificially at the exit of the ball. Simple dressings." A photograph of the patient was made under Dr. Bontecou's direction (Phot. Surg. Cases, S. G. O., Vol. I, p. 22). A reduced copy of this picture is presented in the accompanying Avood-cut (Fig. 60). Iu a few weeks the wound healed entirely, and the patient was transferred to Vermont, May 26th, and admitted into Baxter Hospital, Burlington, on the 30th. On June 29th, he was transferred to Sloan Hospital, Montpelier, where Surgeon Henry Janes, U. S. V., reviewing the history of the case, remarks: "The ball entered four inches from the median line, betAveen the tenth and eleventh ribs on the left side, passed backward and dowmvard and emerged behind, one inch above the crest of the ilium and tAvo inches from the spine. The patient states that the shock was not great, and that he Avalked, without assistance, a half mile to the ambulance, Avhich conveyed him about two and one-half miles to the field hospital. On the next day, he Avas taken about seventeen miles to the base hospital at City Point, Avhere he remained seven days. While there, a considerable quantity of foreign substance, mostly shreds of clothing, was removed from the posterior Avound. On April 10th, he Avas transferred to HareAvood Hospital, Washington. On April 13th, after taking cathartic pills, other fragments of clothing were removed from the posterior Avound. April 14th, there was a stercoraceous discharge from the posterior Avound. For the succeeding three weeks he was kept under the influence of opium. The faecal discharge then ceased, but intestinal gases escaped for several days longer. He had some colicky pains; but not much tenderness, and no vomiting. His appetite Avas pretty fair most of the time. On May 25th, he was transferred to Burlington. The posterior Avound closed early in June; the anterior opening healed a month later. On June 29th, he was transferred to Sloan Hospital, Montpelier, since which time he has had a variable appetite and constipation; otherwise he is in fair health. July 25th, he complains of some lameness along the course of the spine; passages from the bowels regular, appetite good, and patient gaining daily." These particulars are recorded on the back of a photograph made at Sloan Hospital (Card Phot. Ser., S. G. O., Vol. I, p. 12). Payne Avas discharged from service September 8, 1865, and Avas pensioned. June 18, 1867, Pension Examiner Marcus O. Porter, of Middlebury, NeAV York, reports: "A rifle ball entered just below the left nipple, between the tenth and eleventh ribs, passed backward and downward, and emerged three inches lower than the point of entrance. The intestines Avere penetrated and faecal matter passed out of the Avound for three or four Aveeks. An adhesion of the intestines appears to have been fonned to the abdominal wall at tho point of exit of the ball. He is entirely unable to perform manual labor on account of Aveakness of the right side, and the pain and soreness excited by muscular effort." He Avas last paid to December 4, 1872. Fig. 00.—Cicatrices after a shot perforation of the descending colon. 94 PENETRATING WOUNDS OF THE ABDOMEN. [CHAT. VI. Case 283.—Private W. II. Blodgett, Co. B, 5th Minnesota, aged 18 years, of good habits and strong constitution, was Bhot by Sioux Indians early in the afternoon of August 18, 1862. After the reception of the- wound he walked a distance of twelve miles, to Fort Ridgely, arriving about 2 o'clock a. m., and Avas admitted into the post hospital. The ball had entered betAveen the Iirst and second floating ribs, eight and one-fourth inches from the linea alba and two inches perpendicularly above the anterior superior spinous process of the left ilium, making an antero-posterior passage through the body six inches long, and escaping near the inferior articular process of the first lumbar vertebra on the same side; the missile had evidently lacerated the descending colon, near the sigmoid flexure, both in entering and escaping from the body. During the first two days some fetid gas escaped from the boAvels; but after the slough had separated the discharges of faecal matter from both orifices became continuous and very copious, so much so, that the patient had to be put in a separate room and his bedding changed. On the fifth day, a very large number of small living worms (trichocephalus dispar) appeared on each of the Avounds from inside the lacerated boAvels. These entozoa disappeared after a feAV fomentations with a dilute solution of chloride of zinc. The treatment consisted in a strictly liquid and mucilaginous diet, cleanliness, the Avearing of a large flannel bandage around the body, an occasional mild cathartic, if needed, and, once, an opiate to stop a slight diarrhoea. The inflammatory symptoms from the boAvels were light, and lasted but a short time. The Avounds were dressed with lint and simple cerate, the edges being occasion- ally touched Avith lunar caustic. As the Avounds closed the discharge of faecal matter ceased, and, in four Aveeks, consisted only of a little mucous matter. By October 1st, the posterior Avound had entirely, the anterior nearly, healed; the abnormal fascal discharge had entirely ceased. The soldier Avas able to eat. the usual food Avithout any inconvenience, and had regained his strength. Stooping and raising up quickly produced a sensation of heaviness in the abdomen. He Avas discharged from service October 24, 1862. Acting Assistant Surgeon Alfred Muller reports the case. A communication from Pension Examiner E. J. Kingsbury, dated June 22, 1867, states that the Avound has produced a stricture of the boAvels to a certain extent; also chronic gastro-enteritis and chronic constipation. He is totally disabled from obtaining his subsistence by manual labor. Blodgett Avas last paid December 4, 1872, his condition remaining unchanged. Case 284.—Lieutenant W. E. Carter, Co. G, 4th Vermont, aged 33 years, was Avounded at the Wilderness, May 5, 1864. He Avas admitted to Armory Square Hospital, Washington, on May 25th, Avhen the injury was recorded as a "gunshot wound of the abdominal Avails." On June 13th, he Avas furloughed, and on August Cth, was readmitted and subsequently transferred to Volunteer Officers' Hospital, Avhere he Avas admitted on August 10th, and from which he Avas returned to duty on August 12, 1864. Dr. George T. Stevens, late Surgeon 77th New York, in a communication received at this office in June, 1868, gives the following account of the case: "Within half an hour he received three Avounds: first, through the abdomen, from left to right, cutting the intestine; second, a bullet Avound through the hand, at the articulation of the upper phalanx of the thumb Avith the trapezium; third, a bullet Avound of the left thigh, near the knee, the ball penetrating to the bone. The Avound of the abdomen was made by some rough missile, either a bullet much battered, or a fragment of shell, or, as the lieutenant supposed, by an explosive bullet. It had entered at a point near the outer extremity of a line betAveen the left inguinal and lumbar regions, and had made its exit at a corresponding point on the right side. In its course, the missile had Avounded the intestine, and had torn the abdominal Avails so as to alloAV the boAvel to protrude from both the left and right Avounds. He Avas taken to the hospital of the 2d division, Sixth Corps, Avhen I returned the protruded boAvels. and brought the wounds together by sutures. On the evening of May 6th, Lieutenant Carter, Avith the rest of the Avounded of the Sixth Corps, Avas removed to Chancellorsville. On the evening of the 7th, as the army Avas to fall back, and as there Avas insufficient transportation for all the Avounded, it was determined to leave those Avho seemed least able to bear moving. The surgeons, whose duty it Avas to designate those to be left, selected Lieutenant Carter, among many others, declaring that any attempt to move him Avould be absolutely fatal. After the rear guard had passed, in the retreat, Lieutenant Carter's brother and a wagoner placed him on a stretcher and carried him until they overtook the Vermont Brigade, three miles to the rear, Avhen the commander of his regiment detailed men to carry him. After some time an ambulance Avas procured, in Avhich he was carried until evening, Avhen he was transferred to another ambulance, in Avhich he rode all night, reaching Fredericksburg at daylight on the morning of the 9th, and finally obtained comfortable quarters. I found him, on the 10th, suffering considerably from his wounds, and with a high inflammatory fever. Water dressings Avere applied to the Avounds, with ice to those of the abdomen, and opium Avas freely administered. Like most other Avounded men, he became very anxious to have a movement of the boAvels, and begged for cathartics, Avhich were refused. On the 12th, an officious agent of the Sanitary Commission, hearing of his distress for physic, procured and administered to him a large dose of castor oil. Cathartic action soon commenced, and matter was discharged freely from both orifices made by the missile. Immediately upon discovery of the mischief, I administered a very large dose of opium, and he AA'as kept fully under the influence of that drug for several days. The severe inflammatory symptoms gradually subsided, though faecal matter continued at times to escape from the wounds. May 24th, he AA'as sent to Washington, to Armory Square Hospital, this being the twelfth time he was moA'ed after receiving his wounds. RecoA-ery progressed steadily; faecal matter frequently passing from the wounds until healing took place, which Avas early in July, Avhen both orifices Avere closed, the intestine adhering to the abdominal wall. He returned to his regiment in August, but, finding the duties of the command of his company too severe for him, he resigned. In a letter to me, dated May 31, 1868, he says: "The extent of disability remaining is two ruptures, a useless thumb-joint, and a good deal of pain in my left leg." Previous to rejoining his regiment he had been promoted to a captaincy, which he resigned September 14,1864, and Avas discharged the service. Examining Surgeon C. P. Frost, of Brattleboro', Vermont, reported April 18, 1868: "Ball entered left inguinal region of abdomen, just above and external to the left internal abdominal ring, and came out nearly at the corresponding point on the opposite side. The intestinal coats Avere perforated, as Avas mad? certain by a faecal discharge from the wound for nearly a month after it was received. There is a hernial protrusion at the point of entrance of the ball, which compels him to Avear a truss. At the point of exit the abdominal walls are Aveak, and much more pain is felt there than Avhen he Avas originally pensioned, still further incapacitating him from labor than it did at that time. He Avas also Avounded by a musket ball, which passed through the metacarpo-phalangeal articulation of right thumb, producing anchylosis of that joint, A musket ball Avas also lodged in the popliteal region of the left leg, and Avas extracted. Disability seven-eighths." Last paid to March 4. 187?,. SECT. III.] WOUNDS OF THE LARGE INTESTINES. 95 Case 285.—Private R. E. Davis. Co. II, 4th New Hampshire, aged 25 years, Avas Avounded at Jacksonville, March 25, 1862. There is no record of this case prior to his admission to hospital at Beaufort, September 15, 1862, with "gunshot wound." He was discharged October 19, 1862. J. H. Streeter, M. D., of Roxbury, Massachusetts, late surgeon of the Enrolment Board, third district of Massachusetts, fonvards the folloAving copy from the record of admissions to the Veteran Reserve Corps: "Gunshot wound of left iliac region, wounding intestines. Examined June 21, 1864; Avound perfectly healed; had not fully recovered his strength." He adds: "There is no doubt in my mind of the nature of the injury received, as the man was intelligent and gave an accurate description of the inevitable effects of such a Avound, especially the discharge from the Avound for several months of stercoraceous matter." Pension Examiner 15. S. Warren, of Concord, New Hampshire, reported, August 27, 1863: "Appears to have been struck by a ball upon the anterior aspect of the abdomen, one and a half inches above the anterior superior spinous process of the left ilium, a little toAvard the median line; apparently passed directly through the body, grazing in its exit the crest of the left ilium, nearly three inches from the sacro-iliac symphysis. There arc also several buckshot in the upper third of left thigh, Avhich can be felt through the skin. Disability one-half, and permanent.'' Pensioned at 84 per month from October 19, 1802, but never paid. Case 286.—Sergeant J. E. Fletcher, Co. D, 8th Connecticut, aged 20 years, was struck at the battle of Antietam, September 17, 1862. by a musket ball, Avhich entered six inches to the left of the umbilicus, and, passing someAvhat doAvnward, emerged an inch and a half to the left of the spine. The ball opened the descending colon, and Avhen the patient was examined by Surgeon T. II. Squire, 87th New York, there Avas a profuse faecal discharge from the wound of exit. The ensuing peritonitis was circumscribed, and the patient Avas transferred to Frederick, a few Aveeks subsequently, in a satisfactory condition. The faecal fistula finally closed and the patient recovered, and was discharged from service January 9,1863, and pensioned. Having applied for an increase of pension, he Avas examined by Pension Examiner R. Farnsworth, of Norwich, who reports, October 1, 1872, that "the sigmoid flexure of the colon was Avounded. The pensioner states that a portion of bone Avas discharged from the exit orifice several weeks after the infliction of the wound. The injury renders defecation difficult, OAving probably to the contraction of the colon. The injury to the parts at the junction of the ilium Avith the sacrum is Avhat causes the most suffering, and unfits him for much manual labor. The inability to labor has increased. He suffers at intervals from severe cramp in the side, preventing him from making any effort for a considerable time." His application for increase of pension was allowed. He Avas paid September 4, 1872. Case 2-7.—Assistant Surgeon E. F. Hendrick, 15th Connecticut, reports that "A soldier of the 16th New York, aged about 30 years (the name I do not remember), Avas wounded at Suffolk, Virginia; May 3, 1833, by a conoidal musket ball, which entered three inches to the left of the umbilicus, and escaped from the left lumbar region two inches from the spine; the descending colon Avas probably perforated. Faecal matter escaped both at the anterior and posterior openings. He Avas placed on his back, and the discharges from the intestines alloAved to escape through the posterior wound. The case progressed favorably, and in seven Aveeks the anterior opening had closed. Soon after, the patient was placed upon his abdomen and kept in this position for several weeks. Enemeta were administered to facilitate the discharge of faecal matter through the rectum, which had not occurred since the first or second day after the reception of the injury. The discharges soon passed through the natural channel, and, by September 1st, the posterior wound had closed; about a mouth later the patient was transferred to the Veteran Reserve Corps, and soon after went North, on a furlough, to visit his friends. He at this time was rapidly regaining his health and strength." Case 288.—Private W. D. Wikel, Co. D, 20th Pennsylvania Cavalry, aged 18 years, Avas wouuded in the left side of the abdomen, at Piedmont, June 5, 1864. He Avas left upon the field, and Avas subsequently removed to Staunton, Avhere he came under the observation of Assistant Surgeon William Grumbein, 20th Pennsylvania Cavalry, Avho had been sent through the enemy's lines to attend the Union Avounded. He remarks that "the ball passed through the sigmoid flexure of ihe colon, and emerged from the left iliac region; the Avound was pronounced mortal. Faecal matter escaped through both openings; the suppuration Avas very profuse, especially from the anterior opening. The wound gradually closed, and twTo months after the receipt of the injury the patient Avas about, Avell." On September 1st, he was paroled and placed on board the tfag-of-truce steamer New York, and conveyed to Annapolis, Avhere he Avas admitted into the 2d division hospital. On the 22d, he Avas transferred to Camp Parole, and, on October 14th, to Mower Hospital, Philadelphia, Avhence he Avas discharged from service May 26, 1865. Pension Examiner W. M. Guilford, of Lebanon, Pennsylvania, reports that he examined Wikel, on his appli- cation for increase of pension, February 26,1870: " The ball had entered the left groin a little below the anterior superior spinous process, and escaped through the ilium, a little below its crest, posteriorly. Both orifices are discharging slightly at this time; the wounds are retracted and corrugated. Tlie pensioner alleges that at times the Avounds discharge much more freely. The limb of the corresponding side is somewhat atrophied. Disability total, third grade, and probably permanent." In April, 1873, the application for increase Avas still unadjudicated. Case 239.—Private John B. Adams, Co. C, 19th Maine, aged 28 years, Avas wounded at Gettysburg, July 2, 1863. He Avas treated in field hospital until August 5th, when he Avas admitted to Camp Letterman Hospital. Assistant Surgeon II. C. May, 145th NeAV York, makes the folloAving report of the case: "Wounded by a minie ball entering three inches above the anterior superior spinous process of the left ilium, and emerging three inches to the right of the fourth lumbar vertebra. November 2d, the anterior wound is nearly healed; has, ever since injury, and still continues to have, faecal evacuations through the posterior Avound. Also Avounded in the right leg by a mini6 ball entering over the internal malleolus, passing upAvard and backward, and lodging under the integuments over the belly of the gastrocnemius, whence it Avas removed; Avounds healed. Also, wounded in left leg by a mini6 ball entering the outer aspect of the gastrocnemius, and emerging near the popliteal space ; Avounds healed. The patient received the last tAvo Avounds while crawling off the field on his hands and knees." On November 7th, he Avas trans- ferred to Baltimore, and, on the 8th, was admitted to NeAvton University Hospital. On May 24,1864, he Avas transferred to Ncav York, and admitted to DeCamp Hospital, and, on June 2d, Avas sent to Augusta, Maine, where he Avas received into Cony Hospital on the following day. June 28, 1865, he was discharged the service. Pension Examiner J. B. Bell, of Augusta, reports. July 28, 96 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. 1865: " Woundj>f spine, left kidney, and descending colon, causing an artificial anus, Avhich has now closed ; but the bowels do not act properly." For the lame back the disability is rated at tAvo-thirds; and for lameness, caused by wound of both legs, is rated at one-third. Disability total and permanent. Pension Examiner C. W. Snow, of SkoAvhegan, reports, May 8, 1872: " Ball entered just above crest of ilium, on left side, and emerged over spine, fracturing one or more processes of vertebrae. Fa-eal matter passed through opening in back for several months. Gunshot wound of both legs. Wound of abdomen causes great trouble, the side being Aveak and painful; solid and hearty food causes great distress; diet is chiefly bread and milk. Disability total, third grade." Weight, 150 pounds ; age, 36 years ; respiration free; pulse regular. Latest certificate on file, May 8, 1872. Pension, 818 monthly. Case 290.—Captain Henry B. Barnard, Co. L, 2d NeAV York Mounted Rifles, aged 27 years, Avas Avounded at Petersburg, July 30, 1864, by a conoidal ball, which entered the anterior aspect of the upper third of the left thigh and came out at the right gluteal region; in its passage, it Avounded the sigmoid flexure of the colon. He Avas taken to the field hospital, and, on August 3d, Avas transferred to Washington and admitted into Armory Square Hospital, under the charge of Surgeon D. W. Bliss, U S. V. Faecal matter and urine escaped from the Avounds. Tonics and good diet were ordered. The patient did well, and, on September 8th, avus furloughed, at Avhich time the wound Avas still open. About two months afterward, he returned to the hospital on his way to his regiment, and Avas "perfectly Avell." He is reported by the Adjutant General of the State of New York as having been discharged.from service January 20, 1865. Pension Examiner H. F. Montgomery reports, March 22, 18,J5 : "There is uoav, on the inside of the left thigh, one inch from the groin, an ulcer Avith a hard inflamed base and a fistulous track upward and downAvard, possibly connecting Avith the urethra or rectum." Pension Examiners B. L. Hovey and II. F. Montgomery, of Rochester, reported November 24, 1871, that " the left thigh measures, in circumference, one-half less than the right at a corresponding point. He complains of pain in the back, and lameness after protracted labor." He Avas last paid December 4, 1872. Case 291.—Private Thomas H. Graham, Co. G, 1st Michigan, aged 18 years, was shot through the abdomen, at Bull Run, August 30, 1882, and was placed in an ambulance and sent to Washington, and admitted to Judiciary Square Hospital on the following day. There was but slight haemorrhage, and the shock and depression Avere less intense than is commonly observed in penetrating shot Avounds of the abdomen. Surgeon John H. Brinton, U. S. V., saw the patient, and took much interest in the case, making notes of its principal features, and a diagram. Pension Examiner R. C. Hutton, also, has made several extended reports of this case, Avhich Dr. A. L. Lowell, of the Pension Bureau, lias politely transcribed and transmitted to this office. Dr. Brinton described the wound as inflicted " by a conoidal musket ball, Avhich entered near the lower boundary of the left lumbar region, at a point about six inches to the left of the mesial line of the abdomen, and, passing backward and a little obliquely downward, made its exit about two and a half inches to the left of the spinal column, injuring the crest of the ilium in its course." Dr. Brinton further states that, " after a feAV days, a faecal discharge occurred from both the openings, and continued until October 25th, Avhen it ceased. The colon only Avas Avounded. October 31st, nearly well ; slight discharge of pus from the entrance Avound, but no faecal matter; exit Avound closed." The hospital record shows that Graham Avas discharged from service June 6, 1863, and pensioned. Several reports from pension examiners are on file, but the latest, by Dr. R. C. Hutton, of HoAvell, Michigan, covers the Avhole ground. After rehearsing the facts above related, Dr. Hutton continues: "The crest of the ilium Avas fractured, and probably considerably shattered, as the subsequent involvement of a considerable portion of the ilium, in a carious condition, indicates. The original wounds are indicated, on the diagram hereto attached, by the numerals 1, 2, both of which remain open ulcers. Subsequently ulcers became established in the order designated by the letters a, b, and c, on the diagram. The points of interest are that a probe may be passed through the original ^inus, from I to 2, or from 1 to a, there being but a slight septum intervening betAveen the two last-designated openings. A second probe, introduced at 6 or c, will readily intersect the first anyAvhere along its middle third. There is but a slight septum interposing betAveen the openings b and c. From each of these sinuses there is constantly escaping an unhealthy sanious discharge, together Avith the faecal contents of the bowels. Occasionally kernels of corn, apple seeds, and other indigestible articles have passed through the stomach and been ejected through these several sinuses. He is of healthy stock, and is a broad-shouldered, deep-chested, capacious Fig. CI.—Diagram of fistulous sinuses following a shot stomached, powerful looking organization, and, before he avus thus Avounded, perforation of the colon and fracture of the crest of the „„;i;„„„;i„ ...,; 1 .1 it- l -k~ i i_ n • i 1 ± |,ium ordinarily Aveighed l8.> pounds. Noav he bears a salloAV, sickly countenance, cannot stand erect, his left side being shortest. The left hip joint has become partially anchylosed, lateral motion of left leg being entirely destroyed. He can elevate the knee but three or four inches, and is, consequently, quite lame, and frequently unable to move about. The discharges from these Avounds make him extremely offensive to society, under the most favorable appliances at his command. He Avould have died long ago from utter detestation of his condition, Avere it not for his indomitable pluck and patriotism. I have been intimately acquainted with him before and since his return from the Avar, and knoAV that the condition of his disability has been constantly growing Avorse, and that for the past four or five years he has generally needed the attendance and aid of some person to assist him in dressing his Avounds daily. I regard his ease as utterly hopeless of relief." This report is dated March 6, 1872. SECT. III. J WOUNDS OF THE LARGE INTESTINES. 97 w Epiqqstvic '.'::■' •'■'.•' I/jpocliori. 1 mi h UrnJbtlcpaL Lumbar \ 11 Wjpnaastric \ILiac \\ \/ .3. The counter-indications, in this case, to an operation for the removal of necrosed portions of the ilium, and the closure of the preternatural opening in the colon, are not stated. Without other data than the descriptions afford, it would appear possible to resort to such a proceeding, even without interesting the peritoneal cavity. But Dr. Hutton probably reserves good reasons for rejecting such interference, and pronouncing the case "utterly hopeless of relief." Both Drs. Brinton and Hutton illustrate the posi- tions of the lesions in this case by diagrams, one of which has been copied on the opposite page. In the others (Fig. 62), the abdomen is subdivided by trans- verse and perpendicular lines, as described by Quain and Wilson,1 and the point of entrance of the ball is marked by Dr. Brinton as near the inner angle of the left lumbar region, and by Dr. Hutton somewhat lower and further to the left. The regions into which the abdomen proper is subdivided by modern anatomists are probably well selected for convenience of description. But the designation of the anterior lateral regions, or flanks, as lumbar regions, is at variauce with common parlance. In a surgical point of view, it is questionable if it would not be more convenient to make the arbitrary division into four zones anteriorly, with reference to the topographical importance of the anterior superior spinous processes of the ilia, and the incompleteness of peritoneal covering of the colon in the upper iliac regions.2 Penetrating wounds in the supra-iliac, iliac, and inguinal regions are commonly less grave than those in other parts of the abdomen. It is inferred that the lesions in the two following cases were in the descending colon, though precise information on the subject is wanting: Case 292.—Private Houston Quinn, Co. C, 11th Mississippi, aged 22 years, Avas Avounded at the second battle of Bull Run, August 30, 1862. The Confederate records give the folloAving account of the case : "He Avas admitted to hospital No. 12, Richmond, on September 28, 1862, Avith gunshot wound through the hip, injuring the colon, the ball lodging. There Avas an artificial anus, and the wound Avas doing well, and was dressed Avith cerate. The soldier Avas discharged October 5, 1862, the ball being still retained." Case 293.—Corporal W. B. Brown, Co. F, 24th Alabama, wounded at Chickamauga, September 19, 1863, by a conoidal ball, Avliich passed through the abdomen. Faecal matter passed from both orifices for fifteen days; finally both fistula; healed, and the faeces passed naturally. There were no peritonea] symptoms, and he Avas sent to the rear in safe condition, October 31,1863.3 It is known that forty-one of the subjects of the foregoing fifty-nine abstracts of cases of partial or complete recovery after shot wounds of the large intestine still survive, and their present condition has been ascertained from the pension returns. Four pensioners (Cases 248, 268, 270, 272) are known to have died, at periods of from four to six and a •Quain, Elements of Anatomy, Seventh ed., London, 18G7, Vol. II, p. 824, Fig. 577. Wn.sox, The Anatomist's Vade Mecum, Am. ed., 1859 p. 516, Fig. 327. 2 Three transverse lines—the upper connecting tho prominent points of the lower costal cartilages, the second, a little above the highest points of the crests of the ilia, the third at the anterior superior spinous processes of the ilia—intersected by two vertical lines from tho eighth costal cartilages to the middle of the ligaments of Poupart, would subdivide the front of the abdomen into twelve spaces, those in the upper zone named epigastric, right and left hypochondriac; those in the second zone, upper umbilical, right and left lateral or supra-iliac; those in the third, lower umbilical, right and left iliac; those in tho lowest, hypogastric, and right and left inguinal. 3 This case is reported by Caklyi.e TlilutY, Chief Surgeon cf Iliiidiuan's division, in the Confederate Stales Medical and Surgical Journal, 1864, Vol. 1, p. 77, Casi; 49. 13 Fig. 62.—Diagram of the subdivisions of the abdominal regions. 98 PENETRATING WOUNDS OF THE ABDOMEN. [CIIAF. VI. half years sul>8equent to the dates the injuries were sustained. Of seven Confederates and seven Union soldiers, whose ulterior histories have not been traced, the probabilities are that they still live; since cases in which recovery was rapid and complete are, for the most part, included in this group, and none of the names appear on any of the various mortuary records that are accessible for reference in this office. In the four fatal cases adverted to, the stercoral fistula? remained pervious; and in five of the forty-one cases still under observation, the preternatural openings are yet unclosed; the wounds had fairly healed, in the fourteen remaining cases, before they passed from observation. Therefore, in fifty-nine cases, the stercoral fistula? persisted in nine; and in fifty closed—within a month, in seventeen cases; within a year, in twenty-eight; in five, at periods extending from one to four years. The intestinal wounds were complicated by fractures of the ilium in eighteen cases; with fractures of the transverse processes of the vertebra?, in two cases at least; with fractures of the humerus or bones of the forearm, in three cases; with fracture of the ribs, in one case. Balls voided at Stool.—It is probable that, in nearly all instances in which balls are voided at stool, the projectile enters the digestive canal through some portion of the colon. When discharged at an early period after the reception of the injury, it may be inferred that the missile primarily and directly penetrated to the cavity of the gut, and that the edges of the orifice through which it entered, having contracted adhesions to the parietes or to the adjacent viscera, faecal escape has been prevented. When the missile is discharged at a later period, it is reasonable to suppose that it has lodged in parts contiguous to the great intestines and gained admission to the cavity of the bowel by ulcerative absorption, or by the irritation of its presence producing an abscess that seeks an outlet in the nearest hollow viscus. Pathological anatomy teaches us that foreign bodies, sacculated in the abdomen, tend to be eliminated through the colon. The experience of the War furnishes examples of both varieties of cases of this group, of which some instances1 have been already adduced. In one of these, the case of Captain Stolpe, it was supposed that the projectile, which appeared in the alvine discharges five days after the reception of the wound, had penetrated the stomach. But this appears highly improbable, for there were no acute symptoms of gastric disorder; and it will be recollected that in Case 196, in which a musket ball unquestionably entered the stomach, it remained there unmoved for eight days. Dupuytren (Legons orales, T. VI, p. 464) thought that if a ball lodged in the stomach, it would be propelled through the pylorus; but the facts observed in Case 196 indicate that a wound of that organ, interrupting the normal peristaltic movement, may arrest the propulsion of the foreign body.2 That a ball may pass promptly through the entire alimentary canal, without inducing grave disturbance, is attested by the instances in which captured- couriers are alleged to have safely swallowed dispatches concealed in leaden balls, and by the following remarkable instance, communicated by Dr. S. C. Ayres, of Cincinnati: Case 294.—Captain EoAvland E. Hackett; Co. A, 26th Kentucky, aged 38 years, was wounded at the battle of Nashville, December 15, 1864, and admitted to Cumberland Hospital, under the care of Assistant Surgeon S. C. Ayres, U. S. V., who Avrites: "My recollection of the case is as follows: I had charge of Wards 11 and 12 at that time, and Captain Hackett Avas 1 See cases of STOLPE (First Surgical Volume, pp. 515, 5!>8), and BELT (ibidem, p. 584, and Second Surgical Volume, ante, p. 36), and ENGLISH (ibidem, p. 37). 2 That a ball may penetrate the stomach, Avithout causing any symptom of derangement of the alimentary canal (!), and be propelled onward and voided by the anus on the sixth day, is established, if credit be given to the report published in the Repertorio Medico-Far maceutico de la Sociedad de Emulacion de Barcelmut, by Dr. t OX, of a lad of fifteen, who survived a shot wound of the lung and stomach twelve days. This marvellous obser- vation is translated iu V Experience, and in the New York Journal of Medicine, 1845, Vol. IV, p. 117, and is cited by GL'TlIIilK (Inj. of Abdomen, Lecture III. r- 3t) without criticism. SECT. HI] WOUNDS OF THE LARGE INTESTINES. 99 brought into Ward 12, late at night, after the second day's fight, December 16, 1804. I examined him and found that he had been struck on the dorsum of the tongue, and that three of the incisors of the loAver jaAV had been knocked out. I introduced my finger into the Avound and felt one of the teeth lodged in the base of the tongue and removed it Avilhout difficulty. There wms no hemorrhage of any account, and he Avas not suffering much pain. His voice had a very mufHed peculiar sound, as if something Avas lodged in the throat. At the time of the reception of the Avound he was acting as major of the regiment, and was on horseback. He was Avounded as our troops were making a charge on the rebel Avorks near the 'Cranny White' pike. He was cheering his men at the time he avus shot, and naturally had his mouth wiile open. This may account for the fact that Ihe teeth of the lower jaAV Avere knocked out and that the ball struck the dorsum of the tongue about midAvay betAveen the tip and the base, and also for the fact that the lower lip Avas not injured. When I saAV him, I thought there Avas no indication to interfere, and therefore only instructed him to keep quiet in bed. The next morning he Avas quite comfortable. There had been no hemorrhage, and no unfavorable symptoms had appeared. I instructed him to watch his evacuations, thinking that possibly the ball might have passed into the oesophagus and thence into the stomach. The next morning, about thirty-six hours after the wound Avas receiA'ed, he passed the ball by the rectum. The Avound healed kindly, and, in a short time, his A'oice assumed its natural tone. My recollection of the ball is that it was not a rifle ball, but one about the calibre of a Colt'rf revolver." The report from Cumberland Hospital, signed by Surgeon B. Cloak, U. S. V., states that the missile Avas an "Enfield rifle ball," and that the officer was transferred to Louisville, January 2, 1835. The report of the officers' branch of the Clay Hospital, at Louisville, signed by Surgeon F. Greene, U. S. V., returns the case as a "shot Avound of the tongue from an Enfield rifle ball," and that this officer Avas discharged on January 15, 1865, to report to his command after twenty days' leave of absence. The register of volunteer officers records Captain Hackett as promoted to a lieutenant colonelcy April 1st, and honorably mustered out Avith his regiment July 10,1865. Doubtless, in Captain Stoipe's case, the ball, after traversing the diaphragm, penetrated directly into the transverse colon, which, sustained by the general equal pressure, speedily contracted adhesions, and allowed no extravasations to take place. The cases of Belt and English (Case 169), on the other hand, were examples of secondary perforation of the intestinal wall. Other examples of both varieties of injury were observed. The case of Dowdy, mentioned in Circular No. 6, is interesting. It is identical with the instance recorded by the late Surgeon W. H. Rulison,1 9th New York Cavalry. Case 295.—A Confederate soldier, registered as private James T. Dowdy, 28th Virginia, aged 23 years, Avas Avounded at Gettysburg, July 3,1863, by a conoidal musket ball, Avhich entered at the tip of the ensiform cartilage, and remained in the body. He Avas admitted, on July 3d, to the Seminary Hospital, and Avas removed, on July 29th, to Camp Letterman Hospital. Here Acting Assistant Surgeon James A. Newcombe reports: "The ball passed through the ensiform cartilage. No great shock Avas experienced at the time, and no haemorrhage Avhatever took place, either by sputa or stool, and only very little escaped externally. About fourteen hours after the reception of the Avound, a copious stool Avas passed. The patient heard something fall heavily and loudly to the bottom of the vessel. Suspecting it to be the ball, he requested the nurse to look carefully for it. A large mini6 ball Avas found." Surgeon Rulison mentions that the ball Avas considerably battered, "showing that it had struck something before Avounding the man." On September 17th, DoAvdy Avas transferred to the West Buildings Hospital, Baltimore, Avhence he Avas paroled, September 25, 1863, and sent to City Point. In a visit to Virginia, in July, 1870, the editor learned that this man Avas still living, in good health, in Bedford County, and desired a rectification of the report of his case in Circular No. 6. He did not Avish, he said, to exemplify Lord Byron's definition of glory, by being shot through the body and having his name spelled Avrongly in the gazette. He should have been registered Sergeant Albert Dowdy, Co. G, 28th Virginia, and Avas Avounded at Chester Station, on June 16, 1863, a fortnight before the battle of Gettysburg." The late Surgeon H. W. Ducachet,2 U. S. V., recorded two examples of this group. In both instances the missiles appear to have penetrated the wall of the transverse colon—anteriorly, in the one case; in the other, from behind. Other reports have supplied additional particulars of these cases. Case 296.—Lieutenant J. S. Harrold, Co. H, 14th Indiana, aged 22 years, Avas Avounded at Chancellorsville, May 3,186'.!, by a conical ball, which entered an inch and a quarter below the umbilicus and a quarter of an inch to the left of the median line. The patient was sent by rail to Aquia Creek, and thence, on the transport steamer Mary Washington, to Georgetown, and Avas admitted to Seminary Hospital on May 6th, Avhere Acting Assistant Surgeon H. E.Woodbury reported that "the appearance of the Avounded man Avas good; there was a slight pain in the abdomen, and nausea; tho boAvels moved very frequently; the Avound looked Avell. The appearances indicated that the ball, entering the abdomen midway betAveen the pubes and umbilicus, in the median line, had passed on, channeling the bowel in its course. The patient's statement is, that he has been troubled Avith giddiness and nausea—had also pain and difficult micturition—and no appetite; took medicine from several surgeons on the boat, but does not know its nature. On the morning of May 8th, he had slight pain in the abdomen, and at four in the afternoon there was a yelloAV, scanty, alvine dejection, that contained a minid ball. After this the patient was comparatively comfortable, but there Avas nausea and some diarrhoea, and he Avas directed to take one-eiglith of a grain of sulphate of morphia in mint-Avater. There Avas vomiting in the morning, and diarrhoea recurred, but not in a severe form, and he Avas ordered an injection of starch 1 lii'usoN, AV. H. The Escape of Balls by the Rectum, in the Am. Med. Times, 1863, Vol. VII, p. 212. 2 DUCACHET. Gunshot Wounds of the Abdomen, Balls being passed by the Rectum, in tho Am.. Med. Times, 1863, Vol. VII, p. 134. 100 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI and laudanum, winch was repeated on the 14th, when the patient looked much better, and the Avound was in excellent condition. On the ISth, voniiting and epigastric pain recurred, and required the use of fomentations and neutral mixture. The nausea and irritability of the bowels returned, at intervals, until the 10th of June, but there Avas a gradual improvement in the general condition notAvithstanding these draAvbacks. On the 13th, the officer Avent home on leave of absence. On September 19th, he avus mustered out, and afterAvard pensioned. Though recorded as discharged at this date, this officer would appear to have seen much active service subsequently, since the report of Pension Examiner J. T. Belles, March 4, 1867, states that he Avas " wounded at six different times, and in different parts of the body, of Avhich I Avill only mention Iavo, as either of them alone is sufficient to entitle him to a full pension. First, he Avas shot in the left forearm, destroying the shaft of the ulna and causing its removal, and injuring the muscles of the part, thereby causing complete anchylosis of elboAV joint, rendering the forearm useless; second, Avounded in the abdomen, the ball entering at a point above it, midway of the umbilical region, and passing into the intestine, and subsequently discharged at stool. This caused considerable derangement of the muscles of the abdomen and bowels. There is sufficient irritation to cause the loAver part of the boAvels to discharge considerable pus. Exercise is very painful." He Avas still a pensioner in September, 1872. Case 297.—Corporal C. B. Lupton, Co. B, 2d Ncav York Cavalry, aged 20 years, Avas Avounded at Upperville, June 21, 18(53 [Dr. Ducachet stated: "Rockville, July 28th;" but the man entered hospital on June 28th], by a solid conical pistol ball, Avhich penetrated the lumbar region. He Avas conveyed in an ambulance to Georgetown, and entered the Seminary Hospital, Avhence Acting Assistant Surgeon T. W. Miller reports the progress of the case as folloAvs: "The ball entered the lumbar region, passing betAveen the second and third lumbar vertebrae and remaining in the abdominal cavity. On admission, the patient had high fever and great abdominal tenderness. He Avas ordered to have flaxseed cataplasms over the abdomen, to take calomel and opium, and Ioav diet. This treatment Avas continued until July 2d, Avhen the calomel Avas omitted and the opiate continued. On July 4th, the ball was passed by the anus, about 4 A. M., Avithout any inconvenience to the patient." After this, he improved Avithout any adverse symptoms, except, at times, a slight diarrhoea, Avhich yielded to appropriate treatment. On July 28th, he Avas transferred to Armory Square Hospital, Washington, and Avas returned to duty October 3, 1863. The name docs not appear upon the Pension List. Cask 298.—Private Cyrus Stanley, Co. C, 39th Indiana, is alleged to have been Avounded at Stone River, December 31, 1862. His name does not appear upon the list of casualties, and he is supposed to have been made a prisoner. At all events, heAvas admitted into Armory Square Hospital, Washington, March 20, 1863; on May 5th, Avas transferred to Convalescent Hospital, at Fort Wood, NeAV York Harbor, and, on May 12th, to DeCamp Hospital. Here Acting Assistant Surgeon James W. Dickie has noted upon the descriptive list that "the ball entered half an inch below the last rib and four inches to the right of the vertebra, penetrated the abdominal cavity, and lodged. The patient voided the ball at stool ten days after the reception of the injury. When admitted, the Avound had healed and the general health of the patient was good. He suffered, however, from partial paralysis of the right side, and oedema, and loss of motion in the right foot. Bandages Avere applied over the Avound and counter-irritation made to the abdomen; full diet ordered." Stanley Avas discharged from service June 3, 1883, and pensioned. Pension Examiner Manuel Reed, of Portland, Indiana, reported, March 28, 1839: "The missile entered the right loin, passed through the upper part of the right kidney, and lodged in the bowels, Avhere it remained for ten days, at the end of Avhich time it (an ounce musket ball) Avas discharged. From the effects of the said Avound he is permanently disabled. There is incomplete paralysis of the right side. He is affected, in laboring, by not having complete control over the leg and arm, and not having poAver of endurance. The muscles are Avasting aAvay, shrunken, and flabby. He also has constant pain in the back of the neck and in the spinal column, often so severely that he is confined to his bed for days. His entire system is very much debilitated. Disability total, of the second grade, and permanent." This pensioner was last paid September 4, 1872. Case 299.—Corporal Morris D. Tucker, Co. I, 15th Massachusetts, aged 26 years, was Avounded at Spottsylvania, May 12, 1864, being struck in rapid succession by several musket balls. He Avas taken to the hospital of the 2d division, Second Corps, Avhere Surgeon J. F. Dyer, 19th Massachusetts, recorded the injuries as "gunshot flesh Avounds of the left hip and leg." On May 26th, the Avounded man Avas taken to Lincoln Hospital, Washington. The hospital record is very meagre, and makes no reference to a lesion of the intestines. Subsequently, Examining Surgeon A. L. LoAvell, of Wilmington, Vermont, April 17, 1871, gave the folloAving detailed report of the case: "Weight 130; age 32; respiration abnormal, and pulse irregular. A musket ball entered the left thigh, just above the knee and external condyle, passing upward and inward through the muscles and tendons of the outer and also the anterior aspect of thigh; it inflicted a seATere laceration of the s9ft parts, and made its exit through the rectus muscle, six inches above the knee, and entered the chest at the seventh rib of left side. The extensive laceration and great l6ss of muscular tissue, fasciae, and integument, leaves the injured limb seriously disabled and inefficient; a deep, broad, irregular cicatrix, adherent to the femoral periosteum and restricting the functions of muscular structures of the thigh and leg, marks the site of the Avound. The limb is affected Avith acute neuralgia, Avith formication, and impairment of nervo-motor function. Another ball entered the same thigh on its posterior aspect and upper third, passing upAvard, and injuring the sciatic nerve. It is still encysted near the sciatic foramen, Avhere it evidently impinges upon the nerve and causes severe sciatic neuralgia and pain throughout the entire limb. He alleges that his sleep is much disturbed by these paroxysms of pain. The depressed temperature of the limb, and the evident deficiency of muscular tone, demonstrate that the innervation of the limb is seriously injured. The saphenous vein of the left thigh is affected throughout Avith varices. These tAVO wounds of the same limb result in a degree of disability Avhich is evidently total. Another, and by far the most serious injury, Avas inflicted by a musket ball, Avhich penetrated the abdomen and intestines in the left inguinal region. This wound resulted in a faecal fistula, Avhich finally healed after several months' treatment. The contents of the bowels Avere for several months voided at this traumatic opening. He alleges that tlie bullet was voided with the stools, four weeks after ihe injury was inflicted. The Avound closed Avith a very thin and extremely sensitive cicatrix, in Avhich is involved fascia, integument, and peritoneum, and the intestines. The movements of gas and the contents of the intestines are distinctly felt through this cicatrix, and it is alleged that every jolt or strain of the abdominal muscles causes acute pain at this point, and oftentimes nausea. This injury is slowly killing the man. His body is much emaciated. The complexion is salloAV, and expression languid. The tongue is constantly SECT. Til.] WOUNDS OF THE LARGE INTESTINES. 101 coated. The pulse is irregular and thready, and the assimulative functions are seriously deranged. The nerve action is irregular, and sIioavs functional disturbance and irritability. His standard Aveight in health Avas 190 pounds; he now Aveighs i:>() pounds. The hepatic region is tender on pressure, and the abdominal Avails are tumid. The prognosis in this case is very unfavorable. It is my opinion that the injury inflicted upon the viscera has resulted in serious derangement of the sympathetic nervous system, and that this disturbance is perpetuated by local chronic peritonitis. I have carefully inquired into the past history of this pensioner, and find that he is held by the best citizens of his town to be a man of sterling integrity and of excellent social standing. lie is poor, and has a Avife and small children to support. He has, since leaving the hospital, tried to earn something, for the support of his family, at various light occupations, but has been compelled by his physical distress to give up all active employment. Such I find, upon the most respectable authority, to have been this man's history since he returned from the hospital. His condition is groAving Averse, and I question if he survives a year. His condition commands the real sympathy of the entire community Avhere he resides. It is very evident that he has been hitherto very hastily examined and carelessly rated. He has, I am fully satisfied, been entitled to 'total second grade,' act June 6, 1866, since its passage. I therefore recommend that he be rated at that grade from the passage of the act. Disability total, second grade, and perma- nent." On November 15,1871, Pension Examiner Thomas F. Smith, of New York, reports of this pensioner: "The ball entered above Poupart's ligament, on tho left side, and Avas passed through the anus. He has had an artificial anus, and is noAV suffering from chronic peritonitis. Another ball entered upon the external aspect of the right knee and emerged above the knee. This Avound Avas folhwed by gangrene, causing a large loss of muscular tissue. Another ball entered just beloAv the right trochanter major, and still remains embedded in the deep muscles. There is considerable atrophy of the limb, also neuralgic pains. Another ball entered the fifth intercostal space. Respiration is difficult." This pensioner is still on the Roll. Since the War, Assistant Surgeon J. H. Patzki has presented to the Museum a pistol or carbine ball (Fig. 63) that penetrated the abdomen through the ilium, and subsequently was voided at stool. The memorandum accompanying the specimen does not indicate the precise point of entry of the projectile, or the exact date of its elimination. It is highly probable, however, that it entered the sigmoid flexure by ulceration, and was discharged in defecation within thirty days from the date of the injury: Case A2.—"Private George Armstrong, Co. I, 29th Infantry, Avas shot by a large-sized revolver ball, August 23, 1868, Avhile trespassing upon a fruit garden at night. The ball penetrated through the os ilii into the abdominal cavity, beyond reach. The abdominal viscera apparently escaped injury. The wound Avas drained by means of a perforated rubber tube, and dressed Avith carbolated oil. The patient bids fair to recover." This entry is on the August sick report of the 29th Infantry, signed by Assistant Surgeon Patzki. On the September report, signed by Acting Assistant Surgeon J. T. Pindell, there is the following entry relatiA'e to this case: "Private George Armstrong, Co. I. This case Avas reported last month, Avith full particulars. Ball subsequently found, having penetrated by ulceration the abdominal viscera and been discharged by the intestines. Patient is still in the hospital and is rapidly convalescing." As the man was Avounded on August 23d, and is reported as "rapidly convalescing" on September 30th, the foreign body was probably expelled some days prior to the latter date. Indeed the regiment changed station on September 27th, moving to Tennes- see. There were two cases of shot wounds on the September report, of which one is accounted for as "returned _ Z.™!,™ to duty." The remaining case, probably that of Armstrong, is recorded as "returned to duty" on the October bine or pistol report. Assistant Surgeon Patzki, in forwarding the specimen, Avrites: "The ball penetrated the os ilium of st^ol Xspec.5539. Private Armstrong, 29th Infantry,—afterward discharged by the boAvel (see monthly reports for August and September, 1868), the latter forwarded in my absence by Dr. Pindell." The missile is represented the size of nature in FlG. 63. It Aveighs tAvo hundred grains. The apex is flattened by impact on the innominate bone. There is yet another instance that may be grouped in this category, though belonging to a class of injuries that will form the subject of the succeeding Chapter. It was reported by Dr. S. Cabot to the Boston Society for Medical Improvement,1 as follows: Case 300.—"A soldier received a Avound at the battle of Antietam, September 17, 1862, the ball entering the left buttock on a line parallel with the trochanter major, and about two inches behind it, and lodging in the pelvis. Since the receipt of the Avound he suffered some pain in the pelvis, knee-joint, and small of the back. The patient was ahvays convinced, from his own sensations, that the ball was situated in the rectum, some distance from the anus, Avhere, in fact, it was discovered by a surgeon in Philadelphia, who refused, however, to remove it, saying that the attempt would be dangerous. The patient being etherized, a thorough examination of the Avound Avas made with a probe, and with an instrument tipped Avith porcelain, but the ball could not be detected. The finger Avas then passed into the rectum, and the ball was felt lying beneath the mucous membrane. The membrane Avas ruptured Avith the finger and the ball removed Avith the forceps. The patient did Avell." An alleged instance of penetration of the sigmoid flexure of the colon by a musket ball, in a negro lad, who reported that the missile was voided at stool on the fourth day, is printed in a periodical of Cincinnati.52 1 Cabot, Boston Med. and Surg. Journal, 1863, Vol. LXVIII, p. 101. The namo of the patient has not been identified. 2 WlilGHT (T. J.), Cases in Military Surgery, in Am Eclectic Medical Review, 1868, Vol. IV, p. 108. Dr. WlUGHT records this as a case observed by him while on duty with the 53d Illinois Volunteers, at Camp Holly Springs, near Fort Pickering, in the spring- of 1863. Dr. WRIGHT'S name is not found io the lisl of regimental medical officers. 102 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. Fatal Pases.—While contributing thus largely to our information concerning the progress and results of shot wounds of the large intestines, the experience of the War added little to our knowledge of the pathological anatomy of this group of injuries. I have already adverted to the rarity of preparations illustrating the results of injuries of the colon.1 The collection of the Army Medical Museum possesses but few examples. In a preparation presented to the Museum by Assistant Surgeon G. A. Mursick, U. S. V. (Fig. 64), the caecum was perforated by a musket ball, which, entering in the right hypochondrium, passed downward, inward, and back- ward, and lodged against the sacrum. Though the missile had also traversed the lower portion of the right kidney, the patient survived his injuries twelve days. The margin of the orifice in the gut was ulcerated and coated with false membrane. The case will be fully reported in the subsection on shot wounds of the kidney. Another preparation of a shot perforation of the caecum, presented by Dr. W. Leon Hammond, has been figured on page 67 (Fig. 45). A third preparation, presented by Surgeon T. H. Bache, U. S. V. (Fig. 65), well illustrates the relations between the gut and the exterior surface in shot wounds of the colon resulting in the establishment of a preternatural anus. The following are FlG. 64.—Perforation of the colon bv 4.1 i. * 1 C iA amuskotbail.spec.nea.[Halfsize."] tne particulars ot the case: Case 301.—Private John P. M----, Co. E, 11th Mississippi, AA'as Avounded at Gettysburg, July 1,1863. He was admitted to the General Field Hospital; on July 21st, sent to the hospital at Chester; and, on January 11, 183-1, removed to McClellan Hospital, where Acting Assistant Surgeon W. L. Wells gives the folloAving account of the case: "Wounded by a minid ball, Avhich entered in the left iliac region, and passed out beloAV the crest of the ilium after passing through the latter bone. The patient states that there were faecal discharges from the anterior Avound for about tAvo Aveeks after the reception of the injury, and at various intervals since, and that several pieces of bone had been removed from the posterior wound. On January lf.th, there Avas slight fascal discharge from the anterior Avound, and on January 28th, the Avound in the abdomen Avas slightly enlarged to remove a piece of bone one-half by one inch long. On February 12th, all fascal odor had ceased; the patient was doing Avell, but complained of tenderness around the Avound." On the folloAving day the patient Avas removed to West's Buildings Hospital, Baltimore, Avhere he died on March 12, l.*H>4. Surgeon T. H. Bache, U. S. V., Avho forwarded an account of the autopsy, reports the "minie ball entered the left inguinal region, Avounded the descending colon, passed through the ilium in its posterior quarter, then lodged subcutaneously back of the pelvis, Avhere it Avas cut out before the patient came to this hospital. The gut was adherent to the muscular parietes of the pelvis and communicated Avith an abscess •under the iliacus interims and psoas magnus muscles. This cavity communicated Avith the anterior and posterior apertures. In the cavity of the abscess, and near the posterior exit of the ball from the pelvis, two large fragments of bone wero found. The abscess must have been made first by the irritation induced by the bone fragments and by the ball, and increased by the burroAving of pus. The cavity of the descending colon Avas very small; long coils of fasces of small calibre used to pass through the Avound of entrance; air 1 But few pathological preparations of the results of injury of th,e large intestines are found in Museums. In addition to the four specimens, 1782, 221?, 3371), ()0G7, Sect. I, Army Medical Museum, the following are preserved: 5. Specimen 441, New York Hospital Museum: caecum, with a laceration in the caput coli, made by a musket ball; from a man of thirty, who died in about twenty-four hours without reaction (Cat., I. c, p. 108). 6. Preparation 104, Series IX, of the Museum of :Jt. George's Hospital, is a small shot laceration of two-thirds of the circumference of the injured flexure of the colon, from a boy of 12 years, who died the day of the injury; there was visceral protrusion in this ease (Cat., I. c, p. 430). 7. Preparation 18f>7J0 of Guy*s Hospital .Museum is a portion of the descending colon, showing a shot perforation of the wall of the gut nearest the loin; 18G7'2 is the flattened rifle bullet passed by the rectum, a few days after the injury; from J. B------, aged li) years, wounded at Sebastopol, Avho, afterward, died at Guy's of Bright's disease (Cat., 1. c, Vol. II, App., p. 52). 8. Preparation 187726, at Guy's Hospital, is a portion of the descending colon and sigmoid flexure, showing a laceration of the ccats without perforation The following memorandum of preparations, exemplifying injuries of the small intestines, should have been inserted on page 62: The preparations figured in the text (2259, 5T8!)) are the only illustrations of punctured or incised wounds of the small intestine the Army Medical Museum possesses. In the Museum of the New York Hospital, specimen 408 is a portion of jejunum removed from a patient who died two years and a half alter a stab in the abdomen, involving two-thirds of the calibre cf the intestine; the gut is adherent to the parietes by a long slender band; but no trace of a cicatrix can be seen in its tunics (Cat., I. c., p. 190). In the Museum of St. George's Hospital, London, are two such preparations: No. 107, Scries IX, is a portion < f the ileum, fifteen inches from the ileo-caecal valve, showing an oval preparation from a knife stab; the patient died from fecal extravasation. The second is 109, a portion cf the ileum an inch or two from the ileo-caecal A-alve, showing two wounds from the stab of a knife; recent fibiin coats the peritoneal surface about the wound (Cat, I. c, p. 431). The Hunterian Museum has a preparation, presented by Sir W. Blizakd, Series XXA'II, No. 1383, showing a portion of small intestine adherent to the liver and to the abdominal wall, through which, by a preternatural anus, its contents were long emptied. FIG. G5.—A por- tion of the descend- ing colon andof the anterior parietal wall, showing a preternatural anus. Spec. 221G. [One- fourth size.] SECT. III.] WOUNDS OF THE LARGE INTESTINES. 103 would be draAvn into the cavity and expelled, according as the patient moved and worked the abscess walls as a bellows. During the month the patient remained at West's Buildings Hospital the treatment consisted of opiates, Avith bark, stimulants, expec- torants, and beef-tea and other concentrated nourishment internally, and detergent dressings, with compresses and bandages over the Avound. There Avas troublesome cough, and the left lung Avas found much atrophied, after death, with tuberculous deposits throughout, those near the apex in the stage of softening. In the right lung, there were tuberculous deposits at the apex only. The opening square men 01 inc len uiuiu, ;i uuuercu uun, uuu uuiuuueu •— t—j----- ----......~* mum. A wet preparation 01 tne specimen is r rings from the missile. Spec. 2214. [Size of nature.] ed the injury (FlG. 68). 2217, Surgical Section. [Reduced one-third.] In addition to cases that have been related, or that will be noticed in connection with injuries of other abdominal viscera, there were eleven instances of fatal shot wounds of the colon in which autopsies were held. But it is to be regretted that, in many of these, the morbid appearances are imperfectly described, and the reader is left in perplexity regarding the conditions actually observed. Yet some of these cases embrace details of interest, and are, to some extent, instructive. In one instance, the patient succumbed from early internal haemorrhage : Case 302.—Private J. T. HaAvk, Co. E, 15th NeAV York Cavalry, aged 23 jears, Avounded at Green Spring Run, November 1, 1861, by conoidal pistol balls in the right arm and abdomen, Avas admitted to Cumberland Hospital the same day. Actinsj Assistant Surgeon C. H. Ohr reports that, on admission, the countenance Avas indicative of great pain, the skin cold and clammy; had vomited; pulse 90 and Aveak; abdomen full and tender; no bloody stools, but excruciating abdominal pains. Anodynes and stimulants Avere given. Death at ten o'clock in the evening. Autopsy: The great omentum Avas very fat; its loAver part Avas infiltrated Avith coagulated blood; the boAvels in the hypogastric region Avere coated Avith coagula, and fluid blood Avas effused in the peritoneal cavity to the extent of six ounces. The ball, entering at the loAver edge of the right tenth rib, at the chondriac junction, passed under the lower edge of the liver, thence between the intestinal convolutions, until it reached the transverse colon; it perforated this viscus at its left curvature, and passed on, lodging against the false costal cartilages of the left side, on their outer surface, from which point it Avas extracted, having passed in nearly a direct line from the right to the left hypochondriac regions. In other instances the fatal issue was longer deferred, and, in some of them, the late appearance of the symptoms of peritonitis was remarkable : Case 303.—Sergeant X. Mehler, Co. E, 74th Pennsylvania, Avas Avounded at Rappahannock, August 22, IS'32. He Avas admitted into Judiciary Square Hospital at Washington on August 24th, Avhere he died. Acting Assistant Surgeon F. II. Brown states: "Gunshot Avound; entrance two inches to the left of tbe median line, on a level Avith tbe top of the sacrum; the track of the ball Avas not marked; it was excised from beneath the integument four inches to the right of the median lino, at the level of the umbilicus. On the 26th, there was considerable fever, and peritonitis commenced and increased rapidly, and the patient died, rather suddenly, on the 27th, having had considerable trouble in respiration during the day. At the autopsy, the descending colon Avas found pierced opposite the wound of exit; there Ayas a considerable quantity of liquid faeces in the cavity of the abdomen, and adhesions of the peritoneum and pleura about the seat of injury. In this case, though some tenderness existed, no symptoms at all commensurate with the lesion were present until Avithin thirty-six hours of death, and on the supervention of peritonitis. The presence of the faeces in the abdomen did not cause the usual acute pain produced by foreign bodies in the peritoneal cavity." 101 PENETRATING WOUNDS OF THE AP.DOMEN. [GIIAr. VI Care 304.—Sergeant A. Garron, Co. K, 8th New Jersey, aged 22 years, received a gunshot Avound of the abdomen at Chancellorsville, May 3, 181)3. He Avas admitted to the regimental hospital on the same day, and transferred to Washington on May 5th, Avhere he Avas admitted to Mount Pleasant Hospital on the 9th. Acting Assistant Surgeon Ira Perry gives the following information in the case: " May 9th, ball entered three inches above the pubes and one inch to the left of the median line, and still remains in ; slight tympanitis and tenderness; pulse 108; the functions of the bladder normal. Treatment: anodynes to relieve pain and keep the boAvels quiet; spirit lotion to the wound; mucilage and essence of beef. May 11th, se\Ten o'clock A. M., for the last hour has been distressed with a hippocratic expression; pale; skin moist and cool; slight hiccough; has had a stool, and passed some faeces and offensive decomposed blood. Hoffman's anodyne and tincture of opium Avere given to relieve the pain. May 12th, has slept well, and, at six o'clock A. M., had a muco-purulent, sanious, and offensive alvine evacuation, Avith pain, Avhich Avas relieved by injections of mucilage and opium. May 13th, slept Avell; no movement of bowels; Avas comfortable until five o'clock P. M., and then became restless and languid. Hoffman's anodyne, opium, and calomel were admin- istered, Avith an injection of opium. May 14th, slept Avell; pulse 103; tongue coated, and appetite poor; abdomen full; Avound one and a half inches in diameter and gangrenous; toAvard evening, became uneasy and vomited up everything; turpentine Avas applied to the abdomen, and Avine or whiskey administered. On the 15th, he Avas much the same, vomiting everything; pulse 100, and tongue coated yellowish; toAvard evening, he became restless, and the pulse rose to 132; he vomited everything he SAvalloAved. May 16th, at two o'clock A. M., he Avas apparently dying, but perfectly sensible; Avas relieved by anodynes. He died at five o'clock A. M., May 16th. Autopsy, five hours after death: Some fulness, centering at the wound ; slight tympanitis. Section shoAved extensive peritoneal inflammation ; abdominal walls and contents agglutinated, except Avhere there was decom- position. One large sinus Avas filled with pus and decomposed blood; another Avith gas, mostly in the boAvels; and another with a pale gruel-like mixture, as though made from coarse meal. The ball passed in horizontally, perforating the sigmoid flexure of the colon, but was not found; careful search Avas not made, as there was great stench and decomposition and the friends Avere waiting for the body." Surgeon B. B. Breed, U. S. V., records the following example of the formation of a faecal fistula, as a secondary result of the injury inflicted by a musket ball: Case 305.—Lieutenant A. Blackburn, Co. F, 1st Arkansas Cavalr}', aged 35 years, received a shot wound in the right lumbar region, at Pine Bluff, October 25, 1833. About December 16th, he Avas admitted to hospital at Little Rock, and Avas there treated until transferred to the Prison Hospital at St. Louis, February 16, 1854. On admission he Avas much debilitated; he seemingly improved until March 4th, when he Avas attacked by erysipelas, and Avas removed to the erysipelas Avard ; he Avas then very feeble, and there Avas irritability of the stomach, Avith constant discharge of pus and faecal matter from the wound; he also expectorated large quantities of muco-purulent matter with a faecal odor. The treatment Avas tonic and stimulant, enemata being given to keep the bowel clear beloAV the preternatural anus, and rigorous attention Avas paid to the cleanliness of the Avound. He gradually greAV feebler, and died March 30, 1834, having survived the injury over five months. The autopsy shoAved that the ball having entered near the posterior superior spinous process of the right ilium, had passed forAvard and lodged under the skiu about three inches above the anterior superior spinous process of the same bone; an opening was found near the center of the ascending colon, the edges of which Avere united to those of the external aperture, forming a preternatural anus. This opening in the bowel did not appear until four months and ten days after the reception of the injury, and Avould seem to have been immediately due to the extension of the inflammatory process consequent on the attack of erysipelas. Case 305.—Private M. O'Shea, Co. M, 2d Maryland Cavalry, Avounded by a revoh'er ball at South Bend, December 26, 1854. He Avas admitted to Cumberland Hospital on the same day; pulse 125, and feeble; skin dry, harsh, and hot; tongue coated and sordes on teeth ; vomiting of bilious matter and constant eructation of gas; haemorrhage very slight; thin faeces and gas escaped from the wound; little pain". He continued unchanged for several days, and, on January 2d, Avas able to Avalk across the room and enjoy his pipe and lemonade. Faeces continued to be discharged from the Avound, and, on the 10th, he had a large passage by the rectum. On the 14th, he had a severe chill, followed by profuse perspiration; pulse more feeble ; general condition Aveak, and at times there Avas delirium. He died January 15, 1855, tAventy-one days after the reception of the injury. Autopsy twelve hours after death : " Body much emaciated; abdomen flat; the bullet Avas found lodged in the psoas magnus muscle of the right side, opposite to the second lumbar vertebra; the descending colon Avas perforated, and the body of the last lumbar vertebra Avas fractured ; the spleen Avas enlarged and inflamed; the stomach and liver Avere normal in appearance; there Avas extensive inflammation of the bowels and peritoneum, and strong adhesions of the colon to the parietal peritoneum." The case is reported by Acting Assistant Surgeon T. R. Clement. Case 307.—Private J. Mallon, Co. G, 37th Ncav York, Avas Avounded at Colchester, January 29, 1862. He Avas considerably shocked at the time of injury, but Avas still able to assist in battering in the door of a house occupied by the enemy, after Avhich he sank exhausted. He Avas then conveyed several miles on horseback to Accotink; his pulse was small, and his features expressive of profound prostration; he suffered severely, but Avas quite conscious. Stimulants Avere administered until reaction took place, Avhich Avas accompanied by pain, restlessness, hiccough, and nausea. Next morning he Avas conveyed by ambulance to the regimental hospital, about eight miles. On the third day peritonitis supervened; the abdomen Avas tympanitic but not painful; under palliative treatment he greAV someAvhat better until the eighth day, some hope being entertained of his recovery; diarrhoea set in, Avith profuse and purulent evacuations, and obstinate vomiting and hiccough ; delirium and collapse folloAved, and continued until he died, sixteen days after the injury. An autopsy, eight hours after death, showed that the ball had entered at the upper part of the right sacro-iliac symphysis, fracturing the posterior superior spinous process, furrowing the psoas muscle, passing over the promontory of the sacrum, against Avhich it Avas flattened, into the right iliac fossa, Avounding the posterior part of the caecum about an inch from the appendix, furroAving the iliacus muscles, thence deflected upAvard by the right ilium it wounded the transverse colon, anteriorly, in tAVO places, and lodged between the bladder and rectum. The wounds of entrance and exit Avere three inches apart; the ball Aveighed nearly one ounce. The intestines Avere attached, in several places, to one another, to the abdominal parietes, especially of the right side, and to the omentum, which Avas distinguishable as SECT. III.l WOUNDS OF THE LARGE INTESTINES. 105 a thin membrane, considerably expanded, and in a state of decomposition. Underneath the caecum was a Avel of pus, which, together Avith the other purulent fluids removed from the abdomen, and Avhat Avas previously passed at stool, Avould certainly amount to more than a gallon. Fibrinous clots covered the surface of the intestines in thick, soft, and blackish patches, Avhich were then assuming all the appearances of decomposition. Throughout the entire intestinal track this Avas strikingly evident.1 Case 308.—Private P. Sauls, Co. E, 51st Georgia, Avas Avounded at Gettysburg, July 3, 1863, by a minki ball. He Avas admitted to Seminary Hospital on the same day, and, on August 7th, Avas transferred to Camp Letterman Hospital. There had been more or less excrementitious matter passed daily from the Avound since it Avas received. The patient had rapidly emaciated, and died from exhaustion on August 27th, having survived the injury fifty-six days. An autopsy Avas made on the same day, and shoAved that the missile, entering the left lumbar region in a line between the anterior superior spinous process of the ilium and the tAvelfth rib, penetrating the cavity of the abdomen, and, passing transversely through the descending colon, had made its exit on the left side of the spinal column in close proximity to the third lumbar vertebra; the spleen was pierced by tbe ball in its passage, and a large abscess Avas found between the meso-colon and posterior wall of the abdomen, containing a half pint of pus. The case is reported by Assistant Surgeon S. B. Sturdevant, 139th Pennsylvania. Iii four other autopsies, attendant lesions of the solid viscera of the abdomen were observed. In one of these cases, the descending, and in three, the ascending, portions of the colon were interested. Assistant Surgeon R. M. O'Reilly has contributed, since the War, a very interesting preparation of lesions of the descending colon and of the wing of the left innominatum, with an accompanying history, substantially as follows : Case A3.—Private John Mollitur, Co. D, 4th United States Infantry, Avas admitted into the hospital at Fort Laramie, June 27, 1870, Avith a gunshot wound of the abdomen. The bullet entered about two and a half inches to the right of the left anterior superior spinous process of the left ilium, perforated the descending colon about one inch above the sigmoid flexure, and, after carrying aAvay a portion of the crest of the ilium, made its exit posteriorly at a point nearly opposite the point of entrance. Severe inflammation and intra-pelvic abscesses followed, which were finally subdued. The fasces, from the first, Avere passed by the Avound. Tavo attempts Avere made to close it, but failed, on account of the sloughing of the parts and the unfavorable condition of the patient's health. Phthisical symptoms developed themselves, and, together Avith the debility occasioned by the profuse discharges, from Avhich the patient suffered during the first months after his admission, resulted in his death September 25, 1871. An autopsy Avas made six hours after death. Rigor very slight; body much emaciated; heart and liver healthy. The pleura Avas closely adherent to the ribs anteriorly and laterally, requiring considerable force to separate them. The lungs Avere slightly congested, and the loAver lobe of the right lung Avas hepatized and filled with tubercular deposits. The small intestine Avas greatly dilated throughout its entire course; the iliac portion Avas slightly congested. The colon was displaced—the transverse portion Avas lying across the third lumbar vertebra and was firmly bound down by strong fibrous bands, Avhich required division by the scalpel before the boAvel could be released. The large intestine (Fig. 68) Avas diminished to one-fourth of its natural size, Avas pale and flabby in appearance, and had a large and ragged opening situated about one inch above the sigmoid flexure, posteriorly, corresponding Avith the external Avound. Immediately inside the Avound was a cavity, lined Avith smooth membrane, occupying nearly the Avhole space of the internal attachment of the iliacus; jt was closed on all sides, except Avhere it communicated Avith the Avound. The sacrum Avas considerably eroded at its junction Avith the ilium, Avhich Avas also necrosed at the point of articulation with the ischium, and on the superior border near the Avound. The extensive destruction of the Avail of the pelvis in this case is very remarkable. The portions of ilium eliminated must have composed a part equivalent to three inches square, at least. The crest is Avanting from a point half an inch behind the tubercle (tuberculum cristce ilii, of Retzius), and the auricular part of the bone, posterior to a line draAvn from this point and then backward along the superior curved line to the sacro-iliac junction, is gone. From the aggregate of over six hundred and fifty cases of shot wounds of the intestines that appear on the returns, it would be possible to glean some details of other examples of lesions mainly involving the large intestines ; but the eighty-five instances that have been presented sufficiently exemplify, perhaps, the varieties and results of such injuries. Moreover, in examining wounds of other abdominal viscera, cases complicated by intestinal lesions wili come under consideration. No hesitation was felt in detailing 1 An extended account of this case is published by Surgeon W. O. Meagher, 37th New York, in the Am. Med. Times, 1862, Vol. IV, p. 205. 14 Fig. G8.—Section of a mutilated left ilium, and a portion of atrophied colon, with an abnormal opening near the sigmoid flexure. Spec. (iO(S7. 106 PENETRATING WOUNDS OF THE ABDOMEN. ICHAP. VI. at length a large number of cases closely resembling each other in many features, as it was believed that the value of this cumulative evidence would be appreciated by surgeons. In the very valual.de chapter on gunshot wounds, in the Surgical Operations of the late J. Mason Warren,1 there is an interesting narrative of a case of intestinal fistula in a Massachusetts soldier, shot at Chancellorsville, which I take to be identical with Case 263 of the foregoing series. Another recovery from a shot wound of the colon is recorded in the First Surgical Volume, p. 7, in the case of Sergeant N. Gilbert, 1st Michigan Cavalry, who received also a sabre-cut on the head. From an account of this case by the late Surgeon W. H. Kulison,2 9th New York Cavalry, the ascending colon appears to have been the portion of the intes- tine interested. A remarkable case of recovery from a shot wound involving the intestines and bladder, recorded by Assistant Surgeon D. C. Peters,3 U. S. A., will be noticed with injuries of the latter viscus. Many cases of doubtful authenticity, or described with wide discrepancies, in the field returns and the reports of the pension examiners, have been set aside.4 Some of these would be interesting if true. For example: Private Hipwell, 15th Illinois, is reported by the regimental assistant surgeon, Dr. J. W. Vanvalzah, as struck in the left hip by a round musket ball, at Shiloh, and discharged October 24, 1862. Pension Examiner H. A. Buck states, April 5, 1863, that the ball entered the right lumbar region, and, according to the patient's statement, was discharged, eight days subsequently, in defecation. Corporal H. C. Grant, also, of Co. 0, 52d Illinois, 36 years of age, wounded by a musket ball, at Shiloh, April 6, 1862, appears on the records of the Cincinnati hospitals as a case of uncomplicated shot wound of the belly. At the Chicago hospitals, Acting Assistant Surgeon R. N. Isham states that the injury implicated the* intestines; and, in January, 1861, Pension Examiner J. W. Garvin, of Sycamore, Illinois, , 1 AArARREX (Surgical Observations, with Cases and Operations, Boston, 1867, p. 561. Case CCCXXXVII). Dr. WARREN referred the injury to the right iliac region; but in other respects the historj/ corresponds with that of CASE 263. Private Burt was a Massachusetts soldier, and likely to fall under Dr. Warren's observation. No other case corresponding to the facts detailed by Dr. Warren can be found among the casualties at Chancel- lors\-ille. 2KiUS0N. Am. Med. Times, 1863, Vol. VII, p. 242. 3 Peters. Interesting Cases of Gunshot Wounds, in Am. Med. Times, 1864, Vol. VIII, p. 3. 4 After the long list of recoA'eries from shot wounds of the large intestine that has been furnished in the text, it is hardly necessary to accumulate evidence on this point; but those curious on the subject can refer to the following additional instances: 1. Dr. T. F. CLARDY records (Med. and Surg. Reporter, 1860, Vol. IV, p. 473) a recovery after a pistol ball perforation of the ascending colon, with fascal fistula for twelve days; the ball was supposed to have lodged in the iliac fossa. 2. Dr. Doavell (Nashville Med. Record, 1860, Vol. Ill, p. 5) records a recovery, after fascal fistula, from a wound of the caecum made by duck-shot. 3. Pare, A. (Opera, Parisiis, 1582, p. 763', relates a case of wound of the belly; ball passed at stool nine days later; recovery. 4. Valleriola (Obs. Med., Lugduni, 1605, Lib. IV, Obs. 9, p. 290) [see SCHENCKIUS, Obs. Med. Rar., Lugduni, 1644, p. 698], pistol wound of the intestines; ball voided at stool a few days afterward ; recoA-ery. 5. Patinus (Vulnus intestinale periculosum felicitur curatum, in Eph. Acad. Nat. Cur., Norimberga?, 1863, Dec. II, Ann. I, Obs. XX, p. 45), shot wound of colon; ball passed at stool on the fifth day ; recovered. 6. Franc, G. (Tria sclopetor.um vulnera notabilia, in Eph. Acad. Nat. Cur., Norimberga?, 1G83, Dee. II, Ann. I, Obs. XX, p. 64), shot wound in the epigastrium; ball passed at stool a month afterward; recoA*ery. This case is also reported by Mangetus (Bibl. Chir., GeneA'ae, 1721, T. IV, p. 552). The latter author (ibidem, T. 1A', p. 572) gives another case of shot wound of colon; recovery. 7. PURRMAN (Lorbeer-Krantz der Wund-Artzney, Franckfurth, 1692, S. 420), shot wound of colon; ball passed by the anus on the fourth day; recovery in four weeks. 8. FAUDACQ (Reflexions sur les Playes, Namur, 1735. p. 562) records the case of afille sacre, shot in the waist; colon injured; linen, cloth, and small shot passed at stool on fourth, fifth, and sixth day; recovery. 9. BlLCUER (Chirurgische Wahrnehmungen, Berlin, 1763, S. 387, note 8), shot wound of abdomen; ball passed at stool. 10. BUDD^EUS (in BlI.GUER's Chirurgische Wahrnehmungen, Berlin, 1763, S. 347), shot wound of intestines; faecal matter escaped from wound of exit for six months ; recovery. 11. HORN (ibidem, S. 362) relates two cases of shot wounds of colon; recovery in three-and four months, respectively. 12. CRON (ibidem, S. 350), shot wound of intestines and'perforation of ilium: faecal fistula; recovery in two months. 13. POIRIER (ibidem, S. 375), shot Avound of intestine; escape of faecal matter; recovery in forty days. 14. Ravaton (Chirurgie d'Armee, Paris, 1768, p. 235), shot wound.of intestine; slug passed at stool on the sixteenth day; recovery. 15. VOELKER (in SCHMUCKER'S Vermischte Chirurgische Schriften, Berlin, 1786, B. II, S. 148), shot wound of descending colon ; ball passed at stool; recovery. 16. PERCY (Manual du^Chirurgien d'Armee, Paris, 1792, p. 238), shot contusion of colon ; colon after- ward divided; recovery. 17. Idem, p. 239, shot perforation of colon ; recovery. 18. LARREY (Mem. de Chir. Mil. et Camp., Paris, 1812) states that at the sieges of Acre and Cairo he obserA'ed five cases of wounds of the colon ; recoveries without stercoral fistulae. 19. GUTHRIE (On Wounds and Injuries of the Abdomen and Pelvis, London, 1847, p. 36), soldier wounded at Ciudad Bodrigo, in 1812; ball passed by the anus on the fifth day; recovery. 20. Idem (I. c, p. 38). relates the case of a sergeant wounded, at Waterloo, about an inch above the umbilicus; ball passed on the sixth day; recovered. 21. BAUDEXS (Clinique des plaies d'armes a feu, Paris, 183'), p. 341), penetrating shot wound of descending colon; ball removed by incision ; faecal fistula; recovery in about two months. 22. LOXGMORE (The Lancet, 1855, p. 606, Vol. I), gunshot wound of abdomen ; ball passed at stool on the third day; probably recovered. 23. BlF.FEL (in L angexiseck'S Archives, Berlin, 1869, B. XI, S. 417), shot wound of intestine; escape of faecal matter; recovery. 24. FISCHER, K. (Militairarztliche Skizzen, aus Suddeutschland und Bohmen, Aarau, 1867), refers to three cases of recovery from wounds of the ascending colon. 25. Maas (Kriegschirurgische Beitriige aus dem Jahre, 1866, Breslau, 1870, S. 18) cites a case of grenade shot of the large intestine; faecal fistula; recovery in two months. 26. STROMEYER (Erfahrungen uber Schusswunden im Jahre 1866, Hannover, 1867, S. 43) relates the case of a cavalry officer shot through SECT. III.] WOUNDS OF THE INTESTINES. 107 reported that "a minie1 ball entered the abdomen, probably the duodenum, and, at the expiration of twenty-seven days, was passed while at stool. There has been more or less inflammation of a chronic character ever since."1 But, while they are curious, it is unnecessary to devote much attention to these doubtful cases, in view of the large series of authentic instances by which the various results of injuries of the large intestines have been exemplified. It is obvious that the returns do not furnish the elements for an exact estimate of the mortality resulting from lesions of this group, since even a precise approx- imation to the aggregate of cases is impracticable. Yet the facts assembled enable us to approach more definite conceptions of tho probabilities of recovery in wounds of the large intestines, and of the comparative danger of injuries of the different portions of the alimentary canal.2 The cases adduced may not appear to substantiate the statement advanced on page 76, implying that wounds of the descending colon are less dangerous than those of the csecum and ascending portion, since only twenty-seven recoveries were enumerated in the former category, while thirty-two were included in the latter; and, among the fatal cases adduced, after injuries of the transverse colon, those of the descend- ing portion presented the least favorable exhibit. Notwithstanding these facts, a review of all the data bearing on the subject leaves unchanged the impression that wounds of the descending colon are not more dangerous than those of the ascending colon.3 The reader the large intestine; faecal fistula for three months; recovery. 27. Idem. (Maximen der Heilicunst, Hannover, 1855, S. 634) records a case of shot wounds of the descending colon, at Idstedt; ball passed at stool on the sixth day. 28. BILLROTH ( Chirurgische Brief e aus den Kriegs-Lazarethen in Weissenburg und Mannheim, 1870, S. 1SS, No. 33), shot wound of intestine; faecal fistula; recovery in about two months. 29. SOCIX (Kriegschirurgische Erfahrungen, Leipzig, 1872, S. 94) cites two cases of recovery of penetrating wounds of the colon; faecal fistulas; in the second case the liver and gall bladder were probably also injured. 30. H. Fischer (Kriegschirurgische Erfahrungenvor Metz, Erlangen, 1872, S. 129) relates two cases of shot wounds of colon; escape of faecal matter; recovery in five and two and one-half months, respectively. 31. BECK (Chirurgie der Schussverletzungen, Freiburg, 1872, S. 534 et seq ) cites seven cases of recoveries from perforations of the intestines. 32. LENNOX, L. J. (Canada Lancet, 1872, Vol. V, p. 112), records the case of a carpenter of Newfoundland, aged 34 years, wounded by a ball from a Smith and Wesson pistol, which passed through the forearm and entered the abdominal walls a little below and to the right of the umbilicus. Probing failed to detect an opening into the peritoneal cavity There was but little shock or subsequent peritonitis. On August 10th, twelve days after the reception of the wound, the ball was voided at stool. A fortnight afterward, the man was able to be about and to attend to business. 33. HEUSTIS, J. W. (Am. Jour. Med. Sci., 1829, Vol. V, p. 99), relates a case of recovery from a faecal fistula of the ascending colon, from a shot wound in the right loin, with fracture of the ilium. 34. Tew. N. S. (Canada Med. Jour., 1865, Vol. I, p. 358), records a recovery, with faecal fistula, from a shot wound of the ascending colon. 35. Amyaxd (Phil. Trans., Martyn's Abrid., Vol. IX, p. 157) relates the case of a soldier who appears to have been shot through the descending colon, in Flanders, in 1732; faaces escaped by the wounds for several weeks, then gradually assumed the natural channel, and the wounds cjosed. 38. BlNNEY, a Surgeon of the American Revolution (Mem. of the Am. Acad, of Arts and Sciences, Vol. 1, p. 544), relates the case of David Beveridge, a seaman, who recovered in three weeks from a shot wound of the descending colon, with escape of faeces. 37. 31. CHEXU (Stat. Med. Chir. de la Camp, d'ltalie, 1869, T. II, p. 494) records the case of A. Dato, wounded in the rectum at Solferino, June 24, 1859; ball passed at stool eight days after; pensioned August 10, 1801. 38. M. Chenu (Rapp. Mel. Chir. Camp. d'Orient, 186.3, p. 198) relates the case of Van Heteren, who received, at Sebastopol, February 3, 1855, a shot wound of the ascending colon, with per- foration of the innominate, and stercoral fistula; recovery, and pension, July 1, 1855. 1 Were these cases accepted—and they are probably not less veracious than many related in tho old chronicles—the number of instances, in the text, of bullets voided at stool, would be increased to thirteen. The projectiles entered the alimentary canal by deglutition in one instance, by direct penetration of the intestinal wall in five instances, probably, and by secondary ulceration in seven cases. As nearly as can be ascertained, the foreign bodies appear to have entered some portion of the colon in eleven of the thirteen cases, the ascending portion in two, the transverse iu five, the descending colon in four. Fifteen such examples, reported by PARE, VALLERIOLA, PATINUS, Fraxc, Purmaxx, Faudacq, BILGUER, Bavatox, A'OELKER, Guthrie (2), LONGMORE, pStromeyer, Lennox, and CHEXU are cited in the preceding note, the balls being discharged at intervals of from three to thirty days. Hexxkx (op. cit., p. 408, Case LXV) describes the case of the AVaterloo sergeant, Peter Matthews (Case 52 of Guthrie, and 20 in the preceding note, referred to also by South in his translation of CHELIUS, Am. ed., Vol. I, p. 520), and adds that others have come to his knowledge; but all of those he specifies are included in the foregoing list except that of a seaman wounded at Algiers, reported by Dewar (De Vulneribus, Edinb., 1818). Habershon (Guy's Hosp. Rep., 1859, Vol. V, p. 17:t>, Matthew (op. cit., Vol. II, p. 330), and Hamilton (op. cit., p. 357), adduce the case of James Beehan (22 of the preceding note). To these may be added the case of Kelly, reported by Dr. NEILL (Med. Examiner, 1851, Vol. X. p. ltil), in which the passage by stool of a small pebble was the first indication that the intestine had been wounded by a pistol shot in the abdomen; and Dr. Mercer (Proceedings of the Nebraska State Med. Soc, 1870, CASE 8, p. 2(>) records an example of the passage, by stool, of a fragment of the right ilium, after a shot perforation of the ascending colon. BEXEDICTUS (in SCHEXCKIUS, I. c., p. 697) gives an instance of an arrow-head that entered the loin being voided at stool after an interval of two years (post biennium, not "deux mois," as Percy quotes). PERCY also cites from FABRICIUS IIildanis (Op. om., Obs. Chir., Cent. V), a case from DIDIER, of the end of a sword being broken off in the belly and discharged by stool. 2 Doxau (Vber die Schussverletzungen des Darmlcanals, Leipzig, 1868) makes tho following comparative estimate of the fatality of shot wounds implicating the abdominal viscera. The most fatal are those interesting the small intestine ; second, those of the stomach; third, those of the large intestine, within the peritoneal sac; fourth, those of the liver; fifth, extraperitoneal wounds of the largo intestine. AVith BAilDELEBEN (Lehrbuch der Chirurgie und Operationslehre, Berlin, 1865), he places the different parts of tho digestive tube, according to their relative liability to injury, in the following order: 1, small intestine; 2, transverse colon ; 3, caecum; 4, ascending colon ; 5, descending colon ; 6, duodenum. !It would involve a tedious recapitulation of instances to set forth all the facts that justify this conclusion; but it is believed that the student who will consult the facts scattered through the foot-notes will have no doubt of its correctness. In wounds of either the ascending or descending colon, the circumstances of the lesion being extraperitoneal or intraperitoneal will mainly determine the measure of danger. In classifying the fifty-nine recoveries from shot wounds of the large intestine (pp. 77-97), cases reg.irding which the statements were conflicting were placed in the first group as injuries of the descending colon. It is probable that Casks 239 and 211 properly belong to the third group, or injuries of the descending colon ; while 10S PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. cannot have failed to observe that no instance has been adduced as a recovery from wounds of the large intestine, unless a division of its walls was demonstrated by the escape of faecal matter, or by the intrusion of a foreign body within its cavity. No other evidence of such lesions is absolutely conclusive, though other associated phenomena may warrant strong presumptions. Contusion or partial division of the tunics of the colon may be indicated by bloody stools, and symptoms of traumatic peritonitis, conjoined with circum- stances that may suggest the limited nature of the injury, and the portion of the bowel implicated. If the diagnosis of wounds of the bowels in general is difficult, it must be admitted that the differential diagnosis between wounds of the large and small intestines is sometimes unattainable. It has been seen (pp. 65, 80) that the rapidity of the escape of ingesta by the wound affords no criterion. The absence of feecal odor is an important negative sign, the normal closure of the ileo-caecal valve confining sulphuretted hydrogen below that point. Chemical and microscopical analysis of the discharge from the wound might indicate its situation;1 but we have no evidence of this nature. The date at which the escape of the intestinal contents was observed, is noted in forty-two of the fifty-nine cases of recovery from wounds of the large intestine, and was within a day or two in thirty-five cases ; after the separation of eschars on the twelfth, fourteenth, thirty-fifth, and fortieth days, in seven other instances ; while in seventeen cases, this point is left undetermined.2 There will be occasion hereafter to consider separately the subjects of visceral protrusions and of extravasations attending injuries of the abdomen. The remainder of this subsection will be devoted to the two principal forms of active surgical interference that wounds of the intestine sometimes involve, the operations for the relief of abnormal anus, and the various methods of enteroraphy. in Cases 247, 251, 259, 260, 263, the testimony as to the part implicated is conflicting. The statistics of amputations, of resections, and of artificial limbs, exemplify how frequently surgeons, who are careful and exact in most of their statements, err in recording the side of the body interested. Photography is a fruitful source of error in this connection. The object may or may not be reversed, and the observer is liable to be deceived, unless lie accurately ascertains whether he has before him a positive or negative picture. ■As wounds of the colon may be complicated by abnormal openings between the large and the small intestines, as well as accidental communi- cations with the other viscera of the abdomen, of the thorax, and of the pelvis, evidence derived from such precise methods of investigation would have only a conditional A-alue. «. 2 These results correspond, as might be anticipated, with those observed elsewhere, as may be found by examining the particulars of the cases enumerated in note 4 on page 106, to which the following instances may be added: Mouat (Med. and Surg. Hist, of New Zealand War, in Army Med Dept. Rep. for 1865, p. 490) mentions the only recovery in fifteen cases of penetrating shot wounds of the abdomen as an instance of wound of the caecum, in an officer, followed by artificial anus, which closed in eighty days, reopened, and closed soundly in one hundred and forty days. HEXXEN ,op cit, Cases LXVI, LXVIJ) gives two examples of artificial anus, following shot wounds of the colon, closing spontaneously after a few months ; Hiixter (op cit., p. 550) details a similar case, and others are recorded, in the second volume of the Memoirs of the French Academy of Surgery, by Rey. Geraud, and Poneyes. Zipff (Uber Unterleibsverletzungen und deren Behandlung, in Deutsche Klinik, 1861, S. 180) records the recovery, in five weeks, of a youth in whom hempen wads, driven through the loin into the ascending colon, were discharged at stool on the ninth day. Another authentic case of the American War has been discovered since the preceding page was printed: Surgeon T. J. Wright, 64th Colored Troops, reported that Private Walker Han-is, Co. H, 47th U. S. C T., was wounded at Yazoo City, March 5, 1864, by a musket ball, which entered tho left lumbar region. On April 10th, after symptoms of circumscribed peritonitis, the ball was passed in defecation. The patient made a good recovery, and was returned to duty May 23, 1864. \ArILLIAMSON (Mil. Surg., p. 109) records three cases of recovery, Avith abnormal anus, from shot wounds of the sigmoid flexture: Hogan, 32d regiment, wounded June 20, 1857, at Lucknow, whose case is related also by Assistant Surgeon F. DeChaumont (Edin. Med. Jour., 1858, Vol. IV, p. 491): McCartney, 10th regiment, wounded May 11, 1858, at Chitawarah, fascal fistula persisting, March 15, 1859; Hender- son, 13th regiment, wounded at Cabul, October, 1840, faecal fistula remaining at his discharge, August 26, 1844. Besides these three cases, Dr. Williamson notices that of n sailor, wounded in rowing toward the enemy, who suffered for years with abnormal anus, with eversion and protrusion and furnished specimen 1270, in the Museum of the Army Medical Department figured in Plate IV of Dr. Williamson's work, and expresses his regret that the particulars of the case are unknown. Is not the case identical with that described in DeWar'S dissertation ? Dr. Williamson also adverts to the case of James Behan, 19th regiment, described by Drs. LONGMORE, MATTHEW, and IlABERSHON, of which Mr. Hilton furnishes the post-mortem particulars, the preparation being preserved in Guy's Hospital Museum, numbered 186710 (Appendix of 1863 to Cat, p. 52). It will be observed that in the five instances last named, the descending colon was the part injured. Of four shot wounds of the colon recorded in the Surgical Report in Circular 3, S. G. O., 1871, two resulted favorably, in one of which (Case CLV) there was faecal fistula, following a wound in the descending colon, on the eighth day, and ceasing, permanently, on the twelfth. In relation to the date at which faecal discharge is observed, Professor BILLROTH (Chirur- gische Briefe aus den Kriegs-Lazarethen in Weissenburg und Mannheim, 1870, S. 204) states the results of his experience in the late Franco-German war, as follows : "I saw faecal fistulae in various parts of the anterior wall of the abdomen, where the small intestines are very movable. No other explanation seems possible than that shot wounds of the intestines do not uniformly discharge faecal matter immediately any more than injuries of the larger blood-A-essels invariably cause immediate haemorrhage. Probably faaeal matter does not always escape immediately. In consequence of tho local traumatic peritonitis, the intestine adheres to the abdominal wall, and not until this adherence is accomplished, and the eschar of the intestinal Avail separates, does faecal matter escape, emptying directly outward, or else from one wound of an intestine into another. If this hypothesis be correct, the faecal escape, in such cases, would ensue some days after the reception of the injury. This occurred in cases 33 and 44, and, in Czerny's case, 29, in which faecal matter escaped froir the eighth to the fourteenth days." SECT. Hi.] WOUNDS OF THE INTESTINES. 109 Abnormal Anus.—In about one-fifth of the instances of wounds of the large intestine that have been related,1 the abnormal communication between the bowel and the exterior of the abdomen remained open, and constituted what is termed an artificial or preternatural anus. In three of the recoveries from wounds supposed to interest the small intestines, there were faecal fistulas, which closed at a comparatively early period. A feature common to all of these cases was the absence, or slight development, of the crescent-shaped septum, commonly formed in cases of to escape externally, instead of passing into the lower portion. This condition, which has been most elaborately discussed,2 necessarily attends preternatural anus, where the upper and lower bowels of the intestine approach the aperture at an acute angle, as must be the case when a knuckle protrudes and the prolapsed portion is destroyed by mortification. But it is not a necessary or a frequent consequence of the destruction of a limited portion of the intestinal wall by injury. This conclusion, directly at variance with the teaching of Scarpa, is the most important practical lesson deduced from the numerous instances of spontaneous recovery from extensive wounds of the large intestine that have been presented. But when a septum does exist, in traumatic cases, it must be destroyed. 1 Abnormal anus has remained pervious in the case cf Harsh (235), illustrated by Plato IV, for ten years, and in four others—Dugan (2~>2), Escher (281), Wikel (288), Graham (231)—for periods extending from eight to nearly eleven years, without serious constitutional decay. AArith the four pensioners who died—cases of Labar (248), of Clohosy (2J8), of Odell (270), and of Haun (272)—with faecal fistula unclosed after intervals of from four to six years, the local lesions appear to have hod only a remote connection with the fatal results. In the fatal cases of M------(301) and of Blackburn (305), the local lesion, complicated by necrosis of the ilium, was a proximate cause of death. 2 Consult LA Peyronie, Observations avec des reflexions sur la cure des hernies avec gangrene, in Mem. de VAcad, de Chir., 1743, T. I, p. 337; Louis, Mem. sur la cure des hernies int. avec gangrene, ibid., 17.77, T HI, p. 145; Saratier, Mem. sur les anus contre-nature, ibid., 1774, T. V, p. 592; Desault, Mem. sur les anus contre-nature, in Oeuvres Chir., 1813, T. II, p. 352; Sc'ARl'A, Sull' Ernie, Memorie Anatomico-chirurgische, Milano, 1809; Lawrence, A Treatise on Ruptures, 5th ed., 1838, p. 379 ; Lallemaxd, Rep. Gin. d'anat., 1823, T. VII; Deltech, Ibid., T. VII, p. 133; Burger, Uber den widernaturlichen After und die zu dessen Heilung vorgeschlagenen und ausgefiihrten Methoden, Stuttgart, 1847; Reybard, Mem. sur le traite- ment des anus artificiels, Paris, 1827; LlOTARl), Sur le traitement de Vanus contre-nature, Diss., Paris, 1819; J.ALADE Lafond, Considerations sur les hernies abdominales, sur les bandages et les anus contre-nature, Paris, 1822; COOPER (A.), The Anatomy and Surgical Treatment of Crural and Umbilical Hernia, Folio, 1804-7, Part I, p. 34, and Part II, p. 59; Jo:iERT, Traite des Maladies Chirurgicales du Canal intestinal, 1829, T. II, p. 125; Lerlanc, Sur I'anus contre-nature, Paris, 1805; PARIS (G. II.), Traitement des anus contre-nature, Paris, 1824 ; Azemar, Considerations gen. sur les anus contre-nature, Montpellier, 1821 ; MILLET, Considerations sur les anus contrc-nat.itre, Paris, 1822; BAUDKLOCQUE, Quibusdam method-is ad ano contra-naturam medendum, Paris, 1827; LAUGIEE, Anus contre-nature, in Diet, de Mid., 1833, T. Ill, p. 312; FOUCHER, De I'anus contre-nature, Paris, 1857; LAUCTER, Anus contre-nature, 18li."), Noun, diction, de, Med. et de Chir. prat., T. II, p. 0S4 ; GUYON, Anus contre-nature, 1867, in Diet, encyclopid. des sci. mid., T. V, p. 503; GUER1N, Traitement curalif de I'anus contre-nature accidente!, 1865. 110 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. Flo. 70.—Dupuytren's enterotome, J size. Though anticipated by Schmalkalden1 and Physick,2 Dupuytren3 has the credit of introducing into practice an effective means of destroying the septum and restoring the continuity of the canal. Instead of division by the gradual tightening of a ligature, as suggested by Schmalkalden, or by the knife, after prelim- inary transfixion and union of the laminaa of the septum, as practised by Physick, Dupuytren4 crushed the projecting spur by the serrated blades of a steel forceps, which he denominated an enterotome.5 This instrument has been successfully employed in more than forty cases. Some objections are offered to it, however, of which the most valid appears to be that the parts nearest the intersection of the blades are divided earlier than the more distant parts. That uniform pressure might be exerted, Giinther states that Dupuytren altered the instrument by making the blades parallel, as in the modification known by the name of Blasius (Fig. 71), which fig. 7i._Biasiu8's intestine pincers, or Darmscheere. Giinther6 regards as satisfactory in all respects. Delpech attached much value to a modification of his invention. Other ingenious means of accomplishing the object have been proposed by Professor Gross (Fig. 72), M. Liotard, Dr. Lotz, M. Reybard (Fig. 73), and Dr. D. Prince.7 As the anatomical conditions vary somewhat, it is convenient to have at command a variety of instrumental appliances. The de- struction of the septum by mortification can be accomplished by either of the clamps repre- sented, or, the mechanism of the lesions and the obstacle to be removed being clearly appreciated, the end may be attained by other than mechanical means. In 1841, Vidal proposed to destroy the septum by caustic, and in JL his fifth edition, in 1861, he stated that his plan had been successfully employed by surgeons in Paris and in Lyons. Many surgeons disCOUnte- FlQ. 73.-ReytarfWe.tine Pince^ nance any 0perati0n, Until a Systematic and perse- 1 Schmalkalden, Nova methodus intestina uniendi, Viteb., 1798. * PHYSICK, cited by DORSEY, Elements of Surgery, 1818, Vol. II, p. 92; by COATES in the North Am. Med. and Surg. Jour., 1826, Vol. II, p. 269; and by H. H. Smith, Princ. and Pract. of Surg., 1863, Vol. II, p. 434. 'DUPUYTREN, Mimoire sur une methode nouvelle pour trailer les anus accidentels, in the Mim. de I'Acad. de Med., 1828, T. I, p. 464, reprinted In the Lecons Orales, 26me 6d., Paris, 1839, T. IV, p. 1, and his elaborate article in the third volume of the Dictionnaire de Medecinc et de Chirurgie Pratique, p. 117. In 1817, REISINGER, of Augsburg, a friend of DUPUYTREN, published a detailed and authentic account of this operation in a work entitled Anzeige einer von dem Herren Professor DUPUYTREN zu Paris erfundencn, und mit dem gliicklichsten Erfolge ausgefuhrten Operations- Weise zur He Hung des anus artificialis; nebst Bemerkungen, an analysis of which appeared in Laxgenbeck's Neue Chirurg. Bibliothck, B. I; and later, Brkshet gave a fufl historical account of the subject in the eighth and ninth numbers of the Quarterly Journal of Foreign Medicine and Surgery, in a paper entitled considirations et observations anatomiques et chirurgicales sur la formation, la disposition, et le traitement des fistules stercorales et des anus contre-nature. 4If the splendid eulogy which LAWREXCE (Treat, on Rupt., 3d ed., p. 413) bestowed on DurUYTREN's operation is exaggerated, it more nearly expresses the judgment of the profession, than the small carping that sneers at the brilliant results announced by Dl'l'UYTREX, in forty-one cases operated on by himself, DELPECII, and LALLEMAND, in remarking that "artificial anus must be more common in Paris than in London." The writers, who, from patriotic bias, detract from DUPUYTREX's credit by citing PHYSICK's operation on John Axillius, in 1809, are confronted with SCHMAL- KALDEX's proposition of 1798, and by the fact that DUPUYTREN was unacquainted with these antecedent essays. 6 This name is sanctioned by usage; otherwise, as it is proposed to destroy the septum by crushing rather than cutting, enterotribe, enteroclast, enterocraser, or gut-clamp, would be more appropriate. 6GUXTHER, Lehre von den blutigen Operationen am Menschlichen Korper, 1860, B. IV, Ab. XV, S. 175. 'DELPECII, 06*. sur I'anus artificiel, in Mem. des Hopitaux du Midi, 1830, p. 76; GROSS, Wounds of Intestines, &c., 1843, p. 212, and System. &c. 1872, Vol. II, p. 700, Fig. 491; Liotard, Diss, sur le traitement des anus contre-nature, Paris, 1819, and in BOURUERY, Med. Op., T. VII, p. 142, and pi. V.i ■. LOTZ, Am. Jour. Med. Sci., 1Q36, Vol. XA'JII. p. 367, and in Smith's Surgery, Vol. II, p. 435; REYBARD, Mlm. sur le traitement des anus artifici.ls, it des plaies des intestines, 1827; VlDAL, Path. Ext., &«° ed., T. IV, p. 262; D. Prince, Am Jour. Med. Sci., 1869, N. S., Vol. LVIII, p, 412, and AsiIUL*K»T'» Surgery, 1871, p. 372. Fio. 72.—Gross's instrument for the operation for the cure of pre- ternatural anus. [After GROSS.] SECT, in.] WOUNDS OF THE INTESTINES. Ill FlO geuy. 74.—Reybard's instrument applied. | (Med. op., T. VII, pi. 43, Fig. 5.) [After Bouu- vering application of Desault's plan of compression has failed, and the writer cordially subscribes to this view, having obtained unexpected success1 by this method. Hey, of Leeds, appears to have had good results from this plan of treatment. Over a properly adjusted com- press, daily renewed, he placed a metallic weight, gradually adding to its bulk. I think insufficient attention has been paid to Desault's plan. When failing in its curative intent, compression is useful as a palliative measure, as the cases of'Cheston, Rcz- zonico, and others testify.2 Removal of the septum by excision, as practised by M. Raye, or by linear cauterization, as advised by M. Laugier, appears to me less safe than the plan recommended by Reybard, indicated in Figure 71. Suture of the margins of the orifice in the abdominal wall was resorted to by Dr. J. H. Hutch- inson, in Case 210, and by Surgeon Adam Hammer, U. S. V., in the following case of abnormal anus following gangrene of an inguinal hernia: Case 309.—Private Or. Krug, Co. B, 13th Missouri Cavalry, was admitted to the New House of Refuge Hospital, at St. Louis, May 14, 18615, the case being entered on the register as a "wound of lower part of abdomen." Treatment: horizontal position, simple dressings to wound, and the administration of cathartic enemata daily. On December 9, 18(i3, he was trans- ferred to the Marine Hospital, where the diagnosis "preternatural anus" was recorded, and the following report of the case was made by the operator, Surgeon A. Hammer, U. S. V., who also had charge of the first-named hospital: "Prior to admission, the patient says he had inguinal hernia, and that, after the integuments were cut through, feculent matter issued; time of receiving hernia unknown. June 14th, actual cautery and wire suture combined for artificial anus. June 30th, same operation. The orifice is about one inch in circumference, feculent matter passing from the orifice freely. In excellent health; horizontal position and simple dressings; doing well." And on the next report: "July 14th, cauterization with nitric acid. July 18th, same operation, and, September 25th, actual cautery. Faeces passing through anus preternaturalis. In good health. Horizontal position, and simple dressing. Good result, and returned to duty July 25,1865." Krug is not a pensioner. It does not appear that he was wounded in action, and the first hospital entry doubtless refers to a wound made in the operation for strangulated inguinal hernia. This plan, suggested in 1739 by Lecat, and practised without advantage by Cruik- shank, Bruns, Liotard, and Blandin, appears to have expedited the cure in Judey's case; and MM. Foucher and Patry have lately cited other facts in its favor.3 Anaplasty, successfully practised by Collier, in 1820, is said to have been performed by Acting Assistant Surgeon Leale in Case 236, and there is mention of some form of plastic procedure in Cases 240 and 276. Of this plan and of that of suture, it may be said that when the anatomical conditions admit of the closure of the abnormal anus they are unnecessary, and otherwise, that they are ineffectual.4 ■I have, in an old case book, the memoranda of three cases of abnormal anus, which I have neglected to publish, that resulted favorably under treatment by Desault's method: 1. A wound of the sigmoid flexure, in an Irish servant of Mr. Buckland, of Springfield, Massachusetts; 2. A fcecal fistula in the right iliac fossa, from perityphlitis, Mrs. C----, of Belchertown ; 3. A mortified right scrotal hernia, in the case of a railway laborer, James Sweeny, aged 42, Ferry street, Springfield, June 26, 1858. »Hey, Practical Observations in Surgery, 3d ed., 1814, p. 224 ; CllESTON, in CoorER on Hernia, loc. cit., Part I, 1804, p. 36; REZZONICO, Storia di un caso di anopreternaturale guarito colla cura pailiatira, in Ann. univ. di med., T. CLXIV, p. 94, 1858; DESAULT, OSuvres Chir., T. II, p. 370; Lawrence, I. c, 5th ed., pp. 390 and 422; RAYE (C. C), Consid. sur la guerison d'un anus anormalpar un nouv. proc. opirat., in Ann. de la Soc. Med. de Gand, 1838. 'CRUIKSHANK, in CoorER on Hernia, I. c, Part I, p. 38; Bliuxs, Handb. der Prack. Cliir.; LIOTARD, 1. c.; BLANDIN, in Mem. de I'Acad. de Mid.de Paris, 1638; Chassaigxac, Traitement chirurgical de I'anus contre-nature par la suture directe; considerations pratique, in Arch. gen. de Mid., 1855, 5" serie, T. V, p. 529. JUDEY'8 case was communicated January 14, 1823, by Eiciieiiand (Arch. gen. de Med., T. I, p. 291); FOUCHER, I. c.; Patry, in Bull, de la Soc. de Chir. 4COLLlER (('.. V.), Case of Artificial Anus, cured by an Operation on the Principle of Tagliacozzi, in London Med. and Phys. Jour., 1820, Vol. 43, p. 466; Laugier, Autoplastic par transformation inodulaire ; nouvelle meth. opir. pour achever la guirison des anus contre-nature, in Compt. rend. de I'Acad. des Sci., 1839, T. XL1X, p. 248; VELl'EAU, Des anus anormals dipourvus d'eperon ; BuYK, Ein Beitray zur Prokloplastik beim Schneiden- after, in iEstr. Ztschr.fur prakt. Heiikunde, 1861, C. VII, S. 209. 112 PENETRATING WOUNDS OV THE ABDOMEN. [CHAP. VI. Enteroraphy.—From the evidence presented in the preceding pages, it may fairly be inferred that in all punctured and incised wounds of the intestinal canal attended with protrusion, the safest practice consists in closing the intestinal wound by suture, and reducing the protruded viscus, unless its structure is irretrievably disorganized and the adoption of the alternative of establishing a preternatural anus is compulsory. It is highly probable that, in the rear instances in which shot lacerations of the intestines are attended by protrusion, a like practice is applicable. In stabs and shot wounds impli- cating the small intestine, unattended by protrusion, the common practice has been to seek to avert extravasation into the peritoneal cavity ny arresting peristaltic action by opium, and by enjoining absolute quiet, and to indulge the hope that adhesions may form through the efforts of nature. Experience teaches that, in the vast majority of instances, such hopes are illusory.1 Nine times in ten, or oftener, extravasation takes place, and hyper- acute peritonitis ensues, and generally proves fatal within forty-eight hours.2 When the patient rallies from the faintness and depression immediately following the wound, there is almost always tension and tenderness of the belly; then, in John Bell's graphic language, come on dreadful pain and vomiting, costiveness, hiccough, the torments of the miserere mei, and the patient in a great anguish expires. Or else, after the intense pain, there may be an interval of deceitful ease, which is merely a sign of gangrene, and the patient sinks into a low muttering delirium and dies. Guthrie justly declares that "the do-nothing system is generally followed by death."3 I have shown that in wounds of the small intestines of any magnitude, the pathological evidence of recoveries achieved by the unaided effort of nature, even through the establishment of a preternatural anus, is limited to a very few instances, of which none are absolutely unequivocal.4 Therefore in wounds of this viscus, unattended by protrusion, when there is danger of extravasation, the external wound should be enlarged, and the wound in the intestine closed by suture.5 1 In 1843, Professor Gltoss published the Experimental and Critical Inquiry into the Nature and Treatment of Wounds of the Intestines, an invaluable monograph, long since out of print, which placed its author with Hevin and Travers and SCAEPA, as a leading authority on the subject of which it treats. His experimental knowledge augmented by the ripened wisdom evolved in thirty years of observation, in the last edition of his System, Volume II, p. 665, Professor GROSS enunciates the practical conclusions at which he has arrived as follows: "From what has been said, it is evident that the great danger in this class of injuries [wounds of the stomach and intestines] is from fecal effusion, so liable to occur even when the wound is comparatively insignificant. The proper treatment, therefore, to be pursued is simply to sew up the wound and to replace the bowel as speedily as possible, watching the case most assiduously afterward, with a view of preventing undue peritoneal inflammation ; for, whenever this attains tbe ascendency, the patient must necessarily perish. It is folly to think of any other practice; the sheerest nonsense to talk about the irritating nature of intestinal sutures. Enteroraphy is, in itself, one of the most innocent of operations, and it is only surprising that it should ever have been regarded in any other light. What possible harm can result from depositing a little thread in the coats of an intestine, and retaining it there for ten or a dozen days ? Some inflammation must, of course, arise; but this is precisely what is needed for the safety of the patient and the cure of the wound. Even if the wound is not more than a line and a half in length, the bowel ought not to be returned without stitching it. Fecal extravasation might occur, and the patient should, therefore, not be subjected to the risk of such a contingency. In several of my experiments death was produced, not by sewing up the bowel, or by the manipulation employed in performing the operation, but by the escape of fecal matter along the large interspaces between the sutures, which thus allowed the wound to gap, and to favor the occurrence in question. Indeed, it may be laid down as an axiom that, whenever the closure of the wound is incomplete, there is danger of intestinal effusion." 2 The experiments offered by so excellent an authority as TllAVEKS (Inquiry, &c., p. 136) to prove that faecal extravasation was not a necessary occurrence of punctured and incised wounds of the intestines, have been wrongfully cited by writers, who would have it appear that fecal effusion into the peritoneal cavity is a rare consequence of intestinal wounds (see Teale's article in the Cyclopaedia of Practical Surgery, Vol. II, p. 196). Mr. F.iiiunsEN, whose treatise is issued to medical officers, goes so far as to affirm that (Practice and Art of Surg., 1869, Vol. I, p. 448) "it is seldom, indeed, that faeces are extravasated from gut that is not protruding, unless it be very full at the time of injury, or the wound in it be very extensive," and cites two cases of shot wounds of the intestines within his own observation, in which no extravasation took place. The subject is one of such importance that it will be fully considered hereafter, and I will only remark here that, in my opinion, Mr. Erichsen's statement conveys a dangerous fallacy. 3 M. LEGOUEST says (Traitide Chir. d'Armee, 2-'">e €d., p. 384): "Lorsque I'intestin bless6 est rcste dans la cavit6 abdominale, la plupart des chirurgiens modernes recommandent d'abandonncr la gu6rison a la natur; il s'en tiennent a ce que l'on appelle les moyens gen6raux, leur faisant les honneurs du succcs si le blesse guerit, et, s'il succombe, considerant la blessure comme au-dessus des ressources de l'art. Quelques observations heureuses excusent cette maniere de voir sans la justifier; un grand numbre de cas funestes la condamnent." 4 There are pathological preparations of the small intestine showing small white cicatrices resulting from punctures, as in accidental wounds in paracentesis for aseites or ovarian disease; there are not a few preparations of abnormal anus of the small intestine resulting from the mortification of the protruded bowel in hernia; and there are many clinical histories of cases of abnormal anus resulting from wounds supposed to implicate the small intestine; but post-mortem verification of the precise seat of the lesion in these eases is wanting. The preparation figured on page 74 demonstrates a recovery from shot iLJnry of the small intestines, but it is plausibly argued that there was no complete division of the gut in this case. 8 Though but few authorities have committed themselves to this view in print, I am fortified iu my conviction of its correctness by the concurrence of such surgeons as Drs. II. S. Hewtt, N. S. Lincoln, II. McGuike, aud my colleague, Dr. J. S. Billings. * ■1 « Med and Surj> His ai'tlit- Wai of tlie Re'beDior Parti Vol I. Opposite page H3. ^ard phot. PLATE III. SHOT WOUND OF THE ILEUM CLOSED BY THE CONTINUED SUTURE No. 4389. SURGICAL SECTION I ■ > '• '-M 'I . i Ifiti", 0 -■^rveWibri J»-' '»riti«i, »».. . il i.t' .: ..■ w-> ■ I: l -jtf .' *»J l*' ftV ,. •■■".*'. :-v»k'%r:1. '*■■ ♦ f'c-'".i *• ,~* ..■'••-, ->iv v: ' •'■;■ ..' j-v^* > -.. *1'' A- -i'■ '.';'• V'' '■■*'.■:: ■.'-'....' ■•v. . A :'>>'i'.-.;''t ■•>. '•? ^•y'V' TV«i-'■•■:••: V ■*: :.,*;' E?'*r.'-. ••■"'"V* ..•j,y- ■••i-^.v /••v'.'fV: ■;"V:t" VvV,1 ■'•:"'■ f"::-i?-C-.:' .':"v; '. •£ *5N ■:*■■; -^ r v'*-*> «"* " *' "i -{,.'••'*. .-At, ■i .: < •." "tV i-?v ■■'■». ;r¥ ' •'-,.->.'• . ■■ '■"# 1?- * & '■■■ '•''•'•*' , -"'■;' *i--®£i ■■'".' IV' ''■>''^Kf ;;';..■*;■' '; /.^.''' . * ' •>'■ »&;>> .:- • .*'■ ■':■ * -. ■*t '.-i"yf' i.-. B : THE CONTINUED SUTURE. !■ • SURGIi:.-^ iEC'r SF.UT.iii.j WOUNDS OF THE INTESTINES. 113 Wounds of tho large intestines often do well without interference, and, in these wounds, enteroraphy will seldom be requisite, unless the wounded colon protrudes. Yet there are exceptional cases, in which extending the external wound and sewing up the rent in the gut is the best and only means of preventing extravasation, as is well exemplified by the successful case of enteroraphy, for shot laceration of the colon, recorded by Baudens. Examples of gastroraphy and of enteroraphy have been adduced on pages 44, 62, 72, and 76. Sutures were applied in (Jakes 206 and 234 to incised wounds of the jejunum and colon; in Cakes 228 and 229 to shot wounds of the ileum, with protrusion. One of the pathological preparations is shown in Plate III, opposite. In addition to the four cases just enumerated, the two following may be regarded as belonging to the War series: Case 310.—Surgeon P. II. Flood, 107th New York, reports that Private M. B. Ingram, Co. I, 13th New Jersey, aged 21 veal's, received a shot wound of the abdomen, on the march through North Carolina, on April 9, 1385, and was treated at the field hospital of the 1st division, Twentieth Corps, on the following day. The ball had lacerated the small intestine. Surgeon II. Z. Gill removed two inches of the lacerated gut, and the opposing ends were then brought together and retained in apposition by sutures. The patient died on April 11, 1865. There is no record of a necropsy. Case 311.—Tho following facts are compiled from a valuable paper by Professor R. A. Kinloch, of the Medical College of South Carolina, in the American Journal of the Medical Sciences, for July, 1867: Lieutenant T. G. D------was wounded, October 22, 186J. near Pocotaligo, by a musket ball, which entered below the anterior superior process of the right ilium, and, passing obliquely upward, emerged three inches to the left of the median line, below the level of the umbilicus. Symptoms of shock were followed by those of traumatic peritonitis. There was vomiting, constipation, excitement, tender abdomen, and a disposition to collapse. On November 2d, the more violent of these symptoms subsided, with discharges of pus and of fasces through the orifice of entrance. About November 25th, a dejection by the rectum was induced by an enema. On February 13, 1863. Dr. Kinloch saw the patient with the regular attendant, Dr. Dupont. There were several faecal fistula? connected with the orifices of entrance and of exit; the patient was feeble and'much emaciated. Several sinuses were laid open, and the index finger was passed into the entrance opening into the gut, which lay very deep. In April, 1853, there was an attack of abdominal pain, with febrile excitement, and jaundice. On May 11th, the patient was placed in the Summerville Hospital. On May 27th, exploratory incisions were made, and it was ascertained that the fistulae communicated with the upper portion of the bowel; the lower portion could not be found. On June 8th, Dr. Kinloch, in consultation with Surgeon E. E. Jenkins, decided to lay open the peritoneal cavity, with a view of restoring the continuity of the intestinal canal. An incision three and a half inches long was made through the linea alba downward, starting from just below the umbilicus. The lower extremity of this incision was then connected with the external orifice of the abnormal anus, and, numerous adhesions being broken up, a triangular flap was raised. A barrel of intestine was found nearly divided, or so deeply notched as to intercept the continuity of the canal, the upper end adhering to the contour of the abnormal anus, the lower reflected and adherent to the contiguous viscera. The upper end was of increased calibre, the lower contracted, with thickened tunics. Dr. Kinloch excised half an inch of the upper portion of the bowel and two inches of the lower, refraining, as far as possible, from incising the mesentery. One small vessel was Iigated. An attempt at invagination of the upper portion within the lower, by Jobert's method, was precluded by the contracted condition of the lower portion of the gut, and Dr. Kinloch was compelled to resort to apposition'of the divided extremities, which were united by a number of interrupted silver-wire stitches. Then, by three additional wires, as many points of Lembert's suture were introduced, and the serous surfaces were thus, to some extent, approximated. During the operation, the important precautions of protecting the viscera by towels wrung out of tepid water, and absorbing blood and extravasated matter by soft sponges, were minutely observed. After the operation, which was necessarily protracted, the parietal wound was closed by sutures, and supported by compresses and bandages. The patient, taking morphia and brandy, rallied in the course of an hour from the great depression following the operation. Reaction was slight. On the third day, some of the intestinal sutures gave way, and there was a faecal discharge. On July 4th, there was some abdominal uneasiness, and an enema brought away a copious stool. Thenceforward there were regular alvine evacuations, though the faecal fistula persisted. On July 10th, the patient travelled eighty miles by rail, and, on August 12th, he was able to be about on crutches, daily improving in nutrition. On January 14, 1864, an exploration showed that there was a septum or spur at the orifice of the fistula. On March 28th, Dupuytren's enterotome was applied, and the septum was divided at the end of the fourth day. Subsequently the discharge lessened greatly; yet a small fistula with indurated margins persisted. Repeated cauterization, in April, May, and June, and tho twisted suture, failed to close the fistula. But convalescence was fully established, and vigorous general health was fully restored. The reader must be referred to Dr. Kinloch's important paper for fuller details. His concluding remarks are as follows: "I feel confident that surgery is capable of completing the cure of this interesting case. I have been induced to offer the notes for publication with no view of claiming the degree of success aimed at by the several operative procedures instituted, but because the history appeared to me to possess the following points of interest: 1. It adds another instance of recovery after severe gunshot wound of the small intestine. 2. It is an argument against the almost universal practice of abandoning intestinal lesions to nature, rather than risk opening the peritoneal cavity. 3. It is a record of successful conversion of an artificial anus, with its attendant symptoms of failing nutrition, into a faecal fistula, compatible with good nutrition, and a high degree of health and activity. 4. It is illustrative of the readiness with which the function of a large extent of intestine can be resumed after a suspension of over seven months (from October 22, 1362—the day of the reception of the wound—to June 8, 1863, the date of the operation for restoring the continuity of the intestine). 5. It must serve to encourage that hopefulness and boldness so essential to progressive surgery, and at all times preferable to despair." 15 Ill PENETRATING WOUNDS OF T*HE ABDOMEN. [chap. vi. Palfyns Method.—Svstematic writers thus designate the plan of stitching the wounded intestine to the wall of the abdomen, after an eminent surgeon, who lectured in Flanders1 in the early part of the eighteenth century, and taught that it was useless to sew up the bowel, since the divided parts would not reunite and recovery could only be effected by the formation of adhesions to adjacent parts. Hence he recommended that a single loop of thread be inserted through the lips of the intestinal wound at its centre, and to bring the ends out at the external opening, securing them to the integument by an adhesive strip. This simple expedient has had numerous able advocates, among whom the late John Bell2 appears to great advantage as a special pleader, and unfavorably as a teacher of sound surgical doctrine. Scarpa, Richter, Zang, Richerand, Lawrence, Larrey, and Hennen,3 while condemning the employment of intestinal sutures, did not travesty the teachings of those who entertained different views. The plan of Palfyn can hardly be regarded as a method of enteroraphy; but must always hold its place as a valuable resource in some cases of complete divisions of the intestine or of other lesions, in which the establishment of an abnormal anus is accepted as tbe sole available remedial measure. Thomas Smith, of St. Croix, whose inaugural dissertation4 has not, it appears to me, received that attention its originality merited, found a great liability to intraperitoneal fsecal extravasation in practising this plan on dogs. 1 l'Al.l'VN (.].). His work, Van der vornaemeste Huitdwcrkeii de Hcelkonst, Leyden, 1710, was enlarged and republished in German in 1718, and in French, under the title Anatomic du corps humain, avec des remarques utiles aux chirurgiens, Paris, 1827. It was also translated into Italian. PALFYN was born at Ghent in 1650, lectured and practised there, and died 1730. 2 John Bull (Discourses on the Nature and Cure of Wounds, Part II, p. 120) concludes his denunciation of the treatment of intestinal wounds by suture by a professedly impartial comparison of the method of invagination, recommended by 1$. BULL, and his own plan, which is identical with that of Palkyn, to whose writings he does not allude. The drawings copied below (Pius. 75and76) were by his own hand. "There remains," he says, "only one thing for me to do, viz., to make sure of my readers having a fair and entire notion of these two doctrines, by putting them down opposite to each other in the form of plans: Fig. I explains the double suture; Pig. II explains the simple stitch; (a) points out the space which must mortify, according to the DOUBLE SRAM METHOD; (6) shows the single stitch by which we hold the two pieces of gut tight with regard to each other, and both close up to the wound; (c) the dotted line, marks the direction in which the gut (<) lies within the gut (/); (g) shows the mesentery; (h) the way in which it keeps the two ends of the divided in- testine right; and it cannot be difficult to conceive how the stitch (6) will comfr easily away with little harm to the intestine, and not till after it has done its business effectually in uniting the inward to the outward wound; so that though the breach which the stitch left were large, still the fasces would be discharged easily, and it would heal gradually along with the outward wound." This unfair state- ment is treated by Professor GKOSS (Wounds of the Intestines, op. cit., p. 106) without undue severity: "If there ever was an error committed by any writer more serious, culpable, and mischievous than another, it is most assuredly this of Mr. John Bell, who, while criticizing and condemning, in no measured terms, the advice and practice of others, has himself fallen into a most strange delusion. Had he performed the operation iu a single instance upon the human subject, or upon an infer'u r animal—an experiment from which he affects so much to shrink—he would have become fully sensible of its danger and insufficiency. That the operation, as recommended by this eminent surgeon,, might occasionally be attended with success is not improbable, but that it should not be trusted to in the present enlightened state of the healing art must be obvious to all who will be at the trouble to investigate it. Independently of the great risk of fa-cal effusion into the peritoneal cavity, there are few cases, if any, in which it would not be followed by an artificial anus, an occurrence which need never attend entertraphy when performed in the manner previously pointed out." 3 Scarpa, Sull 'Ernie; memorie anatomico-chirurgiche, Ed. II, Pavia, 1819, Mem. IV, § XXV, p. 131; ltlCHTEIt, A. G., Anfangsgrunde der Wundarztneylunst, AVien, 1798, B. V, S. 40; ZANG, Darstellung blutiger heilkunstlicher Opcrat., B, III, S. 490; Kicheuand, Nosographie chir., 1821. T. Ill, p. :»9; La whence. Treatise on Ruptures, London, 1810, p. 280; Laurey, D. J., Recueil de Mem.de Chir., 1821, p. 247; HENNEN, op. cit., p. 420. 4 Smith (T.), .hi Essay on Wounds of the Intestines, Philadelphia, 1805, p. 28: "April 28. Wishing to give Mr. JOHN Bell's method of stitching an intestine a fair trial, I made the following experiments [X and XI]: Having obtained two full-grown dogs, a transverse incision was made into the intestines of each < f them, which was secured by one stitch and fastened to the wound. No. 10 died in about twenty-four hours. The marks of inflammation were very great, and the faeces had been discharged into the abdomen. No. 11 died on the 2d of May. The intestines appeared very much inflamed ; faeces, as in the other instances, were found iu the abdomen, also water which the animal had drunk. The large intestines appeared gangrenous and tore very easily. Experiments VIII and XII were also unfavorable to this method." [I am indebted, for an opportunity of consulting Dr. Smith's rare dissertation, to Dr. George C.. Harlan.—Editor.] Fig. 75.—Intestinal suture according to John Bell. Fl«. 76.—Treatment of wounded intestines accord- ing to John Bell. SECT, in.] WOUNDS OF THE INTESTINES. 115 Lapeyronie's method1 differed from that of Palfyn in this only, that, in stitching the bowel to the margin of the external wound, he inserted the thread through the mesenteric attachment, and thus more closely approximated the upper end of the bowel to the external wound. An instance, in which Larrey successfully employed this method in a shot wound of the small intestine, is recorded on page 73. Reybards Method.—A modern plan, that has attracted much attention in academies, was proposed, in 1827, by M. Reybard.2 The end chiefly held in view is essentially the same as in the method of Pally n, the maintenance of the wounded bowel in strict relation with the abdominal wall; but the inventor sought, in addition, a temporary occlusion of the wound in the gut by means of a disk of ivory or pine,- introduced within its cavity. The disk is traversed by a fine thread, each end of which is armed with a needle. The disk being inserted in the gut is fastened by passing the needles through the lips of the wound from within outward, a quarter of an inch from its margin. The fine needles are then removed, the two ends of the thread are twisted together, and passed, by means of a single curved needle, through the abdom- inal wall near the edge of the external wound, and are then untwisted and tied over a roller or compress. In two days the ligature is to be cut, and it is anticipated that the disk will be expelled by stool. Velpeau and Vidal say that this plan, however successfully it may have proved in experiments on the lower animals, has not been applied on the living human subject. LeDrans Method.—If it is doubtful, as suggested by Professor Gross,3 whether LeDran ever applied his looped suture to intestinal wounds in the human subject, it is unques- tionable that it has been successfully employed by others, among whom Bohn, Schlichting, Laroche, and Percy may be specified.4 Sabatier raised many objections to the sutura ansata, and advocated the substitution of the stitch introduced by Bartrandi, and extolled by Garengeot, and practised, with modifications, by Chopart and Desault and Beclard. Fig. 78.—Longitudinal wouud of the ileum united by the looped suture. The edges a are invert- ed; the four ligatures b bbb are twisted separately, and at c are twisted together to form a cord. that is secured oxtemallv. [Af- ter Velpeau,Noue. Et.'de Med. Op., p. 14.] 1 Laypeyronie, Observations avec des rijlexions sur la cure des hernies avec gangrene, in Mem. de I'Acad. de Chir., 1743, T. I, p. 337. Iu the case of the Marpach soldier, treated by David and JOHN SCHENCKELIUS, and described by CETHErN in Schenckics (06s. med. rar., 1644 p. 332), and also by Stai.part Vandek Wiel (Obs. rar., 1C87, Cent. I, Obs. XXXIX, p. 157), the stitches through the stomach were attached to the abdominal wall; and Stalpart relates that he was told by Paulus Godei-'KIDUS, a Belgian surgeon, of a man stabbed in the lower part of the stomach, through which food escaped, which wound was sewed up after the manner of sewing the intestines, and the thread was passed through the muscles of the belly (ibid., Cent. I, p. 150). Dr. Lopez (North Am. Med. Chir. Ren., 1858, Vol. II, p. 1070) succeeded by this method, after the intervention of an abnormal anus, which gradually closed. 2 Rhyuabd. Mimoires sur le traitement des anus contre nature, des plaies des intestines et des plaies pinitrantes de la poitrine, Paris. 1827. 3(xltOSri ( Wounds of the Intestines, die, p. 99). LeDkaN (Traiti des Operations de Chirurgie, Paris, 1742, p. 80) describes his method as follows: "Pour faire la suture en anse, jefais soutenir par un aide chirurgieu, I'intestin a l'une des extremites de la playe, et jesoutiens moi-meme I'autre extremity. J'ai autant d'aiguilles que je dois faire de points, aiguilles rondes, droites et menues, chacune eniilee d'un fil long d'un pied, et non cire. Je passe a travers de deux levres autaut de fil qu'il est n6cessaire, observant qu'ils soient a trois lignes ou environ de distance l'un de I'autre. Tons les fils fitant passes, j'dte les aiguilles, je noue ensemble tons les bouts des fils d'un des cot6s; je noue de meme ensemble les bouts de I'autre cot6, puis les unissant tons, je fais, en les tortillant deux ou trois tours seulemcnt une espfece de corde. En les tortillant ainsi, je fais froncer la portion d'intesin divisee, alors les points qui 6toiont distans de deux ou trois lignes sont approches l'un de I'autre. C'est ce froncis qui ne permettant pas aux 16vres de s'Gcarter l'une de I'autre, doit occasioner l'adherence de l'une a I'autre, sans que I'intestin soit oblige de se coller a. quelque autre partie." 4Schliciitixg (op. cit., p. 79) says: "Gelyk Bohnius en meer andere door ondorwindinge genoegzaam dit bekragtigen, en ik zelfs veeltyds waargennmmen hebbe." Bebabd (Plaies de I'intestin, in Diet, de Med., T. XVII, p. 04) condemns this suture, after speaking in its favor in the article Plaies de l'estomac, in the twelfth volume of the same work. Bertrandi's suture. 116 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. Method of the Four Masters and of Duverger.—The four famous monks who practised surgery together at Paris, in the middle of the thirteenth century, and many of their contemporaries, attempted to unite wounds of the intestines by direct apposition of the divided surfaces, supporting the intestine by a firm cylinder introduced within its cavity; and great attention appears to have been paid to this subject of enteroraphy by the teachers at the school of Salerno, in accordance, doubtless, with the traditions derived from the Arabians. The Four Masters used to support the bowel by a section of the trachea of an animal; others employed a dried intestine, a canula made of elder-wood, a tallow candle (Scarpa), a gelatine tube (Watson), or a varnished card (Sabatier, Chopart).1 This plan, also designated as the method of direct reunion or apposition, was revived by Duverger, and an account of his successful operation, about 1745, is given in the celebrated dissertation of Louis in the third volume of the Memoirs of the ^ 'Weber (Diss, de curandi intestinorum vulneribus, Berolini, 1830). misquoting, misnames the four masters ("Quatuor magistri, ut Petkls DE ANGELATA nobis reliquit, atque LORIS commemoravit, nominatur JAMERIU3, ROGER, TlIEODOISICUS A CERVIA, qui cannulam sambuci nigras adhibe- bant, atque Guilielmus de Saliceto, qui parte utebatur intestini"), and misleads DlEFFENBACH and Emmkrt. PETltus DE Argelata (I cite the editio princeps of MORETUS, Venetiis, 1480, folio 23, de vulnere gossorum intestinorum) does not so name the four masters; but, after adverting to the practice ofjAMERIUS, ROGER OF PARMA, TllEODORIC OF Cervia, he continues: "Others, as GUY OF Salicet, insert a piece of intestine," and then: "Alii ut QUATOR MAGISTRI ponunt tracheam arteriam alicujus animalis, deinde suunt vulnus, et natura postea expellit illas eanulas." LOLIS, the learned secretary of the old French Academy of Surgery, carefully investigated this subject, believing that it would be not only curious but instructive to find the original description of this method of supporting the divided intestine by a cylinder of some description. But LOUIS (Mem. de I'Acad. de Chir., 1757, T. Ill, p. 193) ooncluded that the original description, with the book and the names of the four masters, was lost irretrievably, unless some better preserved copy of their work than a worm-eaten, illegible fragment, exhibited in 1750, in the library cf the College of Navarre, should be discovered. JOUBERT, Chancellor of the University of Montpellier, in his translation of GUY de Chauliac, in 1578, speaks of a copy of the work of the FOUR Masters, given to him by PHILIP Guillien, a learned physician of Avignon. Louis satisfied himself that this work was tho first fruits of the nascent Society of Surgeons of Paris, and that "the Four Masters lived toward the end of the thirteenth century, and were known only under this name. Devoted to the practice of surgery among the poor, charity brought them together in the same abode, and they composed in common the work, the loss of which is justly deplored, since it deprives us of much of the information we might derive from the insight and experience of these skilful masters." It is not known that Jamerius wrote anything; but the Chirurgia of ROGER OF Pauma, who was chancellor at Montpellier and professor at Salerno, was printed in 111)3, and some of his manuscripts are in the Bodleian Library, and in that of Caius College. Theodoricus was a bishop at Cervia, and his Chirurgia, in four books, was printed in 1498; but he must have flourished more than two centuries earlier, since his work is much quoted by BrunuS. who lived at Patavium in 1252, and whose Chirurgia magna was printed in the Venetian Collection of 1499. William OF Kalicet, a professor at Verona, died about 1277. His Chirurgia, in five books, was printed at Venice in 1470, and, in French, at Lyons in 1492, and at Paris in 1506. JHEROME OF Bruynswyke (The noble experyence of the vertuous handy warke of surgeri, London, 1525, Cap. L) says: "Whan tho guttes is woundyd ouertwhart, or is in pecis, than it is dedly; yf it be lengthe woundyd, it may be holpen. If that the wounde of the belly is not grete inowgh, than shall ye make it greater as I shall shewe you hereafter, than shall you take out proply the guttes, and sow it thereafter as it is nedeful with a skynners nedyll. Jamericus, Theodoricus, Rogerius lay elder pypes in the guttes, under the seme, that the same rotto not. AVilhelmus and some other lay therein a part of a cryer of a throte goll of a beest, as the IV masters sayth. But Lanfrancus and Guido they thinke it not be profytable, for that nature is inclyned to outdrawynge straunge thyngys, and thus yt helpe not therefore it was layd, and it is better that the guttes be sowyd, as afore is sayd, and that it be clensyd of the unclenes." • 2 DENANS, Recueil de la Soc. de Med. de Marseille, 1826; Bulletin de VAcademic de Medecine de Paris. 1738, T. II, p. 719; PHILUl'S, in London Lancet, 13:54-35, Vol. I. p. 292; GROSS, Wounds of Intest., die, p. 146; VlDAL (I. c, T. IV, p. 139); NELATON, item, de Path. Chirurg., 1857, T. IV, p. 141. MM. BOURGERY and CLAUDE BERNARD (Traite complet de Vanat. de Vhomme, comprenant Vanat. chir. et la mid. op., Folio, Paris, 1866-C7, T. VII. p. 110) say of this method: "Nous le repetons, a noire sens on n'a rien imaging d'aussi ingenieux pour la r6union des plaies de I'intestin en travers. et il nous semble meme que les autres chirurgiens qui ont d6crit ce proc6d§, n'en font pas toute l'estime qu'il m6rite. A l'expgrience, entre les mains de son auteur, il a eu sur deaux chiens tout le success desirable ; et depuis, M. P. Guersent en a confirm^ les bons r6sultats en montrat, a la suit d'une operation sur le vivant, les deux bouts d'un intestin parfaitment cicatrises, sans aucun r6tr6cissement dans le lien de la reunion. S'il est un I6ger reproche, que nous adresserions a ce proc6de, ce serait concernant la matidre des viroles que l'auteur a employees metalliques, en argent ou en 6tain. Dans la prevision de la difficult6 que purraient rencontrer a cheminer dans toute la longueur de I'intestin, les trois viroles rfcunies, et les obstacles qui suivraient leur arre dans un point, nous pensons qu'il conviendrait mieux de les fabriquer avec une substance assez solide pour rester en place tout le SECT. III.] WOUNDS OF THE INTESTINES. 117 Fio. 80.—Mode of fastening the ferrules by a thread in the method of Denans. FlG. 83.—Diagram of asection of a divided intestine with the ferrules in place, and the serous surfaces inverted in apposition, and the apparatus secured by a stitch, according to the method of Denans. The ferrules are secured within the intestine by a stitch, which is very ingenious, but very complicated. A thread, armed with a needle at either end, is inserted at the margin of the ferrules and passed within the broadest, or most concentric, ferrule, and out at the farther margin. Figure 82 shows the entrance and exit of the first needle. The thread it carries will include the three ferrules, and, if tightened, would strangulate the in- cluded segment of the intestine. Therefore, the first needle is rein- serted through the puncture of exit, and insinuated between the mucous lining of the intestine and the outer ferrule of that yide, and brought out at the groove where the inverted serous surfaces are expected to unite. Then the second needle is introduced at the first entrance puncture of the first needle, and brought out at the groove already indicated. Thus, as is illustrated in the diagram (Fig. 83), the ligature, knotted at the point D, is entirely within the intestine, and fastens the ferrules together. The eccentric ferrules are separated from each other by the inverted tunics of the bowel that are expected to cohere by their serous surfaces; between the outer and inner ferrules lie the inverted ends of bowel, subjected to such compression as is relied upon to result in mortification. The ferrules, thus liberated, will be expelled by stool. In his first experiment, Denans states, the ferrules were discharged from the bowels in seventeen days. Method of Ramdohr.—Ramdohr, surgeon to the Duke of Brunswick, in the early part of the last century, is said to have been the first to have successfully united a complete division of the intestine, in the human subject, by the suture. But it is scarcely credible that so many of the surgeons of the thirteenth century should have practised this operation, and have devised such a variety of plans to facilitate it, unless their labors were sometimes rewarded by success. Ramdohr did not publish an account of his case, but it was related by Moebius, in a scholastic disputation1 defended at Helmstadt, December 19, 1730, before Heister, and was again described, in 1739, by Heister himself,2 who, upon the death of the patient from pleurisy, a year after recovery from the operation, had come into possession of the pathological preparation, demonstrating the perfect union of the divided intestine. Richerand, Berard, and Boyer essayed this method unsuccessfully; Astley Cooper declared the operation impracticable on living animals. Nevertheless, Lavielle, Chemery-Hale', and Schmid are said each to have succeeded on the human subject. Dr. Zina Pitcher succeeded once, though he invaginated the lower end of the intestine within the upper, and a success is claimed for Dr. Gaston. temps convenable pour causer les adh6rences p6ritoneales et l'6tranglement des bouts de I'intestin, et d'un autre cot6, assez alterable et hygrom§trique pour se dgformer et m6me se convertir en une pate que lintestin expulserait en toute facilitg. Des viroles en gelatine, affermies an besoin en les trempant dans les huiles siccatives, nous paraltraient reunir toutes les conditions d6sirables." In 1838 (Bull, de I'Acad., T. II, p. 719), M. Denans proposed to dispense with the suture and to fasten the ferrules together by a spring. Vulcanized rubber rings with automatic catches have also been proposed. 1 Moebius, in Haller's Disp. anat., Gottingae, 1751, Vol. VI, p. 745. His account is inferior to that by Heister. 2HEISTER (Institutiones Chirurgicse, Amstelodami, 1739) gives the following interesting description of the RAMDOHR method: " Haud prorsus absimile hisce experimentis illud videtur, quod Serenissimi Ducis Brunsvicensis Nostri chirurgus aulicus, Ramdohrius, paucos ante annos feliciter ITS PENETRATING "WOUNDS OF THE ABDOMEN. [CHAP. VI. FIG. 84.—The mesentery dis- sected, and threads placed pre- paratory to invagination, by Jo- bert's method. FlG. 85.—The upper extremity of the bowel invaginated within the inverted lips of the lower (Jobert). Jobert's Method.—In 1822, Jobert proposed a new mode of treating wounds of the intestines involving their entire circumference, and, in 1829, his elaborate treatise on the surgical affections of the alimentary canal appeared.1 The surgeon, having determined which is the upper end of the gut, dissects away the mesentery a third of an inch from each end, and arrests the bleeding that may ensue. Then, holding the upper extremity by the left hand, with the right he inserts a stitch through it two-thirds of an inch from the divided margin (Fig. 84), and confides the loop to an aid. A second stitch is introduced in like manner at the opposite or mesenteric side of the bowel. Then, with the fingers, or with flat forceps, the lips of the lower portion of the gut are inverted—a difficult procedure. When it is accomplished, the left index is introduced into the lower portion of the bowel, and, with the thumb, maintains the inverted hem, and also serves as a guide for the introduction of the inner end of the first loop inserted in the upper portion of the bowel. The inner end of the second loop is inserted in like manner. Then, by gentle tractions upon the two loops, it is sought to invaginate the upper portion within the lower. This being accomplished, the loops may be tightened and knotted, or twisted, or the hem may be traversed by the outer ends of the two loops (Fig. 86), and the stitch then thr^nlcs^nd^Zref ^ent^hy tightened and secured by torsion or by knot. The ends of the for complete division of the intestine -i • , -i -i , , ■ , i n l c n , i 1 (jobert). ligatures are brought out at the lower angle ot the external wound, and the threads are withdrawn on the fourth or fifth clay by gentle traction. admodum in Guelphertrytana femina quadam instituit, dum scilicet, post hemiam incarceratam sponte ruptani, propendente et excisa magna intestinorum parte corrupta, binas .partes extremas, easdemque sanas, superiori in inferiorem insinuata, leniter per injectum filum conjunxit, in abdomen reposuit, Clique circumducti ope ad vulnus abdominis attraxit, atque ita non modo effecit, ut cum vulnere confervesceret, et at glutinationem, quod mirum yideri poterat, intestinnm divisum pervenired, sed feminam quoque velut ex ipsis mortis faucibus retraheret, foeclbus postea non per vulnus, sed per anum egredientibus. Mulier ilia postea sana vixit, at post annum ex pleuritide obiit atque in inciso cadavere intestina divisa inter se rursus coalita dcprehensa sunt; qua? ipse mihi una cum parte abdominis, cum qua coaluerunt, dono dedit, eaque adhuc in spiritu vini asservo, ut dnbitantibus aut discentibus ea semper ostendere possim." 1 Jobert (de Lambali.e) published the first account of his method in the Archives generates, Janvier, 1824, T. IV, p. 71 (Recherches sur Vopiration de Vinvagination des intestins). In his treatise (Des mal. chirurg. du canal intestinal, T. I, p. 86) he prefixes to the description of the operation the following statement of his view of the principles involved: " Si Invagination n'est pas suivie de succ§s, cela est done dil aux nombreux points de suture qui d6terminent l'inflammation, et au dtsfaut d'identito de nature des membranes mises en contact, dont l'une a pour produit une s£cr6tion folliculaire, ct I'autre une exhalation plastique. Ce que j'avance est d'ailleurs prouvi d'une manigre incontestable par les experiences de MM. Richerand, Thompson d'Edimbourg, Smith de Philadelphie, Beclard, J. Cloquet, Emery. Le premier a mis les sercuses en rapport avec les muqueuses, et n'a jamais obtenu de reunion. Les autres ont 6trangl6 I'intestin par une ligature, et ont vu une lymphe plastique, exhal6e a la surface de la ligature, reunir les'deux bouts a mesure qu'ils se divisaient, la ligature tomber dans l'intfjrieur de I'intestin, ct la cicatrisation s'obtenir ainsi par l'adossement des deux sereuses. J'ai rep6t6 ces experiences ct j'ai obtenu les memes effets. J'ai mis aussi une s6reuse en contact avec une mnqneuse ct, pour tout r^sultat, j'ai eu un anus contre nature. 11 est done vrai que les muqueuses n'adherent point avec les sereuses, qui seules, comme le tissu cellulaire, de la nature duquel elles paraissent 6tre, ferment les cicatrices de ces organes; et e'est 0. tort, sans doute, que l'on a ni6 cette v6rit6 si importante, surtout lorsqu'il s'agit d'un proc6de op6ratoire." JOBERT publishes (op. cit, T. I, p. 80) an account of CLOQUET's successful operation in the case of N. Lejeune, as an instance of success bythis method. It is regarded by Lawrence (I. e., p. 306), VELPEAU (Med. op., T. IV, p. 143), and Professor Gross ( Wounds of Int., p. 122), rather «s an example of LEMBERT'S method. FLEURY (Mem. sur la suture intestinale, in Arch. gen. de Med., 2e s€ric, 1837, T. XIII) records three cases of operations by Jobert's plan. The third was successful. In the London Lancet of April 8,1848, an account is given of an autopsy in a woman, aged 74 years, who had survived, for twelve years, an operation for strangulated crural hernia, by JOBERT, in which the intestine was wounded and united by suture: " A white line was discovered running obliquely from the convex to the concave border of the intestine, and ending in a sort of a star, and was easily perceived upon the red ground of the intestine; it presented the usual aspect of a nodulated cicatrix. The coats of the intestine, along the cicatrix, were found neither thinned nor thickened, and, after a careful washing with warm water, the same whitish line was perceived to run on the internal surface as had been noticed on the external. Two valvulae conniventes were observed to have been cut, leaving no doubt that the line was the cicatrix of the intestinal suture applied twelve years before." This account is translated from the bulletin of the proceedings of the Academy of Medicine of Paris, of March 10, 1848 (Arch, gen de Med., 4e sferie, T. XVI, p. 523). The original account of the operation is in the Archives, 2' serie, T. XIII, p. 310. 93 SECT III.] WOUNDS OF THE SMALL INTESTINES. 119 Lembert's Method.—In 1S2(\ Lembert proposed his ingenious suturo,1 which is applicable to nearly all varieties of intestinal wounds. Admirably adapted to the purpose of maintaining exact coaptation of the serous surfaces, it is the plan that for nearly half a century has been the most widely approved and practised. Its application to a longitudinal wound is shown in the wood-cut (Fig. 87). The diagram on page 59 illustrates the mode of inversion and apposition of the serous surfaces accomplished by it. Instead of completely inverting one lip of the division, like Jobert, each lip is inflected at a right angle, and the two are united by stitches carried obliquely, so as to avoid perforating the mucous tunic. Fig. 87.—Five interrupted sutures of Lembert. ' fication of Gely's Method.—Professor Gross2 regards this method as "merely a modi that of Lembert." The inventor1 claims that it affords greater security against faecal extravasation. His opponents al- lege that it involves the hazard of dan- gerously coarctating the calibre of the canal. It is termed by the French the suture en pique, and was proposed in 1844. Ge'ly declares (op. cit., p. 29) that it is differentiated from the basting stitch ^T?T^o OQ n^A TCA «~J ™^-r-r 1^~ «~„~;J„„~,1 F,GS- 88' 89' 90.—First, second, and third steps of the application of Gfily's ^PlGS. ZO and IV), and. may De Considered, modification of the interrupted suture to a longitudinal wound of the small , . r n , " -\ i intestine. [After Gely.] a complex variety ot that obsolete suture. A waxed thread is armed at either end with a common small needle is introduced (Fig. 88) parallel to the wound, without and a little back of one of its angles, at a distance of four or five millimetres, and brought out after traversing the bowel for about the same distance. The same manoeuvre is then practised with the second needle on the opposite lip of the wound. The ends of the threads are then crossed (Fig. 89), the left-hand needle passing to the right, and reciprocally. Each then serves to take another stitch exactly similar to the first, with the precaution of entering the puncture of exit of the thread brought from the opposite side (Fig. 90). This manoeuvre is then repeated as often as may be necessary to cover the entire extent of the One of these FlG. 91. — Four points of suture placed and ready to be tightened. [After GELY.] 1 Repertoire genirale d'Anatomie et de Physiologie pathologique, 1827, T. II, p. 101, cited in the London Lancet, 1826-27, Vol. I, p. 848; in the Medico-Chirurgical Review, 1834, Vol. XXI, p. 299; and VlDAL, Traite de Pathologic Externe et de Med. Op., T. IV, p. 506. In the communication to the Academy (Stance de 26 Janvier, 1826) the name of the inventor, then an interne of the Paris hospitals, is given as M. Lambert, and M. LEGOUEST and others still refer to him by that name. But in the authorized reprint of his paper (Nouveauproctde d'enteroraphie, in Arch. gen. de mid., 1827, T. XIII, p. 234), and in subsequent communications and discussions, the name is spoiled LEMBERT. The examples of success by this method are numerous. The first (July 13, 1826), that of N. Lejeune, set. 41, with wounded strangulated left congenital hernia, treated by CLOQUET, was claimed by JOBERT (op. cit, T. I, p. 80); but Lawrence (I. c, p. 306), Velpeau (I. c, T. IV., p. 143), and Professor Gross (I. c, p. 122), adjudge it to have been an example of Lembert's method. DIEFFENBACH'S case (Wochenschr.fiir die gesammte Heilkunde, Nov. 26, 1836) of mortified right crural hernia, in a farmer, a?t. 50, in which three inches of the intestine was cut off and the ends united by Lembert's method, was practically successful, the patient surviving in good health for several weeks, when, after severe labor in the field, he died from strangulation in a different part of the intestine from the seat of operation. The intestine at the seat of excision was found united, though suppurating slightly at two points. It is probable that in many of the cases reported as successes by the interrupted suture, the stitch of Lembert was employed. The case reported by Dr. GRUMBACHER (Badearztliche Mittheilungen, 1857, B. I, and ZlPFF, in Schmidt's Jahrbiicher, 1864, B. XIII, S. 66) strikingly exemplified its utility, and as much may be said of the examples adduced by Grellois (Rec. de Med., 1860, 3" sene, T. Ill, p. 58), CUVELLIER (ibid., p. 139), McELRATH (New Orleans Med. and Surg. Jour., Vol. II, p. 1070), and KuNKLER (Pacific Med. and Surg. Jour., Vol. II, p. 6). 2 Gross. System, I. c, Vol. II, p. 666. GEly. Recherches sur Vemploi d'un nouveau procidi de suture contre les divisions de I'intestin, Nantes, 1844, en 8, avec 3 pi. 120 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. FIG. 93. — Serous surfaces approxima- ted by five stitches, which are tightened, the last tied, and the ends cut off close to knot. [After GELY. 1 wound (Fig. 91). The threads are now to be tightened. This is accomplished by taking successively, in a dissecting forceps, each of the transverse points, and even each one of the two threads of which it consists, and making suitable traction, at the same time depressing the lips of the wound. These presently are approximated with such exactness that no trace appears externally of the threads that have caused the apposition (Fig. 93). It only remains to tie the ends of the opposite threads and to cut them off close to the knot. The knot is as completely concealed between the serous surfaces as are the stitches. If the united interior of an intestine by this method G^ss^nu^ccd^eiose (Fig.. 94) is examined, a valvular fold, formed by the a longitudinal incision of the . . . 1 -. -• . -i •Til ileum, and uady to be tight- approximated tunics, is observed, and on either side the ened. [After GELY.] 11 ' ' line represented by the loops of thread which completely close the wound. The inventor claims that the execution of this stitch presents no serious difficulties; that it closes accidental openings with such exactness that primary or consecutive effusion of liquid or gas- eous intestinal matters are effectually precluded; that the elimination of the suture through the intestinal cavity is assured; and that the immense advantages of immediate reduction of the wounded bowel and of fig. 94.-intomTof the occlusion of the parietal wound are secured.1 In sup- small intestine, showing the .. ,. ~ , ,-. ■,. r. -, vaivuiar fold produced by p0rt of these claims, M. Gely adduces his successtul the approximated tunics. 1 [After gely.] experiments on clogs and his operation on the woman Leclerc, aged 45 years, successfully treated by enteroraphy, August 25, 1842, for a strangulated mortified left crural hernia. M. Blatin has proposed a slight modification of this method,2 which does not improve it. The theoretical requirements are very well met by M. Geiy's plan, which, if successfully applied in a few more instances, will probably become the established mode of practice. By M. Geiy's method 1 Dr. Gely's remarks (op. cit, p. 17) on M. Lembert's plans are so candid and judicious that it may be well to translate them at length: "M. Lembert sought to improve the method of M. Jobert by relinquishing invagination in complete divisions. Instead of practising, like the latter, a complete inversion of the coats of the lower end of the bowel, he inflected the margins of each end at a right angle nearly, and maintained them in contact by points of interrupted suture, the threads being carried obliquely through the coats of the bowel, so as not to perforate the mucous membrane. The two extremities of tlie divided intestine are thus united in the same manner as the lips of an incomplete oblique* or longitudinal intestinal wound. The inflection of the lips of the wound, not exceeding a right angle, constitutes a demi-inversion as compared with the complete inversion practised on the lower end by M. JOBERT. This mode of (adossement) applying the serous surfaces back to back, which is likewise effected by the method of M. Dexans, is the simplest and easiest of execution, and as effectual in promoting adhesion as that which M. JOBERT employed. It may be regarded as a radical modification of the method of that surgeon, and is, in our opinion, the fundamental feature of that cf M. LEMBERT, the feature that has earned for it general approbation, and caused it to be preferred, by many surgeons, to the method from which it is derived. Every ulterior modification of the methods of enteroraphy must indubitably accept this principle as a starting point. But is the kind of stitch employed by M. Lembert really superior to that of M. Jobert, and does it completely fulfil all the conditions desirable? It appears to us obvious that a negative response may be made to these questions, notwithstanding the praise that has been bestowed on this procedure. M. JOBERT, who employed in his earlier experiments the inter- rupted suture, speedily discerned its inconveniences, and finally rejected it. He saw that it could only be made effective by multiplying the stitches, and that then it became very dangerous. The procedure of M. LEMBERT may justly be criticised for closing the solution of continuity imperfectly. It is even inferior in this respect to the looped suture. In several of VELl'EAU's experiments union failed to take place in the intervals of the stitches, and fistulous orifices were left there. If, to avoid this trouble, the stitches are multiplied, then the danger they induce as foreign bodies is rapidly augmented. It is important to remark, that the descent of the thread into the intestinal canal is next to impossible where the operator refuses to perforate the mucous tissue. The knots must be absorbed or encysted where they are, and are liable to inflame the peritoneum. Dieffenbach's patient, who died at the end cf six weeks, had still two points of suture with suppuration going on around them. These drawbacks are so manifest that no one has yet dared to advocate this method absolutely. This is why some surgeons would have recourse to the rings of M. DENANS, and why M. Vll.l'F.AU would substitute a modified continued suture. This plan would undoubtedly avoid the danger of primary extravasation; but one asks what will happen, when this suture has destroyed all the tissues it includes, and if this sort of suture does not hazard secondary perforations more than any other? The spiroid suture appears very dangerous on this ground." 2 Blatix (Gazette des Hopitaux, 1844, T. VI. p. 456) proposed to use but one needle, and, successively, threads of different colors. M. X/laton says that this modification has not been applied on the living human subject. As the suture is expected to fall into the intestinal canal, there can be no advantage in threads of different colors, unless to distinguish the two sets in tightening. Fig. 95__View of the mu- cous surface of the intestine before the completion of Geiy's suture. [After GELY.] SECT. III. | WOUNDS OF THE INTESTINES. 121 the procedure is tho same, whatever may be the direction, extent, or situation of the wound. In all, the approximation of the serous surfaces is accomplished by an equal inflexion of the lips of the wound, never exceeding a right angle or a half-inversion, in place of the duplication of one lip, proposed in Jobert's original plan. The application of this suture to complete division of the bowel is shown in Figure 96. When wounds with loss of substance exist in the contiguous coils of the intes- tine, it is easy to place the corres- ponding parts in apposition and to bring about adhe- sion by the plan indicated in Fig- ure 97. Flere the inversion of the lips of the solutions of con- FlG. 96. plete divisions Application of Geiy's suture to com- tinuity is ' not is of the bowels. (After GEly.) J Fig. 97.—Sutures of contiguous wounds, with loss of substance in two knuckles of the bowels. (After Gely.) requisite. Professor Emmert,1 of Bern, proposes a plan (Fig. 98) which appears to be a combination of the stitch of Lembert, loop of LeDran, and the darning point of Bertrandi. He claims that it obviates some of the weightier objections to the methods of Lembert and Gely. A device for placing the knots of interrupted sutures within the ca- nal of theintestinehas lately been proposed2 to the Surgical Society of Paris by Dr. Vezien (FiG.99).M.Legouest3 pronounces it an "in- genious proceeding;" but its utility has not yet been experiment- ally established.4 Re- J Ik;. !!!).—Interrupted suture knotted cently Dr. Ve'zien has witllin 4he ffUt mzimh described and figured5 a grooved director, which he found useful in applying his suture on 1 Emmert (C). Lehrbuch der Chirurgie, Stuttgart, 1862, S. 237. s Vezien. Bulletin de la Societide Cliirurgie, November 8, 1871. 3Legodest. Traite de Chirurgie d'Armie, Paris, 1872, 2me ed., p. 390. 4It appears to be unwise to sneer at the more complicated methods and modifications of intestinal sutures, that their experiments on animals have suggested to various surgeons, or to denounce them in a mass, as some authors are disposed to do. Some of them have been suggested by difficulties actually encountered in practice. Many of them will be found applicable to particular exigencies. But they should not be attempted on the living subject until the operator has acquired some experience by practising, as M. Fano used to require his pupils to do, either upon the fingers of a glove, or, better still, upon a recent subject, or on intestines placed in a manikin. 6 Vkziex, Note sur la suture intestinale, iu Ricueil de Mimoires de Med. de Chir. et de Phar. Mil., 1871, 3e S6rie, T. XXVI, p. 256. 16 FlG. 98.—Emmert's suture, with threads, each armed with two needles; as many of these loops as the size of the wound may re- quire are placed, and the opposite ends of the ligatures are tied together. (After EMMERT.) A.D 122 PENETRATING WOUNDS OF THE ABDOMEN. [('HAP. VI. the cadaver. The plan of M. Bouisson, professor of surgery at Montpellier, which may be regarded as a form of acupressure, and that of M. Be'ranger-Feraud, proposing reunion by means of pins inserted in cork, have not been sanctioned by experience, and may be esteemed as curious rather than ingenious.1 While ignorant of the experiments of M. Denans, Baudens succeeded, in some vivisections on dogs, by a similar though less complicated contrivance. He introduced an elastic ring into the upper end of the bowel and inverted the tunics upon it; into the lower end he inserted a single ferrule, slightly concave, and grooved; the lower end was then inserted into the upper, the elastic band slipping into the groove and securing the inverted lip in place.2 M. Spillmann's project of everting the lips of the divided extremities of the bowel, and compressing them between silver rings clasped together, with a view of inducing mortification of the approximated mucous surfaces, was a retrograde step.3 The devices of Amussat, of M. Choisy, of Dr. A. Thomson, for strangulating the ends of the divided intestine on rings, with the expectation that the approximated serous surfaces would cohere, are based on the celebrated experi- ment of Travers, of encircling the bowel with a ligature.4 The criticism of Lawrence on the method of Denans may justly be applied to these derivations from it: "A patient who could survive the infliction of such surgery must be endowed with great tenacity of life." M. Moreau-Boutard's plan,5 of excising the everted mucous tissue, and approximating the serous surface with the refreshed connective tissue, cannot be practically executed on the human subject. The earliest form of stitch employed in sewing up the intestines was that known as the continued or glovers' suture. After a time it was denounced and fell into desuetude.6 By one of those reactions of which the annals of surgery afford so many examples, it is again in favor, and, in some shape, has lately been more generally approved in enteroraphy than any other. Though the distinction is rarely f0$$ftt$> Jf made by systematic writers, it is plain that two very different r'/MvMllifc if, -:. stitches are confounded under this name. One (Fig. 100), in y which the thread passes from within outward through, one lip of ^ the wound, and from without inward through the other lip, is the true continued suture or stitch of the sempstress; the other (Fig. V? 101), "executed by introducing the needle first into one lip of the v^-J wound from within outward, then into the other in the same way" Fig. 100.—The continued suture, ^y> (Jooper), is the glovers or herring-bone stitch, which gives a spiral or overcast pUCk;ere(l line of reunion. The former admits of the inversion of fig. ioi.-The ,.. ,, . . „ , ' r glovers' suture, the lips of the intestine, and the approximation of the serous surfaces; the suturapeiuonum. latter does not. The former, under the name of the spiroid suture, rendered good service > BOUISSON (Bull, de I'Acad. de Med., 1851, T. XVI, p. 494, and in NELATOX's Siemens de Path, chir., T. IV, p. 150). The suture implantie, as M. IJOLlbSOX calls it, is made with pins approximated as in the twisted suture. The external wound must be left open, to admit of the withdrawal of the pins. M. BERANGER-FERAUD (London Lancet, 1870, Vol. I, p. 234) employs rows of pins inserted in cork, after the fashion of the teeth of a comb. Neither method has been practised on the living human subject. 'Baudens, Clinique des plaies des armes a feu, 1836, p. 339. The author says: "J'ai op6r6 sur des chiens, et j'ai parfaitement r6ussi; si l'occasion se pr^sentait, je ne craindrais pas d'employer sur l'homme ce proc6d6 dont l'exicution est facile et dont les r6sultats me semblent devoir 6tre avantageux.' He does not say why he prefers to invaginate the lower end within the upper. 3Spillmaxn, in Dulac's thesis Des diversprocidis enteroraphiques, Paris, 1845. M. DULAC remarks: "Ce procgdfe n'apas besoin de refutation." 4 PHILLIPS (London Lancet, 1834-5, Vol. I. p. 202) gives the fullest account of Amussat s plan and experiments. Consult, also, GROSS (Wounds of the Intestines, p. 152); Teavers (On the Intestines, p. Ill); LAWRENCE (op. cit, p. 356). CllOlSY'S plan is described in RAMPON's thesis, Considera- tions sur quelques points de pathologic, Paris, 1837, p. 15, and in VlDAL (op. cit, p. 141). 6Consult JOBEKT's report, Mem. de I'Acad. de Med., 1846, T. XU, and Cyclop. Pract. Surg., 1861, Vol. II, p. 731, and VlDAL (op. cit, T. IV, p. 141). cC00PEE (S.), Dictionary of Practical Surgery, 8th ed., 1872, Vol- II, P- 669, without comment by the editors, is permitted to say: "When we remember, in making this suture, how many stitches are unavoidable; how unevenly, and in what a puckered state, the suture drags the edges of the skin together; and what irritation it must produce; we can no longer be surprised at its now being never practised on the living subject. It is commonly employed for sewing up dead bodies; a purpose for which it is well fitted; but for the honour of surgery, and the sake of mankind, it is to be hoped that it will never again be adopted in practice." SECT. III.] WOUNDS OF THE INTESTINES. 123 in enteroraphy in the hands of Nuncianti and of Velpeau,1 and it has latterly been advocated *by Dr. Bcybard, of Lyons, to the exclusion of his own and of all other special devices." Professor dross, than whom no authority is more competent, states that "when judiciously employed, it is capable of affording the most happy results in the treatment of intestinal wounds, no matter what may be their situation, direction, or extent."3 It is easy to combine with this form of the continued suture the oblique short stitch of Lembert, and this was the plan that Dupuytren ultimately approved, after witnessing the diversified expedients that exercised the ingenuity of his disciples.4 The methods of enteroraphy5 have been arranged in three classes, according as direct reunion by the apposition of like tissues, invagination and the approximation of mucous with serous surfaces, or coaptation of two serous surfaces was had in view; and these have been subdivided into fixed sutures, attaching the intestine to the abdominal wall, and free sutures, cut close and returned within the cavity. Divested of pedantic superfluities of description, the various methods show a real progress and better understanding of the difficulties to be overcome. The direct apposition of the cut surfaces, sought by the old masters, is theoretically sound, although the obstacles to its accomplishment appear insurmountable. Possibly, by the use of canulse of gelatine or some more appropriate substance they may yet be overcome. Whatever tissues are brought in contact, reunion takes place through plastic exudation, and the stitches that will prevent faecal effusion long enough for adhesions to form will prove the best. Approximating the bowel to the external wound affords the surgeon a certain sense of security, since he may indulge the hope that, if the stitches give way, the patient may recover with an abnormal anus. But the evidence is now overwhelming, 1 GUTnuiE (Wounds of Abd., p. 26), and JOBERT in his article on wounds cf the intestines, in the British Cyclopedia of Practical Surgery, quote the paper of Professor HirPOLUE Kuxciaxti, of Naples, and his three successful cases cf enteroraphy: A tailor cf 23, with laceration from rude taxis of a strangulated inguinal hernia. A rent, an inch long, was united by the spiral suture, which came by stool on the seventeenth day; recovery was complete on the fortieth. Equal success attended a similar operation for an accidental wound of the intestine inflicted in a lady of 36, with strangulated crural hernia. The suture was discharged by the intestine on the thirteenth day. The third case was of a man with mortified inguinal hernia, lacerated by slight pressure. The rent being sown up, the ligature was discharged internally on the fifteenth, and the man was cured on the fortieth day. VELrEAU (Nouv. elim. de mid. op., T. II, p. 426), "A mon sens, le precede le plus rationnel est celui de M. LEMBERT, et e'est a lui qn'on finira inevitablement par donner la preference, si jamais l'observation vient u confirmer les donnees thfeoriques qui l'ont fait naitre," and afterward, p. 428: " Ce n'en est pas moins cette suture spiroide, combin6e avec les principes de M. Lembert, qui me semble devoir l'emporter." " Reybard, Considerations sur le traitement des plaies de Vabdomen avec lesion des intestins, precedies de nouvelles remarques sur le mode de cicatrisation apres les sutures, in Gazette Ilebdomadaire de Med. et de Chir., 1862, p. 427. Bulletins de VAcadimie royale de midecine, Paris, 1845, T. X, p. 1036; Memoires de V Acad. roy. de mid., Paris, 1846, T. XII, p. 517. 3 Gross, An Experimental and Critical Inquiry into the Nature and Treatment of Wounds of the Intestines, Louisville, 1843, p. 51. The details of seventeen successful experiments on dogs are related, the continued suture having been employed in intestinal wounds varying in extent and direction. * Dupuytren (Lecons Orales), T. V, p. 183, and T. VI, p. 455. SI. M. Paillaud and Marx, the editors of Dupuytren, warmly maintain the superiority of Lejibert's method, and also its claims to priority. M. Lemrert, they observe, read his memoir before the Academy of Medicine January 26, 1826; it was not until July, 1826, six months subsequently, that Jobert described an analogous stitch. Jobert's priority in proposing invagination is not questioned. Lemeert, as 51. BEAUGRAXD informs us (Diet, encyclopil. des Sci. Mid., deuxieme serie, 1869, T. II, p. 146), died in 1851. DUPUYTREN' (Lecons Orales, T. V, p. 185) says: " Nous croyons encore plus simple et plus efficace pour cette section complete de la circon- f6rence de l'iiitestin, le proc6d6 que nous avons conseille dans le cas de plaie longitudinale ou parallele a l'axe de I'intestin, e'est-a-dire le renversement en dedans des deux bouts de I'intestin, renversement suivi de l'application de la suture du pelletier. Si quelque chose pouvait donner du poids a notre opinion, e'est que M. Lembert lui-meme ait ite conduit a penser comme nous sur ce point, et ait substitu6 la suture en spirale aux points s6par£s que constituaient ses procSdes." 6Celsus (Medicinse, Lib. VII, XVI), regarding interference with wounds of the small intestine as futile, taught that the large intestine might be sewed, and would sometimes agglutinate: "Latius intestinum sui potest: non quod certa fiduciasit; sed quod dubia spes, certa desperatione sit potior; interdum enim glutinatur." In note 2, on page 63, an extract is given from Reed's translation of the work of the old Spanish surgeon ARC^EUS (Method of curing Woundes, etc., London, 1588), on the fatality of injuries of the small intestines. Continuing, he records four examples of successful entero- raphy of the large intestines: * * * "But of others in whom it happened the greater guts to be perished, we have cured three, being wounded in the gut called colon. And the fourth, the gut longanon (rectum) being hurt. Of these, one had the gut colon broken in three places, yet all of them, by God's help, were restored before the twentieth day. All these bowells we did sowe Up, with a needle and thrid, with that kind of stitch which the glovers doe use. I did use also towards them all that kinde of curing which is delivered unto us by John Vigo, which we doe judge best of all others, if a man use it well, and with a pleasant delicate hand. We have therefore followed all his precepts, this onely thing excepted, that we have given no meats, and have used the potion onely sette forth by him ; for that we did consider those whome we had in cure to be somewhat strong, and of a more lustie nature, and able enough to abide from meats. For out of Spaine we would not enterprise to use so thinne a dyet." Glaxdorp, of Bremen (Speculum chirurgorum, 1619, Obs 34), records a case cf recovery from an incised wound of the colon, united by Ihe glovers' suture. Three instances cf successful American cases of enteroraphy for stabs of the great intestine, by Drs. POST, MASOX, and CllKSXEY, are recorded on page 76. Of modern European cases, the following may be cited: Jenkins (G UTIIHIE, Wounds of Abd., p. 27, Case 32), in a complete division of the ascending colon by a razor, sewed the two ends together by the continued suture; there was faecal fistula, but ultimate recovery; Mr. N. WARD (The Medical Times and Gazette, 1855, N S., Vol. Xl, p. 632) relates a recovery, after enteroraphy fcr an incised wound of the ascending colon, in a female lunatic, aged 51. 121 PENETRATING WOUNDS OF THE ABDOMEN. ICIIAP. VI. that the risk of fcecal extravasation is less when the threads are cut close and the gut returned. Then the beneficent equable pressure may be counted upon to avert effusion and to favor adhesion to the surrounding parts. It then becomes most important that the suture should fall readily within the cavity of the bowel (Fig. 102). It appears to the writer that here the methods of Jober-t and of Gely have an incontestable advantage over that of Lembert and all others in which the suture does not perforate the mucous tissue. That enteroraphy is the proper treatment for punctured or incised wounds of the intestines with protrusion, is now questioned by none ; that, in similar wounds without protrusion, of the small intestine and of parts of the large intestine covered by the peritoneum, it is proper to enlarge the external wound and find the wounded part, and secure it by enteroraphy, a mass of affirmative Fig. 102.—Intestinal suture par- x J x J tiaiiy detached. [After gross, evidence has been brought forward. The experience of the War Wounds of Infest.. Plate, Fig. 2, o 1 and system, Fig. 482.] c|oeg nQ^ ena|)}e us £0 demonstrate the benefits of applying the same principles to shot wounds; but contributes some elements toward the determination of this vexed question. Dr. F. H. Hamilton, a medical inspector in the army during the War, and a lecturer and writer on military surgery, has opposed, with, extreme earnestness, surgical interference with shot wounds of the intestines, and has condemned in emphatic terms the adverse opinions of M. Legouest. It is not to be supposed that any partizan feeling intrudes in his discussion, or that the discovery and enforcement of the wisest practice is not singly held in view, and hence it is a matter of surprise that M. Legouest is represented as alone in his opinions, and that Bauden's teaching1 and his successful 'Baudexs (Clinique des plaies d'armes a feu, 1830, p. 322), treating of shot wounds of the intestines, observes: "When naiure, as here [circumscribing the lesion by adhesions], undertakes the cure, the part of the surgeon is restricted to aiding her, combating by appropriate treatment the symptoms of entero-peritonitis. But, unhappily, these sorts of cases are exceedingly rare, and how many disappointments occur from permitting the formation of mortal effusions without opposing them by a surgical intervention, of which the boldness would, at least occasionally, be rewarded by success. It has, indeed, been established as a principle to sew up the intestine, or to establish an artificial anus, when the wound of the abdominal walls is large enough either to permit protrusion of the injured parts, or the ready observation of their lesions without much searching; but I do not know that it has been advised to enlarge shot wounds of the abdomen in order to seek for deeply hidden intestinal lesions. Far from this, I find it everywhere forbidden to probe wounds of this sort, or to make any exploration, for fear of disturbing either a clot occluding the mouth of a small artery, or of destroying adhesions, or, finally, from the puerile apprehension of rupturing a gut already contused or disorganized by the impact of a ball. Ah, well! I emphatically declare, and my conviction is based on experience alone, that when a ball traverses the abdomen through the region occupied by tho digestive tube, the latter is almost always profoundly disorganized, and nine times in ten, at least, there supervene mortal complications, developed under the influence of an hyper-acute peritonitis, lasting scarcely ever more than twenty-four hours. In these grave conditions, the walls of the belly arc perforated, and, as at the outset, the wounded man ordinarily presents no very alarming symptoms, there is a disposition to believe that the ball has glided over the surface of the intestines without injuring them, or else that it has undergone such deviations or deflections as have left these viscera untouched. The wound is dressed simply; the honor of a cure of visceral injury, if it exists, is abandoned to nature, and the surgeon is content to watch over the traumatic phlegmasia. But death presently supervenes. At the autopsy, it is seen that one or many loops of intestine have been perforated; that matters have been extravasated; that an intense inflammation has invaded the peritoneum, and the attendant consoles himself by saying that the mischief was beyond the resources of art. This is erroneous. The surgical domain should not be restricted within so narrow a sphere, and, to extend its limits, I do not fear to place the knife in the perforation made by the projectile in the wall of the abdomen, to enlarge it, to pursue into that cavity itself the examination of the track it has traversed, and to apply to the intestinal lesions a prompt and effective remedy. It is thus, if I had been called to that celebrated publicist, whose recent loss we deplore, I would not have hesitated to extend the entrance wound of the ball for several inches, to remove the extravasated matters, and to apply a suture to the torn intestine. After these preliminaries, having no longer effusion to apprehend, I would have had only to contend with an entero-peritonitis, which perhaps would not have proved mortal. I know that a multitude of considerations foreign to his art intimidate the surgeon who treats his patient at heme, and that the fear of being esteemed inhumane or too bold, should his operation be unsuccessful, often stays the hand that alone can preserve the days of the wounded man. But this is not humanity, and I would ever choose for my rule of conduct that well-known aphorism: melius ance]>s remedium quam nullum. But, it will be rejoined, we agree with you that a wound of the abdominal parietes, even of several inches, is not very dangerous, unless complicated by visceral lesions; we conceive that it is of the highest importance to remedy that lesion in order to place the wounded man in the same condition as if he had received a sabre stroke with simple division of the walls of the belly; we agree, also, that nearly all shot perforations of the region cf the belly occupied by the intestines are complicated, nine times in ten, by perforations of the latter, perfi rations which, nineteen times in twenty, are followed by fatal effusions; but by what signs do you ascertain whether there is or is not perforation ? The signs are general and local. Among the first are the nervous prostration and signs of extravasation, to be considered hereafter, -. ,;.; s that are sometimes characteristic, and may alone suffice to indicate the operation. The local signs are derived from the situation, the direction, the depth of the track pursued by the projectile; the index finger is readily introduced into the belly through a perforation of its wall, and with the pulp of this finger the form of the peritoneal opening is to be studied, and, according as it is direct or oblique, it will be decided in what direction it is necessary to prosecute the search for the wounded parts. It is known that intestinal wounds are nearly always situated directly behind the peritoneal orifice, and this is so generally true, that it is there, ordinarily, that adhesions form between the wounded gut and the wall of the belly, and if a knuckle of intestine protrudes, it is almost invariably the one that has suffered a solution of continuity. Having remarked that the ends of a SECT. III. I WOUNDS OF THE INTESTINES. 125 enteroraphy in a shot wound of the colon is not placed before the reader. To form a just conception of the state of the question, it is necessary to reflect that the elements for its solution were wanting, at the close of that brilliant epoch in military surgery, when Larrey and Hennen and Guthrie were the guiding lights. After the battle of Waterloo, Thomson might say of " those whom we saw," that " the more that is left to Nature in the process of reunion, and the less her operations are interfered with, the greater will be the chance of ultimate recovery."1 But Guthrie comprehended that " those whom we saw" formed a lamentably small proportion ; that " numbers of others similarly or perhaps more seriously wounded had died. It will he for those who come after us to decide a point so important, and to which their bed attention will be drawn in a manner which, I trust, cannot fail to be of service." And then, citing the remark of Thomson, just quoted, Guthrie adds: "The remark is correct provided it be applied to those cases in which no clear indications for interference are present. When they are present, the do-nothing system is commonly followed by death. A well-regulated interference is likely to be more successful." Larrey records but one recovery from a shot wound of the small intestine, and that one was treated by Palfyn's method. In the next quarter of a century the procedures of enteroraphy were greatly perfected. The largest military operations were those of the French in Algiers. Among the* leading works published on military surgery was that of Baudens, and this contained accounts of two cases of enteroraphy for shot wounds of the intestine, one of which was completely successful. In the war in the Caucasus, in 1819, the eminent Russian surgeon, Pirogoff, was equally impressed with the vital importance of this question in military surgery. "I regret," he says, "that in the cases that came under my observation, I employed the suture only once, and then in a sort of desperation. I gave up the other wounded as lost; as enteroraphy required time, and many wounded were awaiting my assistance, I did not use the suture. But just this gut torn by a vulnerating body contracted spasmodically and became of almost cartilaginous hardness, I have often recognized this condition by introducing the finger into the abdomen : and it is then useless to protract the search, seeking to insert the finger into the intestinal wound, for there can be no question that the latter exists. "With this pathognomonic sign, others not less positive may be conjoined, such 7, T. XXII, p. 260; BOYER (Ph.), Des operations que reclamcnt les plaies de l'estomac et de Vintcstin, Paris, 1841'; MARTINEXCQ, In plagis abdominis vulnerato intestino pellionum sutura, Paris, 1738. PlBRAC, Mem. sur Vabus des sutures, in Mem. de I'Acad. de Chir., T. Ill, p. 408; RlTSCH, Mem. sur un effet peu connu de I'etranglement dans la hemic intestinale, in Mem. de I'Acad. de Chir., T. IV. p. 173. IIf.xroz, De methodis ad sananda intestina divisi adhibitis, in qua nova sanationis methodus proponitur, Leodii, 182'i: Geille. An in plagis abdominis vulnerato intestino pellionum sutura? Paris, 1750 3 On wounds and injuries of the intestines, many of the more important authorities have been cited in the foregoing pages. The following additional references are accessible in the Surgeon General's Office Library: Malayal.^ji tenuium intestinorum vulnus tethalel Paris, 1734, in Haller'S Disputalior.es, T. V. p. 77; Hn .sciie.v, Diss, de vulnerum in intestinis lethalitate, Giessen, 1743; BECK (B.), Versuche uber die Heilungsfahigkeit der Darmwunden, in Illust. Med. Zeitung, B. Ill, S. 142; MARCH, Penetrating wounds of the abdomen, with punctured wounds of the intestines, New York, 1854; YlLLEXEUVE, Quels sont les pheaomt-ies tant primitifs que consecutifs propres aux plaies des intestins, These, Paris, 1838; B.OCLORE, Quels tout les phenomenes tant consecutifs que primitifs propres aux plaies des intestins, These, 1841; CROUZET, Traitement des plaies de I'intestin, These, 1842; FLEURY, Plaies de I'intestin produites par des instruments piquauts ou tranchanls, Paris, 1851; NEUCOURT, Quel est le traitement des plaies c ythe; the false and three of the true ribs of the right side were divided, and the liver wounded about the size of a man's forefinger ; recovery in threo weeks. 23. Smith, N. R. (Cases in Surgery, in North Am. Arch, of Med. and Surg. Sci., 1835, p. 385); knife wound beneath and a little to the right of the ensiform extremity of the sternum; liver injured; recovery. 24. NEWTON, W. S. (The Western Lancet, 1850, Vol. XI, p. 501); W. 0., aged 23 years, cut by a saw; a part of the parietes, six by ten inches, and a small portion of the liver, cut; recovery in a few months. 25. PECK, S. W. (The Western Jour, of Med., September, 1867, p. 524); bayonet wound in the upper part of right lumbar region; liver punctured to the depth of four or five inches; intestine, half divided, protruded; interrupted suture to intestine; gut returned after enlarging the external wound; recovery in thirty days. 26. Hill, U. (Canada Med. Jour.. 1869, Vol. V, p. 289); W. P., injured by a circular saw: 8th, 9th, 10th, and 11th ribs cut; pleural cavity laid open; diaphragm and liver wounded; cut in liver four inches long and one inch deep; recovery. There are definite descriptions at least cf thirty-six fatal raM's of this group; but it would, perhaps, be superfluous to enumerate them. BOHN (Chir. rat, Braunschweig, 1727) cites cases from Tulpius and other old writers. HARRINGTON'S interesting account of a fatal bayonet wound of the liver is in the Med. Rec. and Researches, London, 171)8, p. 593. Other instances are recorded by Scrivexs (Lancet, 1828), Steidele (Richter's Archiv., B. V), and J. MASON WARREN (Boston Med. and Surg. Jour., ]£.V». Vol. LII, p. 181). 4 Dr. Lldwig Mayer indulges in a pleasant literary digression on the liver wounds alluded to by the poets. In HOMER, in the eleventh book of the Iliad, Eurypylus strikes Phausiasson Apisaon in the liver; in the thirteenth, Dciphobus throws a shining lance, which strikes Hypsenor in tho liver; in the seventeenth, Lycoinedes wounds, in like manner, Apisaon the son of Hippasus; in the twentieth, Achilles thrust his sword into the liver of Hector, and the liver protruded. In the ballad of Chevy Chase, Douglas is killed by an arrow wound of the liver (HERDER). Finally, the heroic battle-poet. TuEODOR KORNER, lost bis life by a shot wound of the liver, at Gadebusch. (See Johannes Scihcrr's Blucher.) 6 Cases ?lD=r2:9; 233 = 249; 238 = 243. SECT. III.] WOUNDS OF THE LIVEK. 131 Gunshot Wounds.—In this'category a great variety of lesions were observed: slight groovings, or divisions of the peritoneal investments only; penetrations with a single outlet; long perforations; extended lacerations; lacerations with protrusion; wounds com- plicated by the presence of splinters from the ribs, of fragments of clothing, of balls and other foreign bodies. If the patients escaped the early danger of haemorrhage, they were likely to die of traumatic peritonitis, or from abscess of the hepatic parenchyma. Yet abundant proof was afforded that very serious shot injuries of the liver were not neces- sarily mortal. This will be fully put in evidence by detailed observations and by tabulated statements, after the principal varieties of lesions observed on necroscopic examination shall have been presented. One hundred and seventy-three cases of shot wounds of the liver appear on the returns as having come under treatment. In fifty-nine, the injury to the liver was the dominant lesion, and the cases in this group may be termed, in a very general sense, uncomplicated cases. In one hundred and fourteen, the hepatic injury was associated with fractures of the ribs or of the vertebral apophyses, or with lesions of the lung, diaphragm, stomach, hepatic ducts, or gall bladder, of the spleen, pancreas, kidneys, or blood-vessels. The military designations of the one hundred and seventy-three patients of this division will be enumerated, that the student, who desires to investigate the subject exhaustively, may refer to the manuscript registers of this office ;* but details will be given of many instances of recovery, and of those illustrations of the pathological anatomy of lesions of this group of which the Museum affords examples. Of the fifty-nine cases of the first group, twenty-five had a favorable result: Cases, 312-336.—Private T. H. Bradley, Co. K, 39th Massachusetts; Sergeant T. A. Buck, 7th Michigan Cavalry; Corporal Z. Butler, Co. H, 27th Indiana; Private E. Carney, Co. K, 7th Wisconsin; Private S. Case, Co. C, 130th New York; Sergeant W. Clifton, Co. F, 77th U. S. Colored Troops; Private W. M. Crandall, Co. K, 42d Ohio; Sergeant F. Crawley, Co. B, 1st battalion, 12th U. S. Infantry; Private J. Cunningham, Co. D, 23th Michigan; Sergeant P. Fallenstein, Co. F, 98th Pennsylvania; Private E. I. Noyes, Co. F, 142d New York; Sergeant D. Perry, Co. B, 14th New York; Corporal J. M. Roberts, Co. F, 83d Indiana; Private S. Scott, Co. G, 53d U. S. Colored Troops; A. Shively, 12th Kansas; Private G. Smith,2 Co. C, 126tb New York; Corporal J. B. Smith, Co. H, 66th New York; Sergeant W. TV."Smith, Co. G, 5th Texas; Sergeant S. K. Snively, Co. M, 13th New York Cavalry; Sergeant G. W. Tindall, Co. C, 4th New York Cavalry ; Private Y. Vineyard, Co. C, 31st Illinois; Private J. W. Vogus, Co. D, 59th Indiana; Private T. Welsh, Co. F, 18th New York; Private J. Westfall, Co. D, 3d Wisconsin; Corporal L. Whittle, Co. II, 73d New York. The names of thirty-four patients, in whom comparatively uncomplicated shot wounds of the liver had resulted fatally, were as follows: Cases 337-370.—Sergeant W. I. Barnes, Co. H, 69th Pennsylvania; Private S. H. Barnum, Co. H, 7th Ohio; Private F. Berst, Co. I, 55th New York; Private G. D. Brown, Co. K, 94th Illinois; Private W. Campbell, Co. B, 2d Pennsylvania; Private A. Cartensen, Co. H, 58th Illinois; Private D. Clauss, Co. E, 44th New York; Private S. Cooney, Co. C, 3d New Hampshire; Sergeant W. F. De Graff, Co. E, 9Gth Illinois; Private A. Douglass, Co. C, 15th Illinois; Sergeant William N. Guthrie, Co. F, 9th New York Heavy Artillery; Private A. Harrington, Co. II, 5th Michigan; Private Job Hirst, Co. H, 4Stli Pennsylvania; Private L. T. Hunt,2 Co. G, 2d New York Cavalry; Corporal J. H. Hyney, Co. F, 98th New York; Private R. Johnson, Co. B, 138th Pennsylvania; Private W. Jones, Co. E, 14th Connecticut; Private P. B. Kennedy, Co. I, 9th New York S. M.; F. C. King, Co. K, 13th New Jersey; Private L. Knowlton, 1st Maine Heavy Artillery; Private Th. W. Lear, Co. A, 104th Pennsylvania; Private J. Matthews, Co. C, 11th Pennsylvania; Private S. Mercer, Co. D, 1st Maryland Cavalry; Private E. Morrow, Co. A, 26th Ohio; Private J. M. Mosher, Co. C, 1st Maine Cavalry; Sergeant A. A. N-----, Co. D, 2d Massachusetts; Lieutenant S. C. Oakley, Co. F, 162d New York; Private S. Peter, Co. D, 31st Indiana; Private W. H. Sanborn, Co." A, 12th Massachusetts; Private J. Seifert, Co. F, 8th Ohio Cavalry; Private J. Sullivan, Co. E, 32d Ohio; Private E. W. Wallace, Co. F, 25th Connecticut; Private A. J. Walters, Co. A, 140th Pennsylvania; Private A. Whitney, Co. H, 1st Michigan Cavalry. An abstract of Case 361, Private Mosher, is printed in the First Surgical Volume, p. 587, with a figure (285) of the ball and coat-button driven through the liver. 1 Tables giving a synopsis of the leading circumstances of the cases of this series have been prepared; but, with the necessary condensation, they give so little insight into the distinctive features of the individual cases, and yet, in the aggregate, occupy so much space, that the method adopted is believed to present a more satisfactory view of the subject. 2Lidell (J. A.) (Gunshot Wound of the Liver, in Am. Jour. Med. Sci., 1867, N. S., Vol. LIII, pp. 344-5) relates the case of Private G. Smith (Case 327) as an illustration of the advantages of abstention from venesection and a lowering regimen in such cases; and that of Private Hunt (Case 350), who was convalescent, when last seen, thirteen days after the injury; but Assistant Surgeon C. A. McCall, TJ. S. A., reports the fatal termination of the case, five days subsequently, April 24, 18G5, at the Cavalry Depot Hospital at City Point. 132 PENETRATING WOUNDS OF THE ABDOMEN. ICHAP. VI. Thirty-seven patients recovered from shot wounds believed to interest the liver, complicated by various grave injuries either of the abdomen or of other regions: Casks 371-407.—Lieutenant W. H. Bartholomew, Co. B, 16th U. S. Infantry; Corporal W. A. C. Biles, 28th North Carolina; Lieutenant Colonel J. B. Collis, 7th Wisconsin; Corporal D. Cramer, Co. M, 12th Pennsylvania Cavalry; Private M. Duke, 8th Indiana Battery; Private J. O. French,1 Co. C, 17th Vermont; Corporal W. Freeman, Co. H, 30th Indiana; Private J. Frv, Co. K, 14th Pennsylvania Cavalry; Sergeant J. A. Galloway, Co. H, 8th Pennsylvania Reserves; Private M. Heinig, Co. C, 81st New York; Private H. H. Hardin, Co. D, 18th Kentucky; Private P. Halin, Co. G, 17th New York; Private S. P. Johnson, Co. A, 12th Missouri Cavalry; Corporal F. A. Jones, Co. H, 6th Indiana; Private J. Kewell, Co. C, 7th Connecticut; Private W. Little, Co. D, 88th Pennsylvania; Private J. Labar, Co. E, 28th Pennsylvania; Sergeant T. Murphy, Co. A, 63d New York; Private X. McCleary, 2d Virginia; Private J. F.. Matthews, Co. I, 24th New York Cavalry; Sergeant J. Munroe, Co. K, 5th Artillery; Private M. A. Patterson, Co. F, 1st Colorado Cavalry; Private P. C. Pool, Co. B, 20th Wisconsin; Private J. W. Rush, Co. E, 87th Indiana; Private J. A. Rogers, Co. H, 27th Connecticut; Corporal A. A. Sharer,2 Co. D, 26th Michigan; Private P. Sweeny, Co. G, 7th New York Cavalry; Private F. Siebe, Co. D, 139th New York; Private B. F. Sheridan, Co. A, 9th Massachusetts; Private J. A. Sanner, Co. I, 8th Pennsylvania Cavalry; Private F. Searle, Co. A, 9th New York Heavy Artillery; Orderly Sergeant H. H. Terwilliger, 20th New York State Militia; Lieutenant J. S. Williams, Co. G, 63d Pennsyl- vania; Sergeant J. H. White, Co. D, 53d North Carolina; Lieutenant G. Yount, Co. I, 3d Missouri; Corporal W. Zimmer, Co. E, 17th Ohio. Abstracts of the cases of Corporal Biles (372), of Sergeant Galloway (380), Private F. Siebe (399), and of Private Sheridan (400), are printed in Circular 6.. S. G. O., 1865, pp. 24, 26, and 27; the cases of Sergeant Barnard (373), Colonel Collis (374), Private McCleary (390), Private Sanner (401), and of Sergeant Terwilliger (403), are published in the First Surgical Volume, at pages 47, 584, 244, 570, and 577, respectively; and those of Sergeant F. A. Barnard, Co. A, 37th Wisconsin, Private Labar (388), Sergeant Murphy (389), and Private Sweeney (390), are printed supra, at pages 47, 82, and 86. Seventy-four cases of this group of complicated wounds terminated fatally: Casks 408-481.—Sergeant W. G. Alleger, Co. G, 142d Pennsylvania; Private W. A------, Co. F, 114th U. S. Colored Troops; Bugler W. B------, Co. I, 1st U. S. Cavalry; Private M. Brennum, Co. E, 1st Maryland, E. S.; Private \V. Belcher, Co. C, 22d Virginia Cavalry; Private R. Bell, Co. K, 15th West Virginia Cavalry; Private N. Binn, Co. I, 3d Kansas; Corporal R. Bailey, Co. E, 45th Pennsylvania; Private G. Brown, Co. I, 15th Connecticut; Corporal H. S. Barse, Co. E, 5th Michigan Cavalry; Private TV. P. Bernard, Co. A, 44th Georgia; Private H. Byers, Co. G, 8th Ohio Cavalry; Corporal D. Brown, Co. D, 165th New York; Private M. R. Blizzard. Co. I, 81st Ohio; Private F. Cook, Co. K, 6th Michigan; Private W. H. Christian, Co. K, 5th Tennessee Cavalry; Corporal A. Coffin, Co. G, 6th Kansas Cavalry; Private S. O. Crafts, Co. K, 40th Massachusetts; Private S. H. Coyle, Co. D, 97th Ohio; Private A. Delarue, Co. A, 2d Delaware; Private O. H. Dorr, Co. G, 66th Ohio; Corporal S. B. Davis, Co. B, 8th Tennessee Cavalry; Private T. Easley, Co. B, 117th Illinois; Corporal J. E------, Co. M, 14th New York Heavy Artillery; Orderly Sergeant E. W. Field, 2d Maryland Cavalry; Private G. Fox, Co, C, 101st U. S. Colored Troops; Private L. Glynn, Co. B, 37th New York; Private S. C. Gage, Co. C, 15th New Jersey; Private J. Green, Co. H, 148th Pennsylvania; Private E. Holbrook, Co. F, 16th New York; Corporal F. M. Hogue, Co. D, 14th Indiana; Private G. Horsefall, Co. K, 151st New York; Private L. Hollenbeck, Co. D, 91st New York; Sergeant J. Hart, Co. B, 1st Massachusetts; PrivateE. N. Haines, Co. A, 19th Wisconsin; Private M. Ireland,------; 1st Lieutenant H. L. I------, Co. B, 7th South Carolina Battery; Private W. James, Co. B, 1,5th Tennessee Cavalry; 2d Lieutenant F. J. James, 3d U. S. Cavalry; Private J. Kennedy,3 Co. F, 155th Pennsylvania; Private P. B. Kenney, Co. I, 9th New York State Militia; Private C. G. Kingsbury, Co. D, 39th Massachusetts; Sergeant S. L. Lynn, Co. C, 7th New Jersey; Pt. R. Letson, Co. K, 81st New York; Corporal D. H. M------, Co. II, 6th Pennsylvania Cavalry; Private A. J. Mustain, Co. H, 21st Virginia; Seaman F. MrVaitn, C. S. Steamer Isondiga; Private T. Mullen, Co. B, 1st Iowa Cavalry; Private S. Miller, Co. I, 24th Missouri; Private C. F. M------, Co. E, 19th Veteran Reserve Corps; Corporal J. Menger, Co. C, 151st New York; Private G. B. Parish, Co. B, 7th Wisconsin; Private H. F. Packard, Co. K, 18th Massachusetts; Private W. Roberts, Co. D, 2d New York Artillery; Private C. Boughton, Co. A, 32d North Carolina; Private J. W. Royce, Co. G, 3d Indiana Cavalry; Private W. B. Rudd, Co. C, 42d Ohio; Private A. Stein, Sibley's Brigade; Private W. Stewart, Co. G, 109th Pennsylvania; Private F. Schlagel, Co. A, 94th Illinois; Private J. Sipes, 6th Tennessee Cavalry; Private A. Stevens, Co. A, 20th Michigan; Corporal J. Sumstine, Co. K, 87th Indiana; Private J. S------, Co. B, 1st District of Columbia Cavalry; Private J. Smith, Co. A, 69th New York; Private W. Tucker, Co. C, 33d North Carolina; Private J. T------, Co. K, 60th New York; Private N. E. Wood, Co. F, 5th New Hampshire; Private C. Whitmore, Co. G, 45th Pennsylvania; Private F. Watkins, Co. D, 117th U. S. Colored Troops; Private J. White, Co. A, 90th New York; Corporal J. L. W------, Co. A, 2d Connecticut Heavy Artillery; Private W. W------, Co. F, 51st Ohio; Private J. Woods, -Co. K, 10th New York Cavalry. Abstracts will be found in the First Surgical Volume of six of the foregoing cases: Case 409, Private W. A------, p. 441; Case 410, Bugler W. B------, p. 446; Case 431, Corporal J. E-----, p. 444; Case 471, Private James S-----, p. 440; Case 479, Corporal J. L. W-----, p. 445; Case 480, Private W. W-----, p. 584. It has been impracticable to ascertain the termination of the three following cases of shot wounds of the liver and lungs: Cases 481-483.—Lieutenant TV. G. Wood, Co. B, 60th Georgia; Corporal J. Stringfellow, Co. G, 8th Alabama; Private R. Henry, Co. G, 112fh New York. 1 Williams (P. O.) (Report of a Case of Gunshot Wound of the Liver, in Trans. Med. Soc. New York, 1866, p. 39) describes the wound of Private French, (.'ASK 377, of which an abstract is also printed further on. ■-DL'SExr.UKY (II.) (Cases of Gunshot Wounds of Abdomen involving Viscera, in Am. Jour. Med. Sci., 1865, Vol. L, p. 399) records the case of Corporal Sharer, CASE 397. 'SHEETS (Gunshot Wound of the Abdomen, in Med. and Surg. Rep., 1865, Vol. XII, p. 445) relates the case of Private Kennedy, Cask 417. Second Surgical Vol. Op.pay*'. 13«. Med St Sun* Hist, of the War of the Hf-lielliun He!! phot. Bauuifras < o] PLATE VI. METASTATIC FOCI IN THE LIVER No.4ii40 SURGICAL SECTION A VI M 1" ' i...... rii' of fin ■! -f '...• (hi. I. '': ,.' ! -, ■ ■un! S'v ••■ .' I lie sp.rirmi i-i-| r--.---. i <■■'■. '• lb> v ■■", ! ■■ ' ■ •tim bv Sure..... <• S i';.i...... 11. S \'., w '>. V. S. A., wlii- •■.n.'iii-' ♦. j-"H-nti>rtrirt c • ■ .\ .. t ■' \' '{}.< r . ■ 11T gi\ . ;•!:< til T '.:■■'>'{ ;:!i: v • !•.-■ s\'< v, v. ;! i i..«.vl: nto - ■ -lrif:t- ■ '',■ . ;:',r,> ..{" tilt I" ' j :.■.-■ ■':! tl.-.- >,, , : ; :■•;.! .;v;; p;ra: >ruoi ■.< ,i..j d. . ;i., un- l.-ii ......t IU <: • ut' •( piulv* .,-(,.(1: „fl„., ..., ! '•?, wuncefi. ]'••! ■ ,« ■ 1 >t; left cavil' - ■ ilaivcd mid )»ii.-i .c +■' '■■'• v ^■■■-:^-t,.'; '■'•■.; ■•:*■'".:■' '.' .■>'•••* ■' -^,V:t "■ •,:"';■' .if::'^:'. * SECT. III.] WOUNDS OF THE LIVER. 133 It has been remarked, on page 16, that the Museum possessed no example of rupture of the liver, and it may be added that while the effects of diseases in this organ are fairly illustrated therein, the collection contains no specimens exemplifying the processes in the reparation of its injuries. Of the few pathological preparations preserved, four are examples of metastatic foci. A drawing from one of them, in the recent state, is represented in Plate VI, opposite, and will be described in treating of Pyaemia. The remainder exhibit the direct results of shot injuries. The velocity of the projectile, apart from its size and direction, is an important element in determining the extent of laceration that it will cause in penetrating the liver. At close range, the missile inflicts great destruction of tissue. At moderate ranges, of from one hundred to five hundred yards, musket balls striking the convex surface of the liver cause an entrance wound that may be described as a stellate fracture. The preparations in the Museum present several examples of this: N- C( Case 362.—Sergeant Allen A carriage, while being conveyed to Lincoln Hospital, Washington, June 10, 18 D, 2d Massachusetts, died in an ambulance He had probably been wounded at Beverly Ford the day previously. An autopsy was made seven hours after the reception of the cadaver. The wound was ten inches above the pubis and three inches to the right of the median line, and was a small opening, depressed and blackened around the edges. The small intestine and omentum were agglutinated together by a thin layer of recent lymph. The cavity of the abdomen contained a large quantity of blackish fluid, mingled with dark clots of venous blood. The mucous lining of the trachea was very pale, and was covered with numerous papillated points, which were readily removed with the finger, and probably consisted of a tenacious mucous secretion. A large, dense, venous clot was present in the right ventricle of the heart, and a much smaller and more fibrous one in the left. One inch to the right of the suspensory ligament of the liver was a stellate opening, and on the inferior surface, to the left of the gall bladder, a large irregular fissure, through which the ball had passed; it went through the body, making its exit two inches to the left of the spine and six inches above the sacrum. The intestines were not injured. The specimen represented in the wood-cut (Fig. 103) was contributed to the Army Medical Museum by Surgeon G. S. Palmer, U. S. V., and the notes of the case by Assistant Surgeon H. Allen, U. S. A., who conducted the post-mortem examination. FIG. 103.—Section of liver, show- ing tbe entrance of a shot perfo- ration on the anterior surface of the right lobe. Spec. 1232. [Re- duced to one-twelfth.] Specimen 1646, figured further on, gives another good illustration of this stellate Assuring caused by a ball entering the liver, with moderate velocity, perpendicularly to its surface. Projectiles moving parallel to the surface of the liver sometimes make long grooves. These, and all shot tracks in the liver, present the same granular appearance, due to the prominence of the acini, that is observed on rupturing a portion of fresh liver: Case 440.—Lieutenant Henry L. I------, 7th South Carolina Battery, aged 38 years, was wounded and captured at the Six Mile House, near Petersburg, August 21, 1864. Surgeon L. W. Read, U. S. V., at the 3d division hospital of the Fifth Corps, and Surgeon W. L. Faxon, 32d Massachusetts, at City Point, describe the injury as inflicted by a conoidal musket ball entering the epigastrium and shattering the right elbow joint. The wounded officer was conveyed to Washington and placed in Lincoln Hospital on August 24th, under the care of Acting Assistant Surgeon C. B. Wright, who reported the patient as "anaemic from loss of blood, the countenance anxious, the pulse tolerably strong at 95." There appears to have been no nausea, since the patient took beef-tea and stimulants without inconvenience. There was no jaundice. On the 2;">th aud 26th, the pulse became smaller and more frequent, and the patient complained of loss of sight. Con- centrated nourishment and stimulants were retained; but the patient failed rapidly, and died in the afternoon of August 26, 1864, five days after the reception of the injury. Acting Assistant Surgeon H. M. Dean made an autopsy on the following day, and preserved the specimen, represented in the wood-cut (FlG. 104), with the following memorandum: "Body well nourished; rigor, well marked; height, 5 feet 11^ inches; oesophagus normal. Lining membranes of larynx and trachea were of a pinkish hue. Posterior portion of lower lobe of each lung was very much congested; otherwise the lungs appeared normal; right weighed 20 ounces; left, 15-J- ounces. Pericardium normal. The right side of the heart contained a large black clot; left cavities empty; organ healthy; weight, 9| ounces. Spleen considerably enlarged and pulpy; weight, 14 ounces. Liver, the ball crossed its superior surface, injuring both the right and left lobe; organ weighed 70.J- ounces. Both kidneys were healthy; right weighed f>i ounces; left, 6i ounces." Fin. 104.—Section of convex portions of the left and right lobes of the liver grooved by a musket ball passing from left to right. Spec. 3123. [Reduced to one-fourth.] 131 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. It has been noted, on page 16, that by violence, from crushing weights, or the impart of large projectiles at low velocities, the texture of the liver may be either contused or pulpified or widely fissured. The extensive laceration of the liver produced by a discharge, at close range, of a musket loaded with an ounce round ball and three buck- shot, is displayed in the adjacent drawing (Fig. 105): Case 457.—Private Charles F. M- -, Co. E, 19th Veteran Reserve Fig. 105.—Section of right lobe of liver lacerated by a musket ball and buckshot. Spec. 2.'13. [Reduced to one-fourth.] Corps, was shot, at Sherburne Barracks, April 15, 1864, while resisting a sentinel. The charge entered posteriorly, between the eleventh and twelfth ribs, and emerged anteriorly, between the ninth and tenth. There was collapse from internal haemorrhage, and the patient died in eleven hours from the reception of the injury. Cold external applications and free internal stimula- tion constituted the treatment. At the autopsy, the great lobe of the liver was found much torn, a large piece being separated; the right kidney was severed, and a portion of the transverse colon was torn away. The abdominal cavity was completely filled with blood. The specimen, with notes of the case, were contributed by Acting Assistant Surgeon Daniel Weisel, and has been already noted and figured in the Catalogue of the Surgical Section of ihe Army Medical Museum, 1865, page 487. Such mangling appears to be the almost uniform effect of even small carbine or pistol shots upon the liver at very close range, as is often described in accidents: Case 411.—Private M. Brennum, Co. E, 1st Maryland, E. S., was wounded, May 2G, 1862, by the accidental discharge of a musket. A buckshot entered two inches to the right of the scrobiculum cordis, and emerged from the back about two inches to the right of the vertebral column, passing through the right lobe of the liver and lower lobe of the right lung. A portion of the liver protruded from the wound of entrance. He was at once conveyed to the regimental hospital, where he died in about an hour after the reception of the injury. The necropsy showed extensive laceration of the right lobe of the liver, and fragments of the cartilages of the ribs driven into the parenchyma of that organ. One of the three buckshot that were contained in the cartridge was deflected, and entered the right kidney, carrying away a portion of it. The case is reported by Surgeon F. P. Phelps, 1st Maryland, E. >S. The next case exhibits a shot wound of the concave surface of the left lobe of the liver,1 accompanying other injuries : Case 452.—Corporal D. II. M------, Co. H, Gth Pennsylvania Calvary, in a cavalry engagement near Brandy Station, August 1, 1863, was shot through the body, the ball entering the right flank and escaping from the left of the epigastric region. There is no account of the symptoms observed at the field hospital station, which was crowded with wounded. The name, military description, and entry, "gunshot wound of the abdomen, simple dressing," constitute the only field record. On August 2d, the corporal was transferred by rail to Washington, a distance of forty miles. He barely survived the transit, and expired in an ambulance wagon on the way to Douglas Hospital. The dressings and clothing were saturated with blood, and there had evidently been very profuse bleeding after he was moved from the car to the wagon. At the autopsy, made by Medical Cadet Edward D. Mitchell, it was inferred, from the size of the wounds of entrance and exit, that they were inflicted by a carbine ball. The notes of the autopsy describe a very erratic course of the projectile; but if the position of the entrance and exit wounds is correctly indicated, it must be inferred that the ball entered the right hypochondrium at the edge of the twelfth rib, scraping off its outer lamina about two and one-half inches from its free extremity, and passed inward and downward, penetrating the right kidney (as represented in Specimen 1773, figured further on), and was then deflected by the vertebral column, and passed upward through the duodenum, the posterior and anterior walls of the stomach, the left lobe of the liver near the umbilical fissure (FlG. 106), and emerged two inches to the left and below the end of the ensiform cartilage; or its course may have been the reverse of that described. The intestines were inflated. There was a great quantity of blood in the peritoneal cavity. The emulgent vessels had bled with especial freedom. The perforation of the liver is represented in the wood-cut (Fit.. 106). The wound of the duodenum is figured on page 67, and there will be a drawing of the perforation of the kidney in the subsection on wounds of that organ. 1 The following pathologjpal preparations of shot wounds of the liver are preserved in Museums: 1. Specimen 1401, Pennsylvania Hospital Museum, shows the track of a ball, half an inch in diameter, through tho anterior portions of the left lobe; the exit wound has a jagged margin and is larger than the orifice of entrance; no history (Cat, p. 73). 2. Specimen 41 8, New York Hospital Museum, shows a pistol ball perforation of the left lobe, from a man of 31, who died, eight hour* after the reception of the wcund, from internal haemorrhage; there is an irregular laceration, an inch in diameter, on the concave surface (Cat, p.'J06). 3. Specimen 1506 of the British Army Medical Department at Fort Pitt, shows "an extensive laceration of the convex surface of the right lobe of the liver, from a gunshot wound. FlG. 10d'.—Segment of the left lobe of the liver perforated by a carbine ball. Spec. 1645. [Reduced to one-fourth.J SECT. III.J WOUNDS OF THE LIVER. 135 The extraordinary extent and gravity of the complications attending the next case involve its history in an obscurity which the general description and the account of the autopsy fail to remove. The patient appears to have survived a deep perforation of the liver over four months:1 Case 474.—Private John T----, Co. K, 60th New York, aged 25 years, received a gunshot wound of the right side at Kenesaw Mountain, June 19, ISti 1. He was taken to the field hospital of the Twentieth Corps. On the 27th, he was transferred to the general field hospital at Chattanooga, and, on July 7th, to the Cumberland Hospital, Nashville, under the charge of Assistant Surgeon S. C. Ayres, II. S. V., who furnished the following details of the case: "The ball struck the sixth rib about the middle of its shaft, fractured it, and passed obliquely backward and downward. The physical condition of the patient was bad ; he was pale and emaciated, and was suffering from chronic diarrhoea and from a dry hacking cough. Whenever he coughed there was a protrusion from the wound which very much resembled a hernia, and which receded into the wound when the coughing ceased. A few days after admission, the external wound broke open and discharged a large quantity of blood and pus. No trace of the ball could be found. A tonic and stimulating course of treatment was pur- sued, and nutritious diet was given. The diarrhoea and cough continued, and although the patient improved a little at first, he afterward failed, became more and more emaciated, and died October 31, 1864. A few weeks before his death the external wound ceased suppurating and healed up. At the autopsy, miliary tubercles, quite profuse, with but little softening, were found in both lungs. The lower lobe of the right lung was partly carnified, and there were numerous pleuritic adhesions. The ball had pierced the dia- phragm, passed obliquely downward and backward through the right lobe of the liver, and had carried a spicula of the fractured rib into the substance of the liver. There was a slight indentation on the inner surface of the liver where the ball struck it. The missile was found lodged between the abdominal aorta and vena cava ascendens, and immediately below the right renal vein; it was lying upon the vertebra, and was very firmly encysted. There was no evidence that the bowels had been wounded by the ball in its course from the lower surface of the liver to the place where it lodged. The liver was healthy, and FlG 107 _A Uried~preparation of por- there was no evidence that there had been peritonitis." A preparation of the blood- tions of the aorta, vena cava, and renal , , ,. . , . , , ,-,-, -,™*\ T ■ i A i ... i vein, withaball, which has injured neither vessels and ball is represented in the wood-cut (llG. 107). It is greatly to be regretted yessel, lodged between the two larger. that the portion of the liver, including the cicatrized shot track, was not preserved. sPec- 910> A- M- M- Case 352.—Private Robert Johnson, Co. B, 138th Pennsylvania, aged 20 years, was wounded at Mine Run, November 27, 1863. A conoidal ball entered one inch to the right of the xiphoid appendage, passed downward and forward, and lodged at the anterior third of the ninth rib. The patient was treated on the field until December 5th, and then transferred to the Third Division Hospital at Alexandria. Stimulants and tonics were given, and cold-water dressings were applied to the wouud. The ball was excised on December 14th, by Surgeon Edwin Bentley, U. S. V. From the nature of the wound and discharge, it was evident that the ball had passed through the liver. The patient was very courageous, and, not knowing the nature of the wound, was sanguine of recovery. But rigors soon occurred, and great constitutional disturbances followed, and the patient gradually sank, and died December 20, 1863. The necropsy revealed empyema of the left pleural cavity. The ball had passed through the left lobe of the liver, which, as well as the spleen, was much disorganized. The intestines were black and softened, as though the tissues were iu a state of mortification. The case was reported by Acting Assistant Surgeon A. P. Crafts. Case 414.—Private Nicholas Binn, 3d Kansas, was wounded at Camp Hunter, March 20,1862, by the accidental discharge of a pistol. He was admitted to the Leavenworth City Hospital four hours afterwards. The haemorrhage was very slight. Surgeon George Rex, U. S. V., who reports the case, found that a probe indicated no trace of the direction of the ball beyond the orifice through the integuments. There was no serious uneasiness or indisposition, with the exception of annoying pain referred to tlie right subscapular region. All endeavors to discover the course of the ball failed, although the patient was placed in every conceivable position. He seemed to be doing well until the evening of March 23d, when respiration became suddenly embarrassed. With the dyspnoea the pulse became accelerated, beating 120, and the pain shifted from the scapula to the lower extremity of the sternum. The difficulty of breathing soon became so great that respiration could only be carried on in a sitting posture. The pain and orthopncea alternated. At times the patient breathed freely in the recumbent position; then the diaphragm would be suddenly convulsed, and dyspnoea would immediately ensue. This continued until March 29th, when the patient died. The pulse, when circumstances required, had been easily controlled by a few drops of tincture of veratrum viride, and at times, even during the last few days, there appeared to be some ground for hope of a favorable result. The autopsy Bhowed that the ball had entered the thorax about two inches below the entrance opening in the integument, had passed through the upper margin of the seventh rib about midway between the spine and sternum, and, passing through the diaphragm, the upper or convex portion of the right lobe of the liver, and a second time through the diaphragm, finally lodged in the cellular tissue immediately surrounding the descending aorta, about two inches below the heart. The omentum presented a gangrenous appearance, and the cavities of the chest and abdomen contained large quantities of bloody serum mixed with pus. In the five foregoing cases, both the thoracic and abdominal cavities were implicated, and the symptoms and morbid appearances alike presented great complexity. 11 confess, with mortification, that, though familiar with its details, of which, indeed, a brief abstract was printed at page 481 of the Catalogue of the Surgical Section of the Army Medical Museum, this case escaped my memory while compiling the account of cases of traumatic pneumocclc, on page 514 of the First Surgical Volume. This, if added to the scries there collected, would constitute an eighth example of hernia of the lung, observed during the War.—Editor. 136 PENETRATING WOUNDS OF THE ABDOMEN. [cnAP. vi. Fig. 108.—Segment of the right lobe of the liv- er, showing tho entrance wound of a pistol ball on the upper anterior sur- face. Spec. 1646. [Re- duced to one-fourth.] FlG. 109.-The second,third, and fourth lumbar vertebra?, the body of the third perfo- rated from right to left by a pistol ball. Spec. 1647. [ lie duced to one-fourth.] It has been already observed that wounds of the liver are often associated with fractures of the lower ribs and spine, and with wounds of the other viscera at the upper part of the abdomen, and of the diaphragm. A number of examples appear in the First Sirnjical Volume. At pages 570 and 584, instances are given of fracture of the ribs with hepatic lesions; Figures 194 and 196, on pages 441 and 444, represent musket balls lodged in the bodies of vertebrae, after traversing the liver. Instances of wounds of the stomach or intestines attended by lesion of the liver have been noted at pages 48, 82, and 88 of this volume. The entrance wound of a pistol ball, which perforated the eleventh right rib, right lobe of the liver, right kidney, body of the third lumbar vertebra, the spleen, and left kidney, and emerged through the tenth intercostal space, is well shown in the wood-cut (Fig. 108). The specimen was taken from the body of the bugler1 whose case is related in the Second Section of the Fourth Chapter of the preceding Surgical Volume. The perforation of the body of the vertebra is shown in the opposite wood-cut (Fig. 109). The three following are instances of shot perforations cf the diaphragm and liver without copious consecutive haemorrhage: Case 427.—Private A. Delarue, Co. A, 2d Delaware, aged 36 years, received a gunshot penetrating wound of the chest and abdomen at Cold Harbor, June 3, 1864. A conoidal ball passed through the diaphragm and perforated the liver. He was at once conveyed to the field hospital of the 1st division, Second Corps, where simple dressings were applied. On June 15th, he was transferred to De Camp Hospital, New York Harbor. Death resulted June 16, 1864. The case is reported by Assistant Surgeon Warren Webster, U. S. A. Case 445.—Private W. James, Co. B, 13th Tennessee Cavalry, received three shot wounds at Fort Tillow, Tennessee, April 12, 1854. One ball entered at the anterior border of the right scapula immediately above the inferior angle, passed down- ward through the liver, and across the abdomen; another entered midway between the acromion process of the scapula and sternal end of the clavicle, passed through the upper lobe of the left lung, and emerged at the posterior border of the deltoid of the right arm ; a third ball made a large perforation through the deltoid muscle of the right arm from before backward. On the 14th, the patient was admitted to the hospital at Mound City. The first ball was extracted one inch above the crest of the left ilium. Simple dressings were applied to the wounds. Death resulted April 15, 1864, from exhaustion. The necropsy revealed the course of the missiles as described. The case is reported by Surgeon H. Wardner, U. S. V. Case 449.—Private C. G. Kingsbury, Co. D, 39th Massachusetts, aged 28 yeajs, received a penetrating wound of the abdomen at Petersburg, April 1, 1885. He was taken to the field hospital of the Fifth Corps, where simple dressings were applied to the wound. On the 8th, he was transferred, on the hospital steamer State of Maine, to Washington, and admitted to Armory Square Hospital on the 10th. The register and case book at this hospital states that a conoidal ball entered over the ■ second floating rib, left side, midway between the umbilicus and right nipple, and emerged one inch from the spinal column, at the second lumbar vertebra. When admitted, there was pain of an acute character in the region of the wound, with discharge of pus, and a greenish-white secretion exuded from the wound; skin, conjunctiva, and eyes yellow. His pulse was full and rapid, 120 per minute, and respiration greatly impeded; sleepless nights. Death resulted May 29,1865. At the necropsy, the ball was found to have perforated the liver at its upper lobe; exit at inner border of gall-bladder; it also passed through the lower lobe of the right lung. The thoracic cavity on the right side was filled with pus; pleuritic adhesions very firm, almost impossible to remove them. The abdomen was filled with pus and coagulable lymph. Surgeon D. W. Bliss, U. S. V., reports the case. The next case exemplified the hyperacute peritonitis following a shot perforation of the gall-bladder: Case 424.—Corporal A. Coflin, Co. G, 6th Kansas Cavalry, received a pistol-shot wound of the abdomen at Fort Scott, Kansas, September 17, 18.33. He was immediately admitted to the hospital at Fort Scott. The shock was not great, the pulse being nearly normal, and the pain inconsiderable. The pain became intense in a few hours; abdomen, hard and tumid; pulse, rapid and feeble; and death occurred fifteen hours after the reception of the injury. Autopsy six hours after death: the peri- toneal sac was filled with blood, and intense inflammation was established. The ball passed through the cartilage of the ninth rib, the quadrate lobe of the liver, the gall-bladder, and the ascending colon and right kidney, and made its exit near the twelfth dorsal vertebra. The case is reported by Assistant Surgeon A. C. Van Duyn, U. S. V. 1 Part I, Vol. II, Chap. IV, p. 446, case of Bugler William 15- is figured in the Fifth Chapter, page 567 (FlG. 267). The eleventh rib perforated by a pistol ball. From this case specimen 3291 SECT. III.1 WOUNDS OF THE LIVER. 137 A shot wound of the gall-bladder, resulting fatally in twenty-two hours, was errone- ously reported in Circular No. 3, 1871, as an instance of recovery.1 The instance recorded by Parroisse2 remains an exception to the ordinary termination of such lesions. Case 408.—Sergeant W. G. Alleger, Co* G, 142d Pennsylvania, aged 23 years, was wounded at Gettysburg, July 1, 1863. He was treated in the field hospital of the 3d division, First Corps, until the 24th, when he was admitted to Camp Letterman Hospital. Aoting Assistant Surgeon W. B. Jones reported that: "A minie ball entered the cavity of the abdomen' three inches above and one inch to the right of the umbilicus, passed obliquely to the right and upward, passing through the liver and gall-bladder, and emerged between the sixth nnd seventh ribs. From the time of injury until decease, large quantities of bile were discharged from the upper wound; his health seemed to remain good until August 1st, when he began to sink ; a severe diarrhoea commenced shortly after reception of the injury and continued until he died, being controlled at intervals by the free use of camphor and opium. The treatment consisted of cold-water dressings to wound, and administration of beef-tea, brandy, and opium. He died August 0, 1833." Death from secondary haemorrhage, as exemplified in the following case, was an uncommon result of shot wounds of the liver: Case 4:;:>.— Private S. C. Gage, Co. C, 15th New Jersey, aged 28 years, was admitted to Finley Hospital, Washington, May 8, 1863, with a gunshot penetrating wound of the chest and abdomen, received at Chancellorsville on the 3d. A conoidal musket ball had entered at the right side between the seventh and eighth ribs, nearer to the spine than to the sternum. Its course was inward, upward, and forward; and its exit two and a half inches to the inner side of the right nipple, between the fourth and fifth ribs. The liver was wounded in its passage as well as a portion of the lung. Bile was discharged for several days from the lower or entrance wound. On May 12th, at eleven o'clock at night, uncontrollable haemorrhage occurred, and death resulted in a short time, May 13, 1S33. Assistant Surgeon William A. Bradley, IT. S. A., reported the case. The ordinary result of death from primary haemorrhage was often caused by perfo- rations by very small projectiles, as in the following instance: Case 455.—Private T. Mullen, Co. B, 1st Iowa Cavalry, was wounded at Rolla, May 27, 1863, while attempting to pass the guard, by a pistol ball which inflicted a penetrating wound of the chest and abdomen. He was conveyed to the hospital at Rolla, where cold-water dressings were applied and anodynes administered. Reaction never took place, and death occurred, twenty-four hours from the reception of the injury, from haemorrhage into the right pleural and abdominal cavities as well as externally. At the necropsy, the ball was found to have entered between the ninth and tenth ribs, about midway between the anterior and posterior median lines, fractured the ninth and tenth ribs, perforated the diaphragm, passed through the light lobe of the liver, leaving a fissure one inch iu depth and five inches in length; it again perforated the diaphragm, and, coursing directly onward, emerged to the right of the ensiform cartilage. The case is reported by Surgeon H. Culbertson, U. S. V. The mode of fatal termination next in frequency, in shot wounds of the liver, was from the consequences of the formation of hepatic abscess : Case 456.—Private S. Miller, Co. I, 24th Missouri, aged 18 years, was wounded at Bayou De Glaize, May 18, 18u'4. A conoidal ball penetrated the upper surface of the right lobe of the liver and the under surface of the right lobe of the lung. He was treated in the hospital of the 3d division, Sixteenth Corps, until June 2d, when he was transferred, on the hospital boat N. W. Thomas, to St. Louis, and admitted to the hospital at Jefferson Barracks. Stimulants and anodynes were there administered. Pyaemia was developed, and death resulted June 8, 1884. At the necropsy, a large abscess was found in the right lobe of the liver, containing about four ounces of pus. Two-thirds of the lower lobe of the right lung were solidified. The case is reported by Surgeon John F. Randolph, U. S. A. An instance of a traumatic hepatic abscess discharging through the bronchial tubes is noted by Acting Assistant Surgeon J. Robertson: Case 428.—Private O. H. Dorr, Co. G, 66th Ohio, was wounded at Cedar Mountain, August 9, 18lv2, by a musket ball, which entered to the right of the ensiform cartilage and emerged near the angle of the ninth rib. He entered Fairfax Street Hospital, at Alexandria, on August 12th. Upon examination, it was thought the pulmonary organs had escaped injury. There was at no time haemoptysis. The general condition was favorable until August 28th, when there was a chill, followed by severe coughing, the expectoration being purulent and mixed with bilious matter. This form of expectoration continued until the patient's death, September 8, 1852. At the autopsy it was found that the ball had passed through the lower lobe of the right lung, the diaphragm, and had grooved the convex surface of the liver. In investigating the complications of wounds of the lung, there was occasion to observe that general pleurisy and pneumonia, so far from being inevitable consequences of ■CASE CL1X, of Private Murphy, 6th Cavalry, reported by Assistant Surgeon PATZKI, Circular 3, p. 50. On the publication of this report, Assistant Surgeon PATZKI and W. J. WILSON, and Dr. Tuuhill, who made the autopsy in the case, hastened to correct the inaccurate statement that the patient was wounded "November 27, 1870, * * recovered, and was discharged from service December 27, 1870." He was, in fact, wounded on December 26, and died twenty-two honrs subsequently, December 27, 1870. It is due to the clerical assistants at this effice to remark that the mistake was not made here, but at the Post. 2PAUR0ISSE (Opuscules de Chirurgie, 1806, p. 254) mentions that he had seen in the hands of a surgeon, a ball enclosed in a gall-bladder. The preparation was taken from a military man, who had received a shot wound in the internal lateral part of the right hypochondrium, and two years subsequently died in hospital of a pulmonary trouble. At the autopsy, the ball was found in the gall-bladder, on which no cicatrix could be discovered. 18 138 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. shot wounds of the thoracic cavity, as erroneously taught by routinists, were in reality only exceptional results of such lesions, the pathological alterations being ordinarily limited, in a remarkable degree, to the vicinity of the injured parts. This principle obtains with equal regularity in wounds of the liver. General hepatitis is seldom induced by such lesions. This fact, demonstrated by morbid anatomy, might be inferred from the symptoms. Jaundice, which is known to be a constant sign in general hepatitis,1 and infrequent in partial hepatitis, is present in only a small proportion of the cases of wounds of the liver. In considering the liability of the liver to injury in antero-posterior or oblique perfo- rations through the epigastric or hypochondriac regions, the surgeon will reflect upon the general topography of the viscus, its variations in size and position in individuals, its and four drops of tincture of veratrum viride ordered every four hours; this medicine was suspended after the second dose, as it produced unpleasant head symptoms without reducing the pulse. Small -es of calomel and antimony were then administered." Cask 434.—Private L. Glynn, Co. B, 37th New York, received his death wound in a skirmish with the enemy near Colchester, Virginia, February 24, 18:L\ He lived only a few minutes. The ball entered the right side of the thorax, fracturing the ninth rib near the angle, and wounding the lower border of the lung; it then passed through the diaphragm, tearing open the 1M. Jules Si.MON (Art Foie. Nouv. Diet de Med. et de Chir. pratique, 1872, T. XV, p. 9G) observes: " L'ictere n'est point un symptome frequent dan* l'hepatite, partielle; loin de lii. J. Cruvcilhier avait parfaitement remarqu6 que son apparition tenait a des circonstances sp6ciales, a un obstacle mecanique au cours de la bile. Haspel, sur un terrain plus vaste, a observ6 le meme fait, qui fut confirmd depuis par Rouis et William McLean. Ordinaireuient done, il n'y a pas d'ktere, et, si l'ictere sc produit, il est du a la compression des voies biliaires par l'abcds, ou U d'autres causes d'obstacle mecanique au cours de la bile. Hemarqrons que l'ictere est, au contrairc, constant dans l'hepatite diffuse." SECT. III-l WOUNDS OF THE LIVER. 139 PIO. 113.—View exposed on a transverse section of the trunk between the ninth and tenth dorsal vertebrae, dividing horizontally the lungs, the liver, stomach, pancreas, spleen, and left kidney. [After Mayer. J liver, the ascending cava, the stomach posteriorly in two places, at the lesser and greater curvatures, the diaphragm again, the left pleura, fracturing the tenth rib anteriorly, and finally fracturing both bones of the left forearm, near the upper third. The heart was empty, while the cavities of the thorax and abdomen were entirely filled by the resulting hcemorrhage. The case is reported by Surgeon W. O'Meagher, 37th New York.1 Wounds having tracks approaching parallelism with the long axis of the body are more common in modern than in ancient warfare. Balls not infrequently traverse the liver from above downward, or the reverse. Hence it is important to consider the relations of the organ in the horizontal planes. The cases of Corporal E-----(First Surgical Vol- ume, p. 441), of Private Kingsbury (p. 136, supra), and some of the complicated cases of wounds of the thorax and abdomen, in which the lung, diaphragm, and perhaps a kidney or coil of intestine were involved, afford examples of these vertical perforations, the frequency of which is doubtless due to the prone position of the soldier receiving the wound. The following is another instance: Case 470.—Corporal J. Sumstine, Co. K, 87th Indiana, was wounded at Chickamauga, September 20, 1863; was admitted to hospital at Chattanooga on same day. A buckshot had passed through the nose and left cheek, and a mini6 ball, striking to the right of the sternum in a line vertically below the nipple, had passed downward and backward and made its exit close to the crest of the right ilium, involving the lower lobe of the lung and the right lobe of the liver. The patient expectorated blood. Cold-water dressings were applied to the wounds, and a cathartic was given. The next entry is on September 28th, when it is mentioned that the upper orifice discharged blood in the jnorning; bowels regular: wounds suppurating; moderate febrile reaction ; cold-water dressing; whiskey and quinia thrice daily, with nourishing diet. September 29th, considerable irritative fever; pulse 95; appetite pretty good; bowels regular; respiration slightly hurried; treatment continued. September 30th, pulse 96; extremities cool; tongue dry and slightly cracked; countenance anxious; irritative fever; sanious discharge from wounds. October 10th, restless night, with hacking cough and diarrhoea; continued whiskey and quinine, with beef-tea, Dover's powder, and tannin. October 11th, cough and diarrhoea some- what better; ordered a mixture of paregoric and spirits of nitric ether, a teaspoonful every four hours, with whiskey, quinine, and good diet. On November 26th, he was admitted to hospital at Bridgeport, Ala- bama, and, on December 2d, transferred to Murfreesboro', and fur- loughed on January 12, 1864. Adjutant General's Report of Indiana, Volume VI, p. 470, shows that he died while on furlough, January 14, 1864, one hundred and seventeen days after receiving the injury. The case is reported by Assistant Surgeon Jabez Perkins, U. S. V. In the following instance of a nearly ver- tical shot perforation of the right lobe of the liver, one of the larger branches of the hepatic duct was divided: FIG. 114.—View of the abdominal viscera on a horizontal sec- tion between the eleventh dorsal and first lumbar vertebrae, dividing the liver, stomach, spleen, and both kidneys. [After Mayer.] Case 436.- Private John Green, Co. H, 148th Pennsylvania, was wounded at Gettysburg, July 2, 1863. He was treated in the Seminary Hospital, and subsequently in McKim's Mansion Hospital at Baltimore, where he was admitted July 16th. Acting Assistant Surgeon W. G. Smull reported on Medical Descriptive List: "Ball entered three inches from the median line, fracturing the eighth rib near the cartilage, and, passing between the seveuth and eighth ribs, perforated the superior portion of the liver to the depth of an inch, and emerged three inches from the point of entrance, on the right side. Treatment: Cold- water dressings, stimulants, and nourishing diet. He suffered much pain and loss of appetite, and bile was discharged at intervals from the wound. He died August 15, 1863, and a post-mortem examination showed that the ball had opened a small duct, and that there was much peritoneal inflammation, with adhesions. Recoveries from Shot Wounds of the Liver.—Lists of no less than sixty-two reported instances are printed on pages 131 and 132, thirty-seven cases being complicated by 1 O'Meagher, Cases in Military Surgery, in Am. Med. Times, 1862, Vol. IV, p. 205. 67344� 110 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. lesions of other organs. In a number of cases the hepatic lesion was demonstrated by the escape, externally, of bile or of a portion of the substance of the liver ; but there were many instances in which the diagnoses reposed on evidence far less conclusive ■} Case 312.—Private T. H. Bradley, Co. K, 39th Massachusetts, aged 19 years, was wounded by a pistol ball, at Hatcher's Run, March 30, 1865. He was admitted to the field hospital of the Fifth Corps on the same day, and, on April 3, 1865, was transferred to Washington, Armory Square Hospital, entering on the 5th. Surgeon D. W. Bliss, U. S. V., reported as follows : "Ball entered the right side of back, about the ninth intercostal space, and, passing downward and forward, probably through the liver, emerged from the right side of the abdomen three inches below the line of entrance." The treatment consisted of cold-water dressings and the administration of tonics and stimulants. The patient improved rapidly, and was furloughed on April 26th, and was discharged the service accordingly on May 26, 1865. He is not a pensioner. Cases 313-315.—Shot wounds in the right hypochondrium were regarded by Acting Assistant Surgeon Butcher, Surgeon G. Grant, U. S. V., and Surgeon E. Bentley, U. S. V., respectively, as undoubtedly attended by injury of the liver. In the case of Private Carney, bile escaped from the wound; this was a perforation ; in t\\e two other cases, the ball lodged. Sergeant Buck is not a pensioner. Corporal Butler and Private Carney are pensioned, the examiners' reports not corroborating those of the attending surgeons. Case 316.—Surgeon T. H. Squire, 89th New York, reports that "Private S. Case, Co. C, 130th New York, was wounded at Suffolk, April 13, 1863, by a musket ball, which entered the right side of the body three inches above the lower margin of the floating ribs, and came out six inches further back, and on a little lower plane, the wound of exit being three inches from the median line of the back. The wet cloth that was laid on the wounds was stained a greenish-yellow color, from the bilious discharge from the posterior orifice, thus showing that the liver, and perhaps the gall-bladder, was perforated." On April 15th, Cast! was admitted to Hampton Hospital, Fort Monroe; and on October 29,1863, he was transferred to New York, convalescent. He is not a pensioner. Case 317.—Sergeant W. Clifton, 77th U. S. Colored Troops, reported by Surgeon J. B. G. Baxter, U. S. V., as receiving a shot perforation of the convex portion of the liver, February 3, 1865, was returned to duty April 10, 1865, and does not appear on the Pension List. In the next case a musket ball is supposed to remain lodged in the liver: Case 318.—Private W. M. Crandall, Co. K, 42d Ohio, was Avounded at Vicksburg, May 22, 1863, by a musket ball, which penetrated the right side of the abdomen. He remained at the field hospital until June 17th, when he was taken on board the hospital steamer R. C. Wood and conveyed to Memphis, entering Gayoso Hospital June 22d. Here the injury was noted as a "gunshot wound of the gastric region." On October 5th, he was sent to the hospital at Camp Dennison, Ohio, whence he was transferred to the Invalid Corps, November 11, 1863. He was discharged from service June 1, 1864, and pensioned. Pension Examiner Alexander Steele, of Oberlin, Ohio, reports, December 19, 1886: "The ball entered three and a half inches above, and one inch to the right of, the navel, and is supposed to be in the liver. The wound is open, and has been discharging since September, 18 Jo. There is pain on slight motion, which is increased by labor. Sufficient effort is supposed to have been made to extract the ball, but unsuccessfully. The disability is permanent, and equal to loss of a limb, unless the ball is extracted, which does not seem probable; health otherwise good. Habits, correct." He was last paid December 4, 1872. •The following instances of recovery from alleged shot wounds of the liver are found recorded in the annals of surgery: 1. QUEUCETANUS (SCHENCKIUS, 06s. med. rar., 1644, p. 397) relates the case of a nobleman shot in the liver. He was deserted by the surgeons, who considered his case hopeless, but he finally recovered. 2, 3. Purmaxx (Funfzig sonderbare Schusswunden, Jena, 1721) cites two cases of shot wounds of the liver, received before Stettin, 1677; recovered in ten and thirteen weeks, respectively. 4. LE ROUX (Rec. period, d'obs. de med., T. XIX, 1763); shot fracture of ribs, and wound of liver with loss of substance; recovered in two and a half months. 5. BlLGUER (Chir. Wahrnehmungen, 1763, S. 388) records a case treated by Feldscheerer Waltheii ; ball entered below the right short ribs, and was cut out on the opposite side; copious discharge of bile. 6. Pew (Med. and Phil. Comm. of Soc. of Edinburgh, Vol. V, 1777); shot wound of liver, stomach, and lung; recovered in eleven months ; purulent matter con- tinued to escape. 7. MICHAELIS (Nachrichten aus New York, in IllciIXEit's Chir. Bibl., 1782, B. VI, S. 731); shot wound of liver; escape of bile for fourteen days; recovered in three months. 8. David (Gaz. Med. de Paris, T. XIV, p. 957): In 1800, an officer of lancers was shot two inches to the right of the spine, at the twelfth dorsal vertebra, the ball escaping in front; pus tinged with bile for twenty days ; recovered in two years ; in 1815 the officer was at Paris, entirely well. 9. BLICKE (Guthrie, 1. c, p. 51); fracture of eighth rib and penetration of liver; for two months purulent bilious matter escaped. 10. IiYAX (GUTHRIE, I. c, p. 52); Lieut. II------, shot through upper part of liver; tedious recovery on account of shattered state of constitution from this and a previous dangerous wound. 11. Laruey (Mem. de Chir. mil., 1817, T. IV, p. 272); an officer at tho battle of Dresden received a shot fracture of the ninth rib, with lesion cf the liver; fragments of bone removed; recovered in seventy days. 12. GUTHRIE (I. c, p. 53); shot wound in right hypochondrium, received in 1814; bilious discharge continued in 1817, and for some years afterward; missile remained in wound. 13. Idem (I. c, p. 51) cites the case of Sir S. B-----; ball struck the cartilages of the false ribs, removing a portion, and injured the liver; escape of bile for several weeks; recovery. 14. BliUCE (GUTHRIE, I. c, p. 52); shot wound of the liver, received at Waterloo: escape of bile; ball remains in wound. 15. GUTHRIE, (1. c, p. 53); a soldier of the 48th regiment, shot at Albuhera; copious discharge of blood and bile; recovery. 16, 17. Hennen (1. c, p. 435) records the case of Lieut. Col. II------; copious bilious discharge; recovered in two and a half months; and also a second case of recovery, complicated by other injuries. 18. Braux (Rust's Mag. fur die gesammte Heilkunde,, B. XVI, S. 241); a tailor, aged 30, in 1816, received a pistol shot in the right epigastrium; copious bleeding, and escape of brown pus with solid brown particles, similar to liver substance; recovery in eight weeks. 10-2d. Baudexs (Clinique des plaies d'armes a feu, 1836, pp. 220, 304, 353, and 355) records four cases of recoveries from wounds of the liver; in the first case, the lung and diaphragm were also injured, and in the third, the ball was removed from the liver. 23. DUPUYTREN (Lecons orales de clin. chir., 1639, T. VI, p. 178); a citizen shot in the anterior and upper part of the right hypochondrium; escape of portions of tbe liver and of bile; fistulous opening for three and a half months; recovery. 24. BECK (Die Schusswunden, 1850, S. 178); a soldier, shot through the upper part of the liver, right side, at the battle of Staufen, 1848 ; recovery. 25, 26. GIBBS (British Am. Journal, 1848-49, p. 229) gives a case of shot wound in left lobe of liver; hepatic fistula, with escape of bile and blood; recovery; and (ibid., p. 230) mentions another case of recovery, but gives no particulars. 27. LOHMEYER (Die Schusswunden, 1859, S. 165) cites a case from the Danish war, 1850; bile escaped on the sixth day ; recovered in about five months. 28. Massie (New Orleans Med. and Surg. Jour., Vol. IX, 1853, p. 146); accidental shot wound through anterior margin of right lobe of liver, which protruded aud became gangrenous; gangrenous part removed; recovery. .29. Wardner (Chicago Med. Examiner, 1860, Vol. 1, p. 33); pistol-shot wound between ninth aud tenth ribs; on the sixteenth day pus mixed with bile escaped; recovered in seven weeks. 30. Dem me (Militiir-chir. Studien, SECT. III.] WOUNDS OF THE LIVER. 141 Cases 319, 320.—There can be no doubt that Sergeant Crawley and Private Cunningham recovered from severe shot wounds of the liver. The former, wounded at Gaines's Mill, June 27, 1852, was attended by Assistant Surgeon Breneman, and discharged April 24, 1863, by Surgeon John Moore, for "severe wound of the liver." Cunningham, wounded at Petersburg, June 16, 1854, was attended by Assistant Surgeon Forwood; and Pension Examiner Scott, of Ithaca, Michigan, in 1868, confirms the diagnosis, remarking that the ball must "have passed directly through the liver." Case 321.—Sergeant P. Fallenstein, Co. F, 98th Pennsylvania, aged 28 years, was wounded at Winchester, September 19, 1864, by a conoidal ball. He was admitted to the field hospital of the Sixth Corps on the same day, and on October 11th was transferred to the Sheridan field hospital at Winchester. Here the injury was diagnosticated as "gunshot wound through liver." On December 4th, he was transferred to Frederick; the wound was here described as a "gunshot wound of right side of abdomen, without injury of internal organs." On January 4, 1865, he was transferred to Philadelphia, where he was admitted to the Filbert Street Hospital on the 9th, with "severe gunshot wound of parietes of abdomen, with injury to liver." He was returned to duty on January 26th, and mustered out of service June 29, 1805. Pension Examiner J. H. Gallagher, of Philadelphia, reported, June 25, 1866: "Ball entered the abdomen near the linea alba, passed through the right rectus muscle, and was extracted at the back, on nearly a straight line, at the lower border of the chest. The greatest pain is felt at the back, and is of a lancinating character, brought on by stooping and lifting; he also complains of oppression after exercise; he frequently raises clots of blood. Disability one-half, probably permanent." He was last paid to September 4, 1872. Case 322.—Private Noyes is a pensioner, who received a shot perforation of the right hypochondrium at Drury's Bluff, May 16, 1864. Assistant Surgeon E. McClellan was positive that the ball passed through the liver. Case 323.—Sergeant D. Perry, Co. B, 14th New York, received a gunshot wound at Malvern Hill, July 2, 1852. He was admitted to field hospital on the same day, and, on the 20th, was transferred, by Hospital Steamer Kennebec, to Fort Monroe, where he was admitted to Mill Creek Hospital on the 21st, the injury being reported as "a gunshot wound of the side." He was discharged tbe service on account of his wound April 23, 1863. Pension Examiner H. B. Day, of Utica, New York, reported, September 12, 1864: "Gunshot wound of right side; the ball passed through the liver; the wound is still open." On March 2,1870, he reported that "he now is much emaciated; suffers constant pain and soreness of the right side over the region of the liver; pain on top of right shoulder, and weakness and lameness of the right arm, with which he can do but little labor. I do not consider the disability necessarily permanent in the above degree, still he may become worse." He was last paid to March 4, 1873. Case 324.—Corporal J. M. Roberts, Co. F, 83d Indiana, received a shot wound of the abdomen at Vicksburg, May 18, 1863. He was admitted to the field hospital of the Fifteenth Corps, and transferred, per steamer R. C. Wood, to Memphis, where he was admitted to Jackson Hospital on June 1st. Surgeon E. M. Powers, 7th Missouri, states; "The missile entered at the scrobiculus cordis, ranging to the right, and lodged between the angles of the tenth and eleventh ribs on the right side. Condition June 2d: Pulse natural; appetite good; spirits good; no fever; wound discharging bilious matter. Treatment: Cold-water dressing. June 10th, ball cut out. There were no bad symptoms, and no treatment required except an occasional opiate at night. The patient was furloughed July 22d, readmitted on September 14th, and on October 11, 1833, was returned to duty." The monthly report of the City Hospital, Indianapolis, for October, 1864, shows this soldier to have been discharged the service, on certificate of disability, on October 23, 1851, the injury being registered "Gunshot wound of the superior portion of the right lobe of the liver." Pension Examiner W. S. Cornell, of Versailles, Indiana, reported, March 24, 1868: "Ball entered a little below the lower end of the sternum, and was extracted from between two of the lower ribs, over the region of the liver; the wound where the ball entered has opened and is discharging, and has been for the last five or six months, so as, in my opinion, to wholly disable him from earning a living at manual labor. Disability total." This pensioner was last paid in December, 1872. 1861, B. II, S. 138); the missile entered between the ninth and tenth ribs, three and one-half inches from the xiphoid process, and escaped between the seventh and eighth ribs near the spine; pus with yellow matter escaped; at the end of the third week a small fistulous opening remained; recovered in eight weeks. 31. Porta (Demme, I. c, p. 137); an Austrian, aged 25, shot, at Magenta, in the right hypochondrium; several ribs fractured and fragments carried along; for twelve days pure bile escaped; recovered in seven weeks. 32. Idem (Demme, I. c, p. 137) relates a similar case, where bile escaped for some time without febrile action; recovered in two months. 33. Verga (Demme, I. c, p. 138); a French soldier, wounded, at Solferino, below the tenth rib; escape of bilious matter. 34. Wii.ders (Med. Times and Gaz., 1862, p. 10); girl, aged 11, shot through wrist and abdomen; voniiting of greenish-colored fluid ; recovery in six weeks. 35. HAMILTON (A Treatise on Mil. Surg., 18G5, p. 353); a Buffalo policeman, in July, 1863, was shot in the abdomen one inch to the right of the median line, ball escaping on the same side six inches from point of entrance, between the eleventh and twelfth ribs, striking the convex surface of the liver; recovery in four months. 3G. Foumexto (Gazette des Hopitaux. Sept., 1863, p. 430); soldier, aged 21, wounded at Chancellorsville, May 3, 1863, in the right hypochondriac region; treated at Richmond; lung and liver injured; copious bleeding, and vomiting of green bile; recovered in two months. 37. BuOTHERSTON (Edinburgh Med. Jour., 1864, p. 826); shot fracture of the eighth and ninth ribs; fragments of bone, driven into the liver, removed; recovered in two and a half months. 38. OCHWADT (Kriegschir. Erfahrungen wahrend des Krieges gegen Ddnemark, 1864, Berlin, 1865, S. 346); a Dane, wounded April 18, 1864, in the right epigastrio region; bile escaped; recovered in four and one-half months. 39-41. STROMEYER (Erfahrungen uber Schusswunden, 1867, S. 6) mentions three cases of recoveries, from shot wounds of the liver, in 1866, in the hospitals at Langensalza and Kircheilingen. 42. FISCHER (lv.), Militiirarztliche Skizzen, 1867, S. 63); recovery from shot wound of liver; discharge of bile. 43-45. VOLKMANN (Einige Fiille von geheilten penetrirenden Schusswunden des Abdomens und besonders der Leber, in Deutsche Klinik, 1868, No. 1) cites three cases of recoveries from wounds of the liver, with copious escape of bile. 46. BECK (Kriegs-chirurgische Erfahrungen, 1867, S. 238) relates the successful issue of u shot wound of the liver in the Austro-Prussian war of 1866; bile escaped for two months. 47. Whitehead (The Med. and Surg. Rep, 1867, Vol. XVII, p. 311, and Circular 3, S. Gt. O., 1871, p. 49); a sailor, aged 22, was shot from behind; ball removed by incision at a point two and one half inches from the median line, and three and one-half inches below the nipple ; wound bled freely, and bile continued to discharge for at least a month and a half; recovered. 48-52. BECK (Chirurgie der Schussverletzungen, 1872, S. 538) gives five cases of recoveries from shot wounds of the liver, bile having escaped in every instance. 53, 54. Fisc:ii-:a, (II.), (Kriegschirurgische Erfahrungen, 1872, S. 130) remarks : "In four instances we diagnosticated wounds of the liver. Two had exceedingly happy results. Nevertheless 1 would like to insist in one instance only on the correctness of the diagnosis." 5.1 Kleixpaul (Schmidt's Jdhrbucher, 1871, S. 185) records the case of a French sergeant wounded between the sixth and seventh ribs; escape of bilious matter; recovered in about seven weeks. 55. NlCAISE (Gaz. de Paris, 1871) relates a case of recovery in four weeks, with small fistula remaining. 57. VERXEUIL (V Union midicale, 1871, p. 755); a revolver ball passed entirely through the liver in its greatest diameter, ball remaining in the tissues ; no suppuration, vomiting, diarrhoea, or fever; recovered. 58. DEPRES (Gaz. Mid. de Paris, 1871); soldier, at S§dan, shot through the right hypochondrium ; bilious fistula; recovered. 59, 60. CASES CLVII and CLVIII, of Cir. 3. 112 PENFTRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. Cases 325-32S.—Private S. Scott is not a pensioner. He received a shot wound in the right hypochondrium at White River, Mississippi, October 19, 1864. It was thought by Assistant Surgeon D. Seofield, 47th U. S. Colored Troops, to interest the liver. Surgeon B. S. Chase, 53d U. S. Colored Troops, was less positive of the existence of an hepatic lesion.—Private Shively is reported, by Acting Assistant Surgeon Joshua Thome, as shot through the liver, June 20, 1833, and returned to duty S "ptember 2, 1853. The name is not on the Pension List.—Dr. Lidell has related the case of Private Gilbert Smith, in the American Journal of the Medical Sciences, 1857 (already referred to on p. 131, supra), Vol. LIII, p. 344. There is no doubt respecting the severity of the hepatic lesion in this case, and it is interesting to add to Dr. Lidell's report, that G. Smith was reported by the pension examiner in tolerable health in December, 1872, nine years after the reception of the injury.—Corporal J. B. Smith furnishes another instance of undoubted recovery from a severe shot perforation of the liver. Wounded at Fredericksburg, December 13, 1862, and attended by Assistant Surgeon C. A. McCall; he was living, in impaired health, December, 1872. Case 329.—Sergeant W. W. Smith, Co. G, 5th Texas, aged 25 years, was wounded at Gettysburg, July 2, 1833, by a conoidal ball, which entered the right side of the abdomen. He was taken to the field hospital, where he remained until August Kith, when he was transferred to Camp Letterman. Assistant Surgeon T. J. Vance, C. S. A., who attended the case, states, on a medical descriptive list, that " the ball entered the right hypochondriac region and passed through obliquely, and made its exit some four inches below, and to the right of, the umbilicus. The right lobe of the liver was penetrated by the ball, as was proved by the escape of the secretions, and of a portion of the liver. Cold-water dressings were applied to the wounds, and anodynes given. August 20th: the wounds have healed, though he suffers excruciating pain in the region of the transverse colon. Camphor and opium pills were given, and tincture of iodine applied over the vicinity of the pain. September 1st: patient doing well, though suffering occasionally in the region of the liver and colon. September 20th: health good, pain ceased." On Sep- tember 25th, he was transferred to West's Buildings Hospital, Baltimore, whence he was paroled on November 12, 1833. Case 330.—Sergeant S. K. Snively, Co. M, 13th New York Cavalry, aged 22 years, was wounded at Piedmont, Virginia, October 17,1861. He was treated in the regimental hospital, and late Assistant Surgeon J. T. Btirdick, 13th New York Cavalry, gave, April 4, 1866, the following account of the case while in his charge: " Gunshot wound of the right hypochondriac region; a musket ball entered three inches to the right of the umbilicus; the direction was internal and toward the left and downward, injuring the right lobe of the liver; the seat of lodgement of the missile could not be determined, although it still remained in the body. The treatment consisted of the local application of compresses dipped in tincture of opium; morphia internally in large and frequent doses, alternated with tincture of veratrum viride. The patient suffered with nausea and retching, and had painful hajmaturia. A catheter was introduced into the bladder thrice daily." Records on file show that this patient was treated in regimental hospital, at Camp Relief, from March. 31, 1865, to May 14, 1835. He was discharged at Alexandria, July 13, 1865, for "gunshot wound between the seventh and eighth ribs, near the sternum, and shell wound of lower third of tibia; disability total." He is a pensioner, and was last paid December 4, 1872. Case 331.—Sergeant G. W. Tindall, Co. C, 4th New York Cavalry, aged 19 years, was wounded in the abdomen at Aldie Gap, June 17,1863, by a rifle ball. He was admitted to a barn hospital,-near Aldie, on the same day. Assistant Surgeon R. A. Dodson, 1st Maryland Cavalry, reported: "Missile passed through the lower portion of the liver, and passed out one-half inch from the spine. The treatment consisted in the cautious use of stimulants and of nourishing diet. Constitution impaired; four weeks after the injury he was still in a critical condition." On August 2d, he was transferred to Alexandria, whence Surgeon E. Bentley, U. S. V., reported: "Ball entered four inches above, and three inches to the right of, the umbilicus, aud emerged slightly to the right of the spine of the last dorsal vertebra; the wound was in good condition at the time of his admission." He was furloughed on August 28th for thirty days, and was transferred to the Veteran Reserve Corps on December 10th. On March 27, 1864, he was discharged the service. Drs. C. Phelps, W. F. Deming, M. K. Hogan, and T. F. Smith, examining board, New York City, reported, April 3, 1872: "Ball passed through right hypochondrium and emerged before the right border of the lumbar spine, interfering with the movements of back and right upper extremity. Disability one-half, and permanent." He was last paid to September 4, 1872. Case 332.—A shot wound of the right hypochondrium, regarded by Surgeon H. Wardner, U. S. V., as a perforation of the liver. Conflicting opinions from Surgeons Wynkoop, Ormsby, Tilton, and Pension Examiner Baker. Case 333.—Private J. W. Vogus, Co. D, 59th Indiana, was wounded in the assault on Vicksburg, May 22, 1863, by a mini6 ball. He was admitted to the McPherson Hospital, near Vicksburg, on June 5th, and Surgeon G. R. Weeks, U. S. V., made the following report of the case: " The ball passed through the right side of the body, entering near the cartilage of the tenth rib, in a line diagonally upward and outward, about three and a quarter inches from the umbilicus, passing out near the twelfth dorsal vertebra. On June 8th, while he was endeavoring to rise in bed, there was a sudden gush of bile from the anterior opening to the extent of half a pint, in the nurse's estimation, after which time, until June 25th, the quantity was about equal each day, and flowed constantly and slowly, after this period, the bile being mixed with an offensive sero-purulent fluid. June 10th, pulse 68; temperature of body, cooler than natural; tongue slightly covered with a whitish, fur; stools nearly white in appearance, and very offensive; the urine was unaffected in quantity and quality; appetite poor; no thirst; he craved acids, and had a disgust for meat of all kinds. He was in a state of constant hebetude; he was peevish and very easily annoyed. His digestion was bad when meat or fatty substances were eaten; often they would be ejected or would pass undigested; the articles of a starchy nature were readily digested, and sought after greedily. His countenance was sad and sunken, and he became emaciated very rapidly, being reduced almost to a living skeleton ; his mental faculties were blunted, and his appearance was that of a confirmed hypochondriac; I do not remember seeing him laugh once, or even indulge in a smile during the two months he was with us. I had very few facilities for investigating the case, but did the best I could with the material I had to work with. My first observations were made June 10th, in the following manner: I carefully weighed several pieces of dry sponge, and ordered an attendant to apply one until filled with bile; I then substituted another, and accurately weighed the first, subtracting weight of sponge; and in like manner with all the others for twenty-four hours. On the first day I collected 2,832 grains, or nearly six ounces; on the 11th, 2,679 grains; on the 15th, 2,441 grains; and on the 20th, 2,763 grains. The largest SECT, ni.] WOUNDS OF THE LIVER. 143 quantity collected was between the hours of three and six in the morning. During this time, his condition was nearly the same, or at least with very slight variation. I found all the specimens tested slightly alkaline, and pursued the following plan in testing: I had him in the sitting posture, and induced him to exert himself so as to force all accumulated bile away; I then wet the slips of test paper in the next product of the liver that passed away, for the reason that physiologists maintain that the bile is rapidly changed on exposure to the atmosphere, or even while in the gall-bladder. Its specific gravity was 1014.7, and was ascertained in the following manner: I accurately tested my weights and found them correct, i. e., I balanced a three and a two grains' weight with a five, and a six and a four with a ten, and, after satisfying myself of their accuracy, I balanced a half-ounce vial with a cap-box filled with dry sand, then filled it with rain-water and weighed it again, thus getting the weight of the water and also of the bottle; I then had it filled with fresh bile and weighed it again; I then divided the weight of bile by the weight of water, taking the quotient for its specific gravity. I also observed, in its behavior with fats, that it produced a soapy compound when mixed in equal quantities, and did not separate by standing three days. During the progress of this case the most marked changes observed were, the rapid emaciation, the impaired digestion of fat, and the impaired condition of his mental faculties, which closely resembled melancholia and hypochondriasis; also the marked disgust for animal diet. His diet was mostly vegetable, except when animal food was ordered to note changes in digestion. I observed that more bile was given off when oily food was taken than when mercurials were administered. My experimenis were not carried to that extent desirable, for the reason that be was in a condition that mercury was hurtful, and I did not feel warranted in carrying it to that extent that would decrease his chances of recovery. A constant diarrhoea attended him after June 12th. He was sent to St. Louis on July 29th, convalescent." On August 6th, this patient was admitted to Jefferson Barracks, Missouri, and was discharged the service October 3, 1863. He is not a pensioner. Cases 334-333.—There is nothing to corroborate the diagnosis of Assistant Surgeon E. J. Marsh in the case of Welsh, wounded at Gaines's Mill, June 27th, and returned to duty September 3, 1862. His name is not on the Pension Roll.—In the case of Westfall, the opinion of Surgeon J. Hopkinson, U. S. V., that the ball, perforating the right hypochondrium, wounded the liver, though not contradicted, is not confirmed by Pension Examining Surgeons Crane, of Green Bay, and Hall and Murphy, of Oconto, and this also must be classed with the doubtful cases.—L. Whittle (described in Circular 6, S. G. O., 1865, p. 24, as Latimer Whipple) was an unquestioned instance of recovery from a shot wound of the liver. It would appear that this man has fully recovered his health. He received a small pension until September, 1871, when, at the biennial examination, his name was dropped from the roll. Fourteen of these twenty-five cases can be accepted as indubitable examples of recovery from shot wounds of the liver; in eleven cases, the evidence is inconclusive. The thirty-seven recoveries from complicated injuries in which the liver was involved, remain for examination: Case 371.—Surgeon L. D. Waterman, 39th Indiana, reports that "Lieutenant W. H. Bartholomew, Co. B, 16th Infantry, was wounded at the battle of Stone River, December 31,1862, by a musket ball, which entered a little internal to the left anterior superior spinous process of the ilium, seemingly having entered the peritoneal cavity, and then traversing the abdomen, came out in the csecal region of the right side, a little above, and an inch and a half internal to, the right antero-superior spinous process of the ilium. Some soreness and swelling followed; but, on January 8th, nine days afterward, he journeyed thirty miles in an ambulance wagon, to the hospital. Owing to more important duties, no immediate record was made of tbe case, beyond the fact that he had taken opium largely. No history of the case came with him. He had no motion of the bowels; pulse slower than natural; tongue furred; aspect heavy; and respiration less than natural. He was able to sit up sometimes, and also to walk up stairs. The exit wound discharged some laudable pus; the track of the ball across the abdomen was discern- ible only by touch, as a slight groove with elevated edges; there was some loss of flesh, and much restlessness and weariness, from a twelve hours' ride, in a rough ambulance, over bad and muddy roads. I was absent, and no record was kept until January 20, 1863. I learned that, about January 13th, the exit wound sloughed and large quantities of pure bile escaped, occasionally mixed with semi-digested food. He vomited, occasionally, prior to this discharge. The skin, successively, around the wound, down the abdomen, down the right thigh, and gradually upward, grew very much jaundiced. Emaciation and loss of appetite followed. From the 10th to the 13th of January, his bowels had been moderately moved regularly every day; the opium was entirely omitted, and milk toast, soup, and tea given daily. After the fistulous discharge of bile began, all disposition to anal evacuations ceased, as I learned from Acting Assistant Surgeon C. Richmond and Surgeon W. Arnold, 37th Ohio, who attended the case. The tongue grew rapidly dry, cracked, and brown; sordes collected on the teeth, crusts on the lips, and the patient was prostrate, very feeble, and disposed to jactitation; the skin around the orifice of exit, and over the lower part of right hypochondriac region, where the discharge flowed, became very much excoriated, and the discharge, by this time of a green, mossy-looking character, mixed with thin, acrid bile, bubbled in small, but almost continuous, quantity from the wound, so as to amount to a gill or two in twenty-four hours. January 24, 1863, I again saw him, and thereafter regularly. I found him in the condition above described. Pulse small, quick, and about one hundred; no appetite; decubitus dorsal slightly inclined to the right side; orifice of entrance healed; track of ball obliterated; emaciation extreme; face pale, thin, with slight hectic-like flush daily; respiration partial, about thirty; voice, faint and infantile; expression, peevishly somnolent; knees drawn up; and typhoid appearance of the mouth. Every twelve hours, injections of warm water were administered (the bowels seeming rather fuller than comported with the emaciation) and the bowels thus moved twice daily until convalescence. Oyster soup and milk were given him regularly three times a day; wound dressed with oiled silk to protect the skin; the skin, where abraded, was washed with castile soap and covered with isinglass plaster, which was frequently changed. February 1st, healthy bile, with slightly curdled milk, discharged very freely; jaundice disappearing; milk discontinued for a few days; oranges and oyster soup for diet. February 2d, no fajcal discharge, aud less bile and pus; appetite and countenance improved. February 9th, better every way; able to sit up; voracious appetite; bowels natural, only occasionally slight yellowish discharge (enough Ill PENETRATING WOUNDS OF THE ABDOMEN. I chap. vi. to stain cloth) from the wound, mostly pus; swelling around wound gone; wound healed, except small valvular orifice large enough to admit a probe. An inch inward from the wound is an irregular, slightly hard, spot, probably the point of attachment of the intestine and peritoneum. About February 11th, went home on furlough to Pottsville, Pennsylvania." Lieutenant Bartholomew returned to his regiment January 4, 1835, and was promoted to a captaincy. In 1872, he was still in the service, and attached to the 16th Infantry. Cases 372-376.—Some details of three of these cases have been given. Of Corporal Biles, it is known that, being paroled, he entered the Pettigrew Hospital, at Raleigh, and was returned to duty December 2, 1864, eighteen months after the reception of his wound at Gettysburg.—Corporal D. Cramer (375) appears to have recovered from an antero-posterior perfo- ration of the liver and right lung, with escape of bile and with tromatopncea, as fully attested by the description of Acting Assistant Surgeon Paullin and Assistant Surgeon Helsby.—Private Duke is the subject of seven distinct diagnoses; but all agree that the ball entered two and a half inches to the right of the umbilicus and emerged near the posterior iliac spine. Surgeon W. C. Daniels, U. S. V., regarded the presence of an hepatic lesion as established beyond doubt. The pension examiners are silent on this point. In March, 1872, this pensioner survived, iu impaired health. Case 377.—Private Jason 0. French, Co. C, 17th Vermont, was wounded at the battle of Cold Harbor, June 3, 1864, and was taken to the Ninth Corps Hospital, where Surgeon J. Harris, 7th Rhode Island, recorded the injury as a shot wound of the thorax. Thence transferred to Washington, French entered Emory Hospital on the 7th, whence Surgeon N. R. Moseley, U. S. V., reports the following particulars:1 "A minie" ball entered the right side, at the lower margin of the eighth rib, near the angle, and emerged half an inch to the right of the spinous process of the first lumbar vertebra. The countenance was pale, the lips livid, the extremities cold; the pulse 110. There was dyspnoea, nausea, and occasional vomiting. The patient was much depressed from loss of blood, which had continued to flow at intervals during the three days succeeding the injury. Brandy and beef-tea were administered, and warm frictions to the extremities were employed, until reaction took place. On June 8th, the pulse was at 100. On this, and on several subsequent days, the bowels were irregular, the stools being sometimes yellow or dark brown, and sometimes clay-colored. On the 9th, the abdomen was tympanitic and tender, the tongue dry, the pulse 110. Acting Assistant Surgeon P. O. Williams directed a saline cathartic with terebinthinate enemata, and warm fomentations, and wine whey, beef-tea, and chicken-broth. On the morning of June 10th, there were two copious alvine discharges. There was still much abdominal tension and tenderness, and there was a jaundical discoloration of the surface. The urine also indicated a bilious discoloration. The pulse was 108, the extremities cold, the countenance cadaveric. Oil of turpentine and Dover's powder were given internally, and hot fomentations and terebinthinate embrocations were applied to the abdomen. On June 11th, the abdominal tenderness was mitigated, the pulse was 100, the tongue and skin moist, the extremities warm. The patient complained of general itching. The treatment was continued, a portion of ipecac being added to the Dover's powders. From June 12th to the 15th, there was gradual improvement. The bowels were regular, the stools clay-colored, the appetite good. A generous milk diet, with Dover's powder and ipecac at bedtime, was directed. On June 20th, there was a profuse discharge of bilious matter from the anterior wound; from the posterior orifice pus, with occasional clots of blood, escaped. On June 25th, large quantities of greenish bile flowed from both wounds. It was inferred that a slough had separated and exposed the right hepatic duct, so copious was the discharge. The general condition was excellent, the patient resting without anodynes. In place of the Dover's powder, tincture of the sesquichloride of iron was ordered. After July 2d, the bilious discharge subsided and the stools regained their natural color. Henceforward the patient's convalescence was uninterrupted. On August 19th, he was transferred to the Smith Hospital, Brattleboro', and was discharged from service July 18, 1865, and pensioned." Examiner D. W. Putnam, of Morrisville, Vermont, reports, January 5, 1872, that the pensioner suffers from dyspnoea, and that he is permanently disabled. Case 378.—Corporal Freeman had an antero-posterior shot perforation of the right hypochondrium, and the discharges were believed to be tinged with bile; but no peritonitis ensued. The attending surgeon, I. Moses, and Pension Examiners Mcars, Orth, and Beasley, express various opinions as to the extent of the pulmonary and hepatic lesions in this obscure but interesting case. Freeman was still a pensioner, January 1, 1873. Case 379.—Private J. Fry, Co. K, 14th Pennsylvania Cavalry, was wounded at Millwood, December 17, 1864, by a conoidal ball. He was admitted to the field hospital at Winchester, the injury being diagnosticated as "gunshot perforation of bowels." December 21st, he was admitted to the National Hospital, Baltimore, and the case thus reported: " Ball entered one inch to the right of the spine, on a line with the tenth vertebra, and emerged on the left side, at the inferior margin of the ribs." On May 23d, he was transferred to Jarvis Hospital", and Assistant Surgeon De Witt C. Peters, U. S. A., reported: "Ball entered to the right of the eighth dorsal spinous process and emerged in front and below the free extremity of the eleventh rib, opening in its course the pleural sac of the right side, and wounding the lung and liver; there was great effusion into the right pleural sac. On May 31, 1865, he was discharged the service. Disability total." Pension Examiner G. R. Lewis reported, October 6, 1865, that "the ball entered to the right of the spinal column, passing through the lungs and liver. His wound affects him in damp weather, but probably unfits him for manual labor at all times." The pensioner was paid to March 4, 1873. Case 380.—Sergeant J. A. Galloway, Co. H, 8th Pennsylvania Reserves, was wounded at South Mountain, Maryland, September 14, 1832. The ball entered the right breast between the eighth and ninth ribs, a little anterior to their centre, passed through the lower portion of the right lung, liver, and kidney, and emerged below the twelfth rib, about two inches to the right of the spinal column. He was sent to the hospital at Middletown, thence to Frederick, and on the 23th was transferred to Satterlee Hospital, Philadelphia. The patient stated that on the reception of the injury a bloody discharge occurred through the urethra, and that he spat blood and experienced the most excruciating pain in the right shoulder. When admitted, he was in a critical condition, and suffering from dyspnoea and a severe pain in the right side, extending above the clavicle The right lung was in a complete state of hepatization. He still passed a considerable quantity of blood from the urethra. He was placed on a mattress, and the shoulders elevated so as to facilitate breathing, and perfect rest enjoined. Anodynes and astringents were 1 An abstract of this case has been printed by Dr. Peter O. Williams, of Coxsackie, in the Transactions of the Medical Society of the State of New York, 1866, Article VII, p. 39. SECT. III.) WOUNDS OF THE LIVER. 145 freely administered, and he was placed on low diet. This treatment was continued for about two weeks, when tonics, alteratives, nnd nourishing diet were substituted, with counter-irritation over tho liver. December 9th, the upper portion of the right lung was clear upon percussion, but a slight dulness remained in the lower part. The dyspnoea had disappeared, and his general health was good, but he still experienced considerable pain over the region of the liver. He was discharged from service January 1C, 1863. The case is reported by Acting Assistant Surgeon N. Hickman. Pension Examining Surgeon J. C. Cotton reported, January 3, 1872 : "There is dulness on percussion over the whole right lung; respiratory murmur feeble. Has had haemoptysis twice since the wound was received. Never had any pulmonary trouble before. Has cough and pain all the while. Cannot perform severe labor on account of shortness of breath and weakness." He was last paid on September 4,1872. Case 381.—Private M. Heinig, Co. C, 81st New York, aged 21 years, was wounded at Fair Oaks, May 31, 1852, by a conoidal ball, which entered the right side a little below the lower end of the sternum, and emerged on the back about two inches to the right of the spine, having passed through the liver, diaphragm, and lower part of tho right lung. He was treated in the field until June 8th, when he was transferred to the Fifth Street Hospital, Philadelphia. He suffered from haemorrhage and jaundice. He was discharged from service on August 4, 1862. Pension Examiner Edward S. Walker reports, July 10, 1866, that he re-enlisted as sergeant in the 2d New York Artillery, February 8, 1864, and was discharged from service on September 29, 186."), but suffered from pleurisy and was unfit for duty most of the time. He complained of pain in the side, and a feeling of tightness and difficult breathing on making much exertion, or on taking cold. The lower part of the right lung is carnified and adheres to the diaphragm and pleura. He remained a pensioner in March, 1872. Cask 382.—Private Hardin received, at Richmond, Kentucky, August 29, 1862, a shot perforation from near the xiphoid cartilage to the angle of the eighth rib. Acting Assistant Surgeon P. Peter believed, on grounds apparently' adequate, that the diaphragm and convex surface of the liver were interested in the track of the ball. The pension report is not positive. This pensioner was paid December 1, 1872. Case 383.—Private P. Habn, Co. G, 17th New York, aged 19 years, was wounded at Jonesboro', September 1, 1864, by a conoidal ball, which penetrated the eighth intercostal space at the juncture of the posterior and middle thirds, passed obliquely upward and forward, and presented itself between the seventh and eighth left ribs. He was at once conveyed to the hospital of the Fourteenth Corps. Considerable haemorrhage had taken place, and the dyspnoea was dreadful. Air regurgitated through the wound freely, and emphysema rapidly developed itself. He was made as comfortable as possible, a wide bandage being put on, leaving the wound open so as to prevent an increase of the emphysema and yet relieve the thoracic breathing. Brandy was administered with morphia, to alleviate, if-possible, the fearful distress he experienced. Very little alteration took place for several days, when the urgent dyspnoea gradually subsided and all his most unfavorable symptoms improved. His pulse became more full and strong, and everything promised a successful termination to the case. On the eighth day, a large slough came away from the entrance wound, and was followed by a discharge of pure bile, which continued for several days, affording no little amusement to the patient, as, on a full inspiration, followed by a forcible expiration, he could eject pure yellow bile to a considerable distance. On the thirtieth day, all discharge had ceased, and he was transferred to hospital No. 3, Nashville. On November 13th, he was transferred to Jefferson Hospital, Indiana, and returned to duty March 20, 1865. Surgeon E. Batwell, 14th Michigan, who reports the case, states that he rejoined his regiment at Savannah, and participated with it in the battle at Bentonville, experiencing no inconvenience or trouble from marching or fighting. He is not a pensioner.1 Case 384.—Private Johnson is reported by Surgeon J. G. Keenon, U. S. V., to have received a shot perforation of the liver and lung in June, 1864, and to have returned to duty July 4, 1864. Private Johnson is not a pensioner. Cask 385.—Captain Fielder A. Jones, Co. H, 6th Indiana, received a penetrating wound of the abdomen at Cheat River, West Virginia, July 16, 1861. He was treated in private quarters, and was discharged from service Augus't 2, 1861. On August 29, 1861, he was commissioned as lieutenant-colonel of the 8th Indiana Cavalry, with which regiment he served until the termination of the War, and was mustered out July 20, 1865. Examining Surgeon W. J. Wilson, of Macon, reported September 29, 1866: "I have personally known Colonel Jones for the past twelve months and know that he is affected with chronic diarrhoea, which I believe to be the result of a gunshot wound through the right lobe of the liver. The ball entered near the junction of the cartilage with the eleventh rib and emerged between the tenth and eleventh ribs, near their angle. It passed through the right lobe of the liver and fractured the tenth and eleventh ribs. As a result of this wound an abscess yet forms in the liver and is the cause of diarrhoea." In a letter to the editor, dated Fort Seldon, New Mexico, March 13, 1872, Dr. Wilson writes: "For about two weeks after receiving the wound he was confined to bis bed under medical treatment, and recovered in that time, and served throughout the remainder of the War as lieutenant-colonel and colonel of the 8th Indiana Cavalry. He was troubled for about twelve months from the time I first knew him (September, 186.5) with an occasional dysenteric attack, which I attributed to the effects of his wound—probably a small hepatic abscess. I saw him every day, while I was on leave of absence, during the months of September, October, and November last. He then appeared to have entirely recovered his health, and looked stouter and felt better than I had ever before known him—so much so, that the Mutual Benefit Life Insurance Company of Newark had accepted a large risk upon his life with all the facts before them." Cases 386-390.—The cases of Kewell and Little were shot perforations of the right hypochondria, the former diagnos- ticated by Surgeon J. Hopkinson, U. S. V., the latter by Acting Assistant Surgeon George Byers, as wounds of the liver. These men are not on the Pension List. Tlie three other cases have been already noted. Cases 391-395.—Surgeon M. K. Hogan, U. S. V., reports Private Matthews as receiving a shot perforation of the right hypochondrium at Bethesda, June 2, 1884. At Lincoln Hospital, Assistant Surgeon H. Allen diagnosticated a perforation of the liver and probably of the lung. The patient was discharged, and pensioned May 19, 1885. Pension Examiner C. C. P. Clark, of Oswego, concurred in the opinion that the ball traversed the liver, and noted that there was an ununited fracture of the tenth rib. This pensioner was on the list in December, 1872.—Sergeant Munroc received, in an altercation, October 1, 1863, 1 Batewell, E., Notes of Army Practice, in Med. and Surg. Rep., 1865, Vol. XII, p. 251. In this article, Dr. Batwell includes an interesting abstract of this ease. 19 146 PENETRATING WOUNDS OF THE ABDOMEN. ICHAP. VI. an antero-posterior pistol-ball perforation of the right lobe of the liver, according to Acting Assistant Surgeon L. Smith. There was sliirht jaundice. The ball lodged beneath the skin, between the spinous processes of the eighth and ninth dorsal vertebra'. and was removed by Dr. Smith by counter-incision. Acting Assistant Surgeon G. A. Wheeler believed that the ball traversed the thoracic cavity. On admission at Annapolis Junction Hospital there was much pain over the stomach and chest, followed by pain in the liypogaster. In a month the patient amended, and speedily recovered, and returned to duty January 25, 1864. No other facts are furnished to determine whether the ball took a direct or circuitous course.—Patterson, recorded by Assistant Surgeon L. C. Tolles, 1st Colorado Cavalry, as wounded at Apache Canon, March 26, 1862, and discharged January 24, 186:5, is reported by Pension Examiner J. S. Eedfield, of Bourbon County, Kansas, to have recovered from a shot penetration of the right lobe of the liver, the ball being extracted through a counter-incision near the eleventh dorsal vertebra. This pensioner was last paid December 4, 1872 Dr. Redfield states that there is such hypertrophy of the liver as to interfere with the action of the lower lobe of the right lung, and that there have been repeated attacks of renal haemorrhage—Private Pool received, at Prairie Grove, an oblique shot perforation, December 7,1862, the ball entering anteriorly at the ninth rib, four inches to the right of the median line, passing downward and backward, and lodging in the dorsal muscles three inches from the spinous process of the first lumbar vertebra. Surgeon Ira Russell, U. S. V., reports that there was haemoptysis for twelve days. Assistant Surgeon Short, 26th Indiana, noted, at the Springfield, Missouri, Hospital, the abdominal symptoms as most urgent. Discharged April 30, 1863, and pensioned. Pension Examining Surgeon I). L. Downs, of Richland, Wisconsin, reports that the ball penetrated the diaphragm and liver, producing ventral hernia and chronic phrenitis. Examining Surgeons Bickford and Burnham, of Richland, in 1865, declare that the ball traversed the peritoneal cavity, and that visceral injury and muscular contraction disabled this pensioner, who was still on the roll, October, 1872.—Private Rusch recovered from an antero-posterior shot perforation of the right hypochondrium, received at Chicamauga, September 20, 1863, was discharged June 10, 1865, and pensioned. Surgeon J. T. Woods, 99th Ohio, Assistant Surgeon J. Perkins, U. S. V., and Acting Assistant Surgeons France and Elrod, and Pension Examiners Justice and Coleman, of Logansport, appear to regard the wound as limited to the thoracic cavity, but Assistant Surgeon W. C. Daniels, U. S. V., was positive that the liver was implicated. Case 396.—Private J. A. Rogers, Co. H, 27th Connecticut, was wounded in the abdomen, at Fredericksburg, December 13, 1862. He was admitted to the field hospital of the Second Corps on the same day, and transferred to Washington, and admitted to the Stone Hospital on the 20th. The note-book of Surgeon J. II. Brinton, U. S. V., gives the following minutes of the case: "Wounded in the liver, and also in the head, shoulder, and arm; there was constant and profuse discharge from the abdominal wound posteriorly; he sleeps on his back; the color of the discharge is green; this is thin and fluid, and mingled with a thick yellow matter; the attendant thinks there is but one discharge—the yellow is the concrete, the green the fluid portion; the bowels are slightly costive; the appetite poor; the general condition good; after the mixed discharge takes place there is a stream of fine yellow pus. Pulse about eighty all the time. A piece of the overcoat and a portion of rib were removed from the posterior opening. The discharge is not profuse at night; cough will start the flow." A drawing in the note-book, from which the adjacent cut (FlG. 115) is copied, indicates the situation of !f the wounds of entrance and exit. On February 16, 1863, he was transferred to Mount Pleasant Hospital, whence he was furloughed on February 23d. He was admitted to Fio. 115.—Orifices of entrance and exit in T_ . . t TT .. , ,T TT a -i no l l n n" j- i j *.i. a case of shot perforation of the liver. Knight Hospital, JNew Haven, on April 23d, and was finally discharged the service on June 9, 1863; disability one-half. He is not a pensioner. Cases 397-398.—To Dr. Dusenbury's account of the case of Corporal Sharer, in the American Journal of the Medical Sciences. 1865, Vol. L, p. 399, may be added the report of Pension Examiner H. S. Scott, of Ithaca, May 5, 1868: "Ball passed through liver and right kidney. There is spinal irritation, with pain, tenderness, and weakness in the small of the back, and an affection of the kidney, the urine being loaded with mucous deposits, abnormally abundant, and passed frequently." This pensioner was on the roll December 4, 1872.—The case of Sweeney (398) is identical with case 187, on page 47. There were no examples of the extraction of balls from the substance of the liver, and but one instance in which an attempt at extraction was unsuccessfully made. Authors who generally forbid explorations of wounds of the abdomen, sanction an extraordinary latitude in incisions for the purpose of removing foreign bodies from the liver, a practical precept apparently derived from LeDran,1 which would need qualifications, if there was any real danger of its being blindly obeyed. 1 LkDcan (Traiti ou Reflexions tirees de lapralique sur lesplayes d'armes a feu, Paris, 1737, p. 190): ,;I1 faut agrandir la playe du p6ritoine," he says. " comme cello des tegumens communs, parce qu'ici il ne peut se faire de hernie comme il pourroit sen faire ailleurs ; mais il ne faut pas aller plus avant. I'escarTe que la bale a fait, etant utile il prevener l'hgmorragie. Si I'incision perinet de sentir la bale, quoiqu'elle soit entree dans la substance du foye, il faut en faire I'extraction.'' PF.ncr (op. cit, p. 12-J) adopts these precepts, but advises "inciser plus largenient," to give room for the application of "nos pincettes." Nl'SSBAUM (in I'lTlIA & BlLLROTH'S Handbueh. u. s. vr., B. Ill, Abt. II, S. 192) repeats this recommendation, and JiALDEXS (op. cit, p. 353) gives a successful instance in which he followed it. and rejects any practice less bold. KKl'.T. III.J WOUNDS OF THE LIVER. 147 When a portion of tho lacerated liver substance protrudes ai the external wound, it would appear that it may be safely removed by ligature:1 Case 399.—Private F. Siebe, Co. 1), 139th New York, aged -J3 years, received a wound of the right side of the abdomen at Cold Har- bor, June 3, IStil. He was taken to the field hospital of the Eighteenth Corps, and was subsequently scut to Washington, and admitted into Harewood Hospital on the 15th. Surgeon R. H. ISontocon, II. S. V.. states, on the medical descriptive list, that "a musket ball entered the right anterior side below the tenth rib, and emerged behind and about one and a half inches from the spine. Ou admission, the patient was in a very feeble condition ; the discharges from the wound consisted of feces, mixed with greenish streaks, from the ascending colon and liver. He complained of pain in the abdomen, which was increased by pressure; the discharge from the rectum was scanty. Cold-water dressings over the abdomen, opium internally, and light nourishing diet constituted the treatment. July 1st, the pain in the abdomen diminished, but the dis- charge remained the same. July 15th, the patient complains of occa- sional colicky pains. The discharge continued the same until August 15th, but from that date the patient began to improve. By September 1st the wound of exit had healed. September 14th, wounds entirely healed. Colicky pain recurred now and then, but tbe patient was able to be about." He was furloughed October 8. 1-M4, and was returned to duty, entirely well, November 23, lstil, at which date a photograph, copied in the wood-cut (FlG. 116), was taken at the hospital. Pension Examiner C. Rowland, of Brooklyn, reports, February 23, 1867, that '•the ball entered the right side of the sternum, passed through the liver, and made its exit on the right side of the spine, resulting in constant pain in bending his body. He is feeble, and cannot perform manual labor. He alleges that his disability has increased since tbe granting of his pension, June 2, 1SG3." He was last paid September 4, 1872. Cases 4110-401.—The remarkable case of Sheridan, in which there was hernial protrusion of the lung and liver and omentum, is detailed in the First Surgical Volume, at page 51G.—The case of Sanner is briefly noted there, at page 570, among the partial excisions of the ribs. Assistant Surgeon H. Allen states that the ball, "entering between the ensiform cartilage and left seventh rib, perforated the liver, and emerged on the right side, fracturing the tenth and eleventh ribs " Sanner was discharged September 2, 1853. and pensioned. Examiner E. A. Smith, of Philadelphia, remarks on this as a recovery from shot perforation of the liver, bilious matter having escaped from tbe wound for three weeks. Sanner was still a pensioner, December 4. 1872. Case 402.—Private F. Searle, Co. A, 9th New York Heavy Artillery, aged 28 years, was admitted into hospital No. 1. ut Frederick, July 10, 1804, with a penetrating wound of the abdomen, received the previous day at Monocacr Junction. The injury was noted as a "penetrating wound of the small intestine—duodenum." Tonics, stimulants, and opiates were given, aud simple dressings were applied to the wound. He was furloughed September 5, 1SG4. and remained at his home until March 3, lSii.j. when he returned to the hospital. Assistant Surgeon T. H. Helsby, V. S. A., reported that Searle was discharged from service June 10, 186"), on account of a "gunsliot perforating wound of the lower border of the liver (probably) and penetrating wound of the duodenum, with consequent severe neuralgic pains of the abdomen, dysuria. and inability to endure muscular exertion." Pension Examiner A. F. Sheldon reported, February 7, 1837 : "The ball entered four inches from the linea alba (right side), passed through the eighth rib, coursed backward through the body, and made its exit an inch lower than the entrance wound. He is unable to do any hard labor, but can travel about comfortably, and has an agency for the sale of trees. I do not think the disability wholly permanent, as he has improved considerably since I examined him in October last. His general health is now good." Dr. M. V. Sweeting, of South Butler, New York, reported, September 25. 1872: "This man's friends brought him home September 8, 1864, when the case came into my bands for treatment. He brought the following history: ' Struck with a minie ball, which penetrated the liver, capsule of right kidney, and perhaps an intestine.' It seems probable from the discharges that this is the case. I have no doubt that the ball passed through a portion of the liver, causing a leaking of the bile, and, from the bloody discharges with the urine, that the kidney must have been pierced or bit. As to the intestine, I cannot say, but, from some after-symptoms, I think it might have been wounded. He was under my treatment until January 25, 1805. I do not think that his health is as good as at the time of his discharge or a year after. I think that adhesions have formed, and are, perhaps, continuing to form, from the constant irritation, which renders him unfit for any manual labor. His general health is very poor. The slightest exertion causes pinching pains through the bowels, followed by a very severe sick headache. He says he never suffered from a headache previous to being wounded. I believe this originates from the liver. I see him often, and do not think he is able to perform any manual labor. I further believe that the wound will cause his death at no very distant day." Searle was still alive in February, 1873. Fig. 11G.—Cicatrices after a shot perforation of the liver. [from a photograph.] ■In Case :i!)0 (McCleary), Assistant Surgeon W. H. (t.\iu>xei:, V. S. A., removed a portion of the disorganized liver. The case recorded by FAIiltlCirs Hildaxis (referred by AlACl'HEllsox and others to liLAXCAitn), the case of Dikkfenbacu (Zeiisehrift, f. d. ges. Heilk., 1837). and tbe cases of Jassei:, Ol'lTZ. Fkicke, M.utiieesox. and Massif,, already noted, appear to demonstrate that this form of hepatotomy is not hazardous. MS PENETRATING WOUNDS OF THE ABDOMEN. KJHAP. vi. Cases 403-40,5.—Lieutenant Williams was reported from the regimental hospital as mortally wounded at Chanccllorsville, May 3, 1S63. At the Officers' Hospital, at Philadelphia, Acting Assistant Surgeon W. Camac notes that this officer, convalescing from a penetrating shot wound of the abdomen, still had hasmaturia. Pension Examining Surgeon Oliver Everett, of Dixon, Illinois, reported, February 14, 1870, that "the ball, entering the right side between the ninth and tenth ribs, midway between the lower end of sternum and the spine, passed to the left, somewhat downward and slightly backward through the body, wounding the lower lobe of the right lung, the liver, and left kidney, and came out between the spine and the crest of the ilium on left side. There was also a wound of the thigh from a ball which struck it upon the outer side, about six inches above the knee joint, passing inward and backward, and came out on the inner posterior face of the thigh. The health of this officer is poor and precarious from the wound of the viscera, and the use of the muscles of the leg is materially impaired." Williams was a pensioner in December, 1872.—The cases of White and Terwilliger have been already noted {supra, p. 48). Case 405.—Lieutenant George Yount, Co. I, 3d Missouri, aged 24 years, was wounded at Vicksburg, May 22, 1863, by a mini6 ball, which passed through the right arm, about three inches from the wrist, carrying away about two inches of the radius. It then entered the chest between the sixth and seventh ribs, at the junction of the middle and outer thirds of the left half of the chest, ranged downward and backward, and lodged close to the spine opposite the tenth dorsal vertebra, from which situation it was removed the same evening. On being carried to the rear, he came under the care of Assistant Surgeon L. French 31st Iowa, who had him laid upon his face and inclined to the right side to facilitate the discharge of blood. There was consid- erable haemorrhage, with obstinate vomiting tinged with bile and tasting of fresh blood, although none could be discovered. He was conveyed to the hospital of Steele's Division, where quiet was enjoined. In about a week, the anterior wound commenced discharging bile, which continued to a considerable extent. The posterior wound healed, but in about four weeks inflammation set in; the wound was re-opened, when bile discharged freely—judged to be nearly eight ounces daily. The discharge gradually ceased, and the wound healed, but was again opened July 26th, and a piece of clothing removed. He reached home, August 7th, weighing ninety pounds. The posterior wound soon healed; the anterior wound closed about September 1st. Pension Examiner R. S. Lewis, of Dubuque, Iowa, who furnishes the notes of the case, remarks that the patient has "gradually gained strength. He has suffered from two attacks of acute hepatitis, arising apparently from over-exertion. These attacks yield readily to treatment, but admonish him of the extreme care necessary to prevent a recurrence. The radius was resected six weeks after he was wounded. The wound remained open for a little more than a year, but eventually healed, with very good motion and strength in the wrist." He Avas discharged from service November 16, 1854, and pensioned. Examining Surgeon W. M. Skinner, of Anamosa, Iowa, reports, March 12, 1869: "The right arm is lessened in size and weakened. He is subject to paroxysms of pain and cramps in the wounded side, and his general health is a good deal impaired. I regard the disability as equal to the loss of a hand or a foot." Case 407.—Private Zimmer received, at Chickamauga, September 20, 1863, a shot perforation of the right side. Surgeon A. T. Watson, U. S. V., believed that the ball grazed the liver in its transit. Zimmer was discharged September 20, 1864, and pensioned. There are several reports from pension examiners dwelling chiefly on the disabilities arising from the thoracic lesion, of which there was no question. Regarding the injury of the diaphragm and liver there was difference of opinion, and the symptoms are not detailed with sufficient exactness to permit a definite conclusion to be drawn. In eighteen of this series of thirty-seven cases, the existence of hepatic lesions appears to have been indubitable. With the fourteen incontestable recoveries of the first series, the record therefore supplies thirty-two examples not to be excluded, by the most rigorous analysis, from the category of recoveries from shot wounds of the liver. Twenty- three of the thirty-seven cases were complicated by lesions of the diaphragm, and in eighteen of these the lung was injured, and in nine there was fracture of. the ribs. Nine were associated with lesions of the stomach or intestines, and six with wounds of the kidney. In two cases it wras believed that the gall-bladder was interested. This doubtful point will be more fully examined in treating of abdominal effusions.1 An early paper by Dr. George C Harlan,2 in the Proceedings of the Pathological Society of Philadelphia, should be consulted, as the most7important American contribution to the subject of traumatic affections of the liver. 1STKOMEYEK (Maximen, u. s. w., S. 638) says: "I have seen three recoveries of wounds of the liver and one of the gall-bladder. In the case of injury of the gall-bladder there was a great deal of pain during the first few days, which extended over the entire abdomen, but was most severe at the seat of injury." SCHWARTZ, also (Beitrdge zur Lehre von den Schusswunden, Schleswig, 1834, S. 124), relates the case of a soldier wounded at Kolding, April 23, 1849, by a musket ball, which entered the width of two fingers above the right ilium, and escaped near the navel; peritonitis, severe pain, vomiting, fever; gall escaped immediately from the wound of entrance—opium in large doses. In the latter part of May the wound of exit closed; the wound of entrance became smaller and fistulous ; in July the latter closed, and the man recovered entirely. SOCIN (Kriegschir. Erf., Leipzig, 1872, S. 94) recites the case of F. Rippert, wounded at Worth, August 6, 1870; ball entered two inches to the right of the first lumbar vertebra, and escaped from the right iliac region ; colon, liver, and gall-bladder wounded; continued irregular fever; escape of faecal matter from both wounds; several large incisions in abdominal wall; convalescent in ninety-three days. Consult further: WATON, Sur une blessure a la visicule dufiel, in DE HORNE'S Jour. de Mid. mil., 1788, T. VI, p. 550, and Autexrieth, Diss, de sanandis for sail vesiculse fellex vulneribus, Tubingen, 1803. 2HAULA\ (G. C), Four Cases of Wounds of the Liver (Proceedings Path. Soc, Phila.), iu North Am. Medico-Chir. Review, 1859, Vol. Ill, p. 698. The specimens in these cases—one of which resulted from a fall, two from railway accidents, and one from crushing by a cart-wheel—were presented, with the clinical histories, and a summary of the literature of the subject. I regret that, while adverting to ruptures of the liver (p. 16, supra), I had not met with this valuable paper, which Dr. Mayer has freely quoted. In KiLGOUE'S Contributions to Pathology, in Edinb. Med. and Surg. Jour., 1841, Vol. 55, p. 360, there are some valuable observations on wounds of the liver. SECT. III.] WOUNDS OF THE SPLEEN. 149 Wounds of the Spleen.—The spleen is less subject to wounds than the liver, because of its smaller size and deeper situation. Its liability to rupture from slight external violence, especially when morbidly hypertrophied, has been exemplified in the preceding section. The older surgeons1 were of opinion that wounds of this organ were as deadly as wounds of the heart; but modern instances of its successful extirpation in the lower animals, and partial removal in man, without grave functional disturbances of the economy, have prepared us for the view entertained by later observers,2 that shot wounds of the spleen, at least, are less fatal than is commonly stated in works on military surgery. The annals of surgery present a number of examples of wounds with protrusion of the lacerated spleen, where considerable portions of the viscus were removed by excision or the ligature. I have tabulated, in a note, the recorded instances of so-called splenotomy; and the reader will not fail to contrast the successful results of the operation in cases of injury, with its fatality when undertaken for the removal of diseased structure. Larrey [Clinique, T. II, p. 459) was skeptical regarding the reports of recoveries after hernia of the wounded spleen ; but examples have since multiplied, and there is now no question of their authenticity. Protrusion appears to be a favorable complication, the dangers of internal haemorrhage and of peritonitis being, apparently, notably diminished, in this condition. But protrusion is very rare after shot wounds, although a solitary example will be adduced presently, from the report of Surgeon Hatchitt. Hennen remarked {op. cit., 3d ed., p. 444), of the few wounds of the spleen that he had observed, " some of the slighter recovered, the deep invariably proved fatal." Mr. Erichsen teaches that serious lacerations invariably terminate speedily in death; M. Legouest3 enunciates the generally accepted view, that, while mortal haemorrhage or peritonitis sometimes result, in some grave cases complete reparation ensues. Punctured and Incised Wounds.—In his long career, Larrey observed three instances only of wounds of this organ by steel weapons. One of them was received in a duel by a left-handed mounted grenadier, which circumstance leads Larrey to the ingenuous observation that "les personnes qui font des armes de la main gauche sont les plus expose'es a la le'sion de la rate, parce qu'elles pre'sentent a de'eouvert le flanc de ce cote', ou 1'arme de l'adversaire se dirige naturellement."—(Clinique, T. II, p. 460.) This man recovered, and the two other cases, which were instances of slighter sword-cuts, implicating the spleen, had likewise favorable terminations. Leveille' records4 an instance of recovery after a severe sabre wound of the spleen, after intense peritonitis and protracted suppu- 1 JOHN Bell (Discourses on Wounds, Edinburgh, 1795, Part II, p. 96) says: "A wound of the spleen, liver, or vena cava is as deadly as a wound of the heart, so full are they of blood." 8 Thus Klebs, E. (Beitrage zur pathologischen Anatomie, Leipzig, 1E72, S. 12), gives the case of Helsber, wounded August 2o, 1870, as a "healed shot wound through spleen, stomach, liver, both pleurae, with comminuted fracture of the right humerus; death from intraperitoneal bleeding." At the autopsy, on August 25th (S. s7 und Tafel VII), the spleen large, adherent to neighboring parts, firm, dark-red, with largo sacculi, presented, in the upper portion, a large retracted cicatrix resulting from a perforation of the spleen from right to left. As there are but few accurate descriptions of this form of injur}- in the annals of surgery, the reader may be referred also to an interesting history by Professor ALBENESE, of Palermo (Clinica Chirurgica, 1871, Vol. I, p. 22). The patient had four shot wounds. One, with entrance posteriorly in the left eleventh intercostal space, and exit anteriorly through the abdominal walls, had healed completely on the seventeenth day, when the patient died from pya?mie infection due to another of his wounds. "Distaccando le aderenze tra la milza, peritoneo e angolo sinistro del colon, si trova fra essi una racolta di liquido purulento, color feccia di vino nella quantita di 80 grammi circa. II colon descendente per testensione di 8 centimetii circa 6 molto piil ristretto, e le sue pareti sono ispessite; la milsa d quasi il doppio del suo volume normale del peso di grammi 450 e di consistenza ordinaria; sulla sua superficie esterna obliquamente dal suo margine anterioro fino alia sua estremita inferiore si osserva un solco di cicatrice recente lunga circa 7 ctm. e larga uno, che interessa fina alia profundita di tre centimetri la sua sostanza.—Pochi grumi recenti di sangue nella fossa iliaca sinistra." 3LEGOUEST (Traitide Chirurgie d'Armie, 2eme ed., p. 402) observes: "Les lesions de la rate ne determinent pas immediatement des accidents bien graves; il est meme tres presumable qu'un grand nombre guerissent heurcusement lorsqn' elles sont peu etendues. Quand ellcs sont plus consid- erables, la rate peut etre plus ou moins desorganisee, un epanchement do sang rapide et abondant peut se faire dans la cavite du peritoine et entre les feuillets de I'epiploon, et le sujet atteint, au bout de quelques jours, de peritonite, ne tarde pas & succomber. II est plus que douteux que ces blessurcs soient toujours accompagnges, ainsi qu'on l'a dit, d'une hemorrhagic mortelle." See also EltlCHSEN, Sci. and Art. of Surg., 1869, Vol. I, p. 445. 1 Leveill*, Nouveau doctrine chirurgicale, Paris, 1812, T. I, p. 400, case of Cheroux, drummer of the 3d Grenadiers, wounded July 6, 1800. l.-)() l>KNKTRATIX, S. G. O.. 1871, pase 102, a recovery after a bayonet wound apparently involving the spleen.1 The experience of the "War afforded only a single illustration of this form of injury: Cask 1S4.—Assistant Surgeon J. Theodore Calhoun, U. S. A., states, in his "narrative of service": "'I saw one interesting bayonet wound of the spleen. The case was thus: A prisoner attempted to escape from the guard-house, and was bayoneted by the sentry on duty, death ensuing in a very few minutes. Some hours after death 1 made the autopsy. The body was a perfect model of manly symmetry. I regret to say that I took no notes of the ease, supposing that bayonet wounds would be seen in profusion on the battle-field,—a supposition in which, it is perhaps needless to say, I was most decidedly mistaken. The bayonet had entered the side several inches below the spleen, passing upward and inward and penetrating the spleen to the depth of an inch or more. In its passage it had cut several arteries, the haemorrhage from which had been the cause of death,—the only death from primary haemorrhage that I have witnessed since I entered the service,—popular opinion on the frequency of deaths from haemorrhage on the field to the contrary notwithstanding. The cavity of the abdomen was filled with clotted blood. The bayonet used was of the old form.'' Guthrie, while admitting that such lesions are frequently fatal, remarks that he has "seen, after death, cicatrices in the spleen corresponding to former wounds." The treat- ment in such cases will be to place the patient on the injured side and to seek to avert the internal effusion of blood and consecutive inflammation by immobility, cold intus et extra, and moderate compression. Iced drinks should be of benefit, both by distending the stomach and compressing the spleen, and by directly inducing contraction of the spleen. Gunshot Wounds.—Some thirty imperfect observations made during the War added nothing to the information already in our possession regarding this group of injuries, further than to corroborate the presumptions that the risk of immediate fatal haemorrhage was formerly exaggerated; that minor lesions are often repaired and sometimes unsuspected; that extended lesions, associated even with very considerable loss of substance of the organ, do not necessarily result fatally, or in any apparent derangement of the function of hsematosis; and, finally, that there are no distinctive subjective signs of wounds of the spleen.- Two instances were recorded of recovery from alleged shot wounds of the spleen, the descriptions leaving much to be desired in sufficiency and exactness of details : Cask 485.—Captain Michael Murphy, Co. B, 90th Illinois, was wounded at Missionary Ridge, November 25, 1863, by a conoidal ball, and taken thence to a field hospital of the Fifteenth Corps. Surgeon W. W. Bridge, 46th Ohio, described the injury as a " severe gunshot wound of the abdomen, the ball passing through the spleen." The symptoms and progress of the case are not described. It is mentioned that on December '24th this officer was transferred to Bridgeport, Alabama, thence to Nashville, and thence, on the 27th, attended by Surgeon H. Strong, 90th Illinois, to the Officers' Hospital, at Louisville. On tho following day, December 28, IS;;:7!, this officer was granted leave of absence, by order of General W. T. Sherman, on account of being "shot through the body." He Avas mustered out of service June 6, 1865. Pension Examiner B. F. Fowler, of Galena. Illinois, reported, September, 1865: " Ball entered near the edge of the false ribs, about four inches from the median line and about five inches below the nipple of the left breast, making its exit close to the spine, producing weakness of the back. Disability total, and permanent." Captain Murphy continued to receive his pension December 4, 1872. Protrusion of the spleen, lacerated by shot, is rare.a The following purports to be an example of the successful extirpation of the organ under such conditions : Case 48ii.—On the report of Surgeon James G. Hatchitt, U. S. V., of the sick and wounded at the hospital at Perryville, Kentucky, for December, 1862. the following statement was recorded: •"Private TV. IT. Waldcn, 9th Tennessee, had his spleen shot out at the battle of Chaplin Hills. The ball entered half an inch to the left of spinous process of the fourth lumbar 1 Pecoveries from punctured and lacerated wounds of the spleen are not common. The cases cited in the text, a score of instances adduced in the table further on, cud the cases recorded by Pukkmanx and Patuy, are the most remarkable. Purmakn (Lorbeer-Krantz, n. s. w., 1092, S. 414) states that, in 1GT2, a soldier at Jlin.lcn was stabbed in the side, the knife penetrating the spleen; on withdrawing the ragged blade a portion of the spleen, the size of a walnut, was tern out; yet the soldier recovered. M. Sappey (V Union med., N. S., 18ti4, T. XXI, pp. 408, 469) makes an extended report of the extraordinary case observed by Dr. Patry". A shepherd boy, 11 years old, on June 30, if">(). was gored by an ox ; the abdomen was torn open in the left flank ; the stomach was very much distended and a mass of intestines protruded. The omentum and spleen were irregularly lacerated. and the mesentery perforated in several places. Tho parts were cleansed with tepid water; the lacerated portions of the omentum and spleen were removed, aud all the viscera were returned except the stomach, which could not be replaced until its contents were expelled by cmesis. The boy recovered, and was seen by Dr. PATRY, two years afterward, entirely well. .See Guthrie. Lectures, Part II, p. 57. 2 So that there has been in this direction no advance since the time of Hinter (.t Treatise on the Blood, Inflammation, and Gunshot Wounds, London, 171'-!. p. 545), who remarks: " A wound of the spleen will produce no symptoms that I know of, excepting, probably, sickness, from its connection with the nerves belonging to the stomach." A quarter of a century later, Dupuy'tren (Lecons orales, T. VI, p. 430) remarks : " Les blessures de la rate n'ont point de signes particulicrs, ce qui tient a l'ignonince dans laquelle on est des usages de ce viscere, ignorance qui nous prive du secours que pourrait offrir le trouble de ses functions." 'GUTHRIE (Commentaries, London, 1855, p. 591) remarks: " I have not seen nor heard, during the Peninsular War, of a wound in the abdomen through which the spleen protruded, the patient recovering." SF.(' T. III.] WOUNDS OK THK SPLEEN. 151 vertebra, and came out between the eighth and ninth ribs, midway between the spine and sternum. The spleen was cut off with a ligature, and the patient was up in two weeks, and rapidly recovered." The compiler of the surgical report in Circular No. li. S. G. 0., 1S;;5, not printing-this statement, Dr. Hatchitt addressed to the Surgeon General the following letter, dated Frankfort, Kentucky, February 5, 18(38: " Silt: In tlie Medical and Surgical History of the War [preliminary report of Circular 6f] you state that there was no authentic report of the extirpation of the spleen. I have frequently thought of calling your attention to the report I made of the successful excision of Ihe spleen, by ligature, at lVrryville, Kentucky, while in charge of the wounded of the battle at that place. I am reminded of the case by just reading a report of such a ease in the Medical and Surgical Reporter, of Philadelphia, page 37, of the present volume. There was no mistaking the diagnosis of the case I reported. Nothing could be plainer; and, were it necessary, it could be substantiated by several medical gentlemen." In response to this letter, a request was made for more definite details respecting the case of Private Walden, to which application Or. Hatchitt replied. February Pi, IStiS, as follows: "Sn;: Yours of the 10th instant, in reference to the case of extirpation of the spleen, is received. I regret that I can now give so few of the details of this ease. The subject of this case, Private Walden, when first seen by me was under the especial care of Dr. -------Alston, a Confederate surgeon from Texas. Dr. Alston had been unable to pay attention to the easy. It was several days after the battle. The spleen was much congested and strangulated, the entire body of it protruding from the wound, and too nearly gangrenous to admit of an attempt to reduce it. Dr. Alston applied a ligature, and, in a few days, the spleen fell off To the astonishment of all, there was not the least functional derange- ment perceptible following its loss. There was very little peritoneal inflammation following, and the patient kept his bed not exceeding two weeks. Dr. Alston manifested great interest in the case—promised to keep the patient in view, and to keep me informed as to his future health, etc. My recollection is that Dr. Alston kept this private with him until he left Perryville, which was some time in the latter part of February, or first of .March following, nearly five months after the reception of the wound. Dr. Alston wrote me from some point on his route for exchange (I think from Cairo, Illinois) that Walden had been separated from him, the surgeons being sent to some other point than that to which the soldiers were sent for exchange. I have never beeu able to hear of Dr. Alston or the private! again. I think, had the former afterward heard of this case he would have informed me, knowing my anxiety to learn how he would be affected by the malaria of the South. At the time of the battle of Perryville there was no organization in the medical corps, at least none such as would be effective after such a battle; the whole army moving rapidly on, expecting a more important battle, left us without necessary supplies, etc. There was not even a register, or blank book, or paper to be found to keep a proper record of the wounded." A demonstration of the possibility of recovery from a shot lesion of the spleen1 is afforded by the case of Behan, already noted, who died of Bright's disease at Gay's Hospital, four years after receiving a shot perforation of the colon, at Sebastopol. At the autopsy, a piece of bullet was found in the spleen. Of the fatal shot injuries observed, the most interesting, perhaps, is that related on page 19, supra, in which traumatic splenitis and abscess followed a contusion by a cannon ball. In another instance, in which multiple abscesses were consequent upon laceration by a shell fragment, the pathological preparation was sent to the Museum, but spoiled on the way: Case 487.—Private J. Kearnes, Co. I, 33d Illinois, wounded at Chickamauga, September 19, 1853, taken prisoner, but paroled after the battle; on the 29th, was admitted to hospital at Chattanooga; thence he was transferred, on November-30th, to Tullahoma. Surgeon B. Woodward. 22d Illinois, reported as follows: " Wounded by a piece of shell striking him on the abdomen and making an extensive lacerated wound. When he was brought to the hospital, he was suffering from chronic diarrhoea. About one inch below and two inches to the left of the ensiform cartilage there was a fistulous opening, which communicated with an opening one inch above and two inches posterior to the anterior superior spinous process of the left ilium, discharging pus from both orifices. He died December 9, 1833, having survived the injury eighty-two days. Sectio cadaveris revealed a sinuous passage from one orifice to the other, passing through the spleen, the wlrole of which organ was converted into a semi-cartilaginous mass, full of honeycomb abscesses filled with pus. The stomach had not been perforated, but was so adherent to, and consolidated with, the spleen that they could not be separated. The under side of the diaphragm was covered with ulcerations; parts of two ribs against which the spleen rested were carious. From the disorganized condition of the spleen, its functions evidently could not have been carried on for weeks." Part of the pathological preparation, comprising the lower ribs, stomach, and spleen, was forwarded to the Army Medical Museum; but it had decomposed to such an extent that the relation of parts could not be made out, and it was discarded in lSiil, and the number (20Pi, Sect. I) was filled by a specimen of shot fracture of the ulna. Cases 488-490.—Surgeon J. G. Hatchitt, U. S. V., reported another shot perforation of the spleen, from Perryville: Private S. A. Bullock, Co. I, 31st Tennessee, wounded October 8th, died October 29, 1832.—Assistant Surgeon L. M. Eastman, U. S. A., recorded the case of Private F. Bardh, Co. B, 8th New York, wounded at Cross Keys, June 8th, died June 12, 18J2.— Surgeon E. Nicholls, U. S. V., reported Private M. Hodges, Co. G, 27th Missouri, wounded at Kesaca May 15th, died May 19, 18o4. The fatal results of these cases are referred to peritonitis consequent on shot lesions of the spleen; but noteworthy details are wanting. The note occupying the next two pages contains particulars of twenty-six examples of partial or complete removal of the spleen. 1 In the preliminary report in Circular t>, S. G. O., 18fi.'), p. 27, it is remarked that: "All the cases of gunshot wounds of the spleen that have been reported, were fatal. No symptoms are mentioned that particularly distinguished these from other gunshot injuries involving the abdominal cavity, and it is quite possible that the list of recoveries may include cases in which this viscus was injured, though the diagnosis was not made out." Tabular Statement of the recorded Ojieraiions of Splenotomy. The statements of authors regarding the number and results of operations of splenotomy are somewhat discrepant, differences in enumeration arising from varied interpretations of the authenticity of certain cases, and from accepting or rejecting instances in which only portions of the viscns was removed. Dr. I<\ II. Hamilton (Principles and Practice of Surgery, 1872, p. 74 PKNKTltATING WOUNDS OK THE ABDOMEN*. [( UAP. VI. In the twenty-six cases tabulated on the two preceding pages, partial or complete removal of the spleen was undertaken sixteen times on account of traumatic lesions, ten times on account of cystic, hypertrophic, or other pathological alterations. There is the surprising result that the cases of the first group, without exception, terminated favorably. Of the pathological cases, four recovered and six died. The accompanying illustrations (Figs. 117. 118) are copied from Mr. Bryant's paper,1 in which the removal of the spleen in certain cases of incurable chronic enlargement is held to be justifiable.2 The results of the traumatic cases encourage interference for the suppression of dangerous hoemorrhage. Of shot wounds of the spleen associated with lesions of the stomach or intestines, Case 197, on page 50, Case 202, on page 54, Case 308, on page 105, afford examples. In the First Surgical Volume, among wounds of the chest, the cases of Wilcox, on page 445, of B-----, on page 44G, and the case of P-----, on page 589, were complicated by wounds of the spleen. Tlie three following cases have been advert- ed to as shot wounds of the liver: Fig. 118.—Microscopical appearance of the blood in a case of leucocythsemia. [After Bryant.] Fig. 117.—Line of incision in a case of splenotomy. [After BHYAXT.] Case 413.—Private R. Bull, Co. K, 15th West Virginia Cavalry, aged 21 years, was wounded at Ashley's Gap, July 24, 1664, by a conoidal ball, which fractured the tenth rib, penetrated the left lung, perforated the diaphragm, and grooved the anterior borders of the spleen and of the liver. He was treated in the field until the 27th, when he was transferred to the hospital at Frederick. Death resulted August 26, 1664. The case is reported by Assistant Surgeon R. F. Weir, U. S. A. Cask 425.—Private Samuel O. Crafts, Co. K, 40th Massachusetts, aged 26 years, was wounded at Ohistee, Florida, February 20, 1664, and removed to Beaufort on February 23d. Surgeon Charles L. Allen, U. S. V., reported: "Conoidal ball entered below the right nipple, between the fifth and sixth ribs. On February 23d, a linear incision one inch long was made, and the ball was extracted from under the skin on the right side, just anterior to the edge of the scapula. At the time of operation there was great tenderness, but no considerable swelling or inflammation around the wound of entrance; ecchymosis from axilla nearly to crest of ilium. Respiration and circulation were rapid, with dyspnoea; countenance anxious, and expressive of suffering; skin hot and dry; tongue red, with thin white coating; no cough or expectoration. The normal respiratory murmur was heard clearly and distinctly throughout both lungs; no abnormal dulness upon either side. The dyspnoea and rapidity of respiration and circulation gradually increased, also the heat and dryness of the skin; the tongue became more coated, and after a time dry and parched; complete loss of appetite. After a few days, dulness was detected at the base of the left lung, continuing to increase upward, with loss of respiratory sounds in the same region, not replaced by bronchial respiration. Vomiting of impure bile commenced on March 23d, and continued. He died from exhaustion March 26, 1864, having survived the injury thirty-five days. Post-mortem appearances: The passage of the ball was traced through the cartilages of the fifth and sixth ribs, near their junction with the ribs; through the left lobe of the liver, behind the oesophagus; through the thickened part of the spleen; through the diaphragm, perforating the left pleural cavity without injuring the lung; and passed out between the tenth and eleventh ribs. About two ounces of clotted blood were found in the left pleural cavity, besides about sixty ounces of sero-purulent fluid. Around the spleen adhesions had taken place, confining eight ounces of dark grumous fluid; only a very small quantity of effusion into the abdominal cavity." Cask 477.—Private F. Watkins, Co. D, 117th U. S. Colored Troops, aged 22 years, entered the West End Hospital, Cincinnati, August 30, 1664, with two wounds, received in a skirmish at Ghent, Kentucky, on August'29th. Acting Assistant Surgeon R. Bartholow reported that one ball entered between the seventh and eighth ribs, penetrated the left lung, and passed downward through the stomach, spleen, and liver; another entered the spinal canal. Death, September 1, 1864.:! "Bryant (T.), Case of Excision of the Spleen, in Guy's Hospital Reports, 1866, Vol. XII. 2S(Tu;ltze, Extirpation de la rate et de ses fonctions, in Arch. Gen. de Med., 1" serie, 1829, T. XX, p. 429; BLUNDELL, On the Surgery of the Abdomen, in The Lancet, 1828-9. Vol. II, p. 3511; Qititexbaum, Comment, de splenis hypertrophia et historia extirpationis hypertrophici CUM foktena Ai>vr.i:sA infemina viva facta!, Rostock, 1836; SlMOX, Die Extirpation der MHz am Menschen vach dem jetzigen Standpunkte der Wissenschaft, Gie>scn. 1857; Maktixi, Die Extirpation der MHz am Menschen, in Deutsche Klinil; 1859, B. XI, S. 228: Sl'ENCEU Weli.s, On Excision of Enlarged Spleen, in Med. Times and Gaz., 1866, Vol. I, p. 2: Philipeaux. Experiences demontrant que la rate extirpee sur de jeunes animaux et replacee dans la cavite abdominalepeut s'y greffer, peut continuer a y vivre et a s'y divelopper, in Gaz. hebd. de med. et de chir., Sept. 21, 1866, p. 601. 3BARTHOLOW (R.), Cincinnati Lancet and Observer, IV Ser.. 1864, Vol. VII, p. 597. for a full report of this case. sect. III.] , WOUNDS OK T1IK SPLEEN. 15,") In several instances, little more is stated than (hat the patients perished from internal haemorrhage, and that there was a great, effusion of dark blood:1 Casks 491-494.—In the four following cases, the patients perished speedily from internal haemorrhage: 1. Private J. Myers. Co. G. 5th Illinois Cavalry, wounded April Pith: a musket ball divided the descending colon, spleen, and left kidney, and cartilage of eleventh rib; died April 13, IS:;,'). Reported by Surgeon D. Stahl, U. S. V.—2. Unaligned substitute J. Warren, shot perforation of spleen, March 19, 18 i.">; death in a few hours. Reported by Assistant Surgeon G. M. McGill.— 3. B. T. Fairley, Co. B, 4th Pennsylvania Cavalry, aged 26 years, pistol ball perforation of spleen, December 11, 1864; death the same day. Surgeon James Bryan, U. S. V., notes that the superior mesenteric artery was divided in this case.—4. Corporal A. Mitchell, Co. F, 36th U. S. Colored Troops, aged 36 years, was wounded at New Market, November 29th; a musket ball perforated the spleen and fractured the third lumbar vertebra. Reported by Assistant Surgeon J. H. Frantz, U. S. A. The proportion of eases of wounds of the spleen, complicated with lesions of the diaphragm and thorax, was considerable: Cask 49,").—Private J. Applegate. Co. A, 13th Indiana, was wounded at Petersburg, July 4, 1864, and was taken to a field hospital, and subsequently removed to the base hospital of the Eighteenth Corps, near Broadway, where he remained under treatment until he died, July 12, lSlil. At the autopsy, made by Surgeon C. H. Carpenter, 1 18th New York, it was found that the ball, fracturing the left tenth rib, had passed through the lower lobe of the lung, the diaphragm, the spleen, and emerged two inches to the left of the spinous process of the lower lumbar vertebra. There was haemothorax. The abdominal lesions are not described.2 Case 493.—Private Z. Robnult, Co. H, 53d Pennsylvania, was wounded at Fair Oaks, June 1, 1862. He remained at a field hospital until the 27th, when he was conveyed by the transport Louisiana to Philadelphia, and entered Wood Street Hospital. Assistant Surgeon C. W. Hornor, U. S. V., states that "he lingered until June 19th, with symptoms of inflammation of the pleura and peritoneum; pulse 130; pain intense. The post-mortem examination revealed the following pathological conditions: A round ball entered just below the inferior angle of the left scapula, passed in an oblique direction downward between the integument and ribs, fractured the seventh rib, grazed tbe inferior lobe of the left lung, passed through the diaphragm, traversed the spleen, and lodged in the spinal column. The left pleura was inflamed and thickened, with the lung attached, and, in the lower portion, compressed by the bloody serum which had accumulated to the amount of three quarts. The peritoneum was also inflamed to a limited extent." The missile (FlG. 119) was found ball.' Spec. 4484. impacted in the body of the first lumbar vertebra. Case 497.—Surgeon T. H. Squire, 89th New York, reports the following: "William Utter, Co. F, 89th New York, aged 24 years, was wounded, April 19, 1863, while storming fortifications in the Nansemond River, by a musket ball, which made four openings in the body. It first entered the outer aspect of the left forearm five inches above tbe wrist joint, and fracturing the radius, came out on the inner aspect, three inches distant from the wound of entrance; then it entered the left chest below ihe fold of the armpit and three and a half inches from the nipple, and came out on or about the same horizontal plane two inches from the spine and eight inches from where it entered the chest, wounding the left lung, and probably breaking one or more ribs. For the first twenty-four hours or more, lie had severe pain in the whole of the left chest, with some disposition to cough. For the pain and inflammation, I bled him from the arm. The next day he began to spit blood. On April 25th, there was complete dulness over the whole left chest, with orthopncea, and a constant inclination to cough, which he suppresses as much as possible; but occasionally expectorates, tbe sputa indicating pneumonia. He has slept but very little, and often has a dark-red cheek; a slough either has come out or is coming out of each of the wounds, and they are discharging; wet dressings, with splint to the arm, and some morphia for the pain and uneasiness, constitute the treatment. May 1, 1883: This case proved fatal last night; he suffered a good deal during the last two days from shortness of breath, and much of the time he kept the sitting posture, either in a chair or in bed. The countenance was pale: lips slightly livid; free, cold perspiration, and tendency to drowse; some cough, but little or no expectoration; pulse most of the time quite small. Post-mortem revealed the facts that the ball had broken tbe ninth rib about one and a half inches from its junction with the cartilage; that it entered the abdominal cavity just below the diaphragm, made a deep transverse cut or furrow through the middle of the convex side and substance of the spleen, cutting the organ full half asunder, and cutting the abdominal wall again between the eleventh and twelfth ribs, and coming out of the liody at the point indicated in the previous note. Notwithstanding the chief injury was done to the abdominal tissues and organs, the chief pathological results appertained to the chest. The left thorax contained two and a half quarts of wine-colored serum, and when this was nearly all taken ont by means of the sponge, I scooped off from the bottom of the cavity a handful of floating substance, which was regarded as semi-organized coagulable lymph. The lung was well compressed in the upper front part of the chest, and recently adherent to a small surface corresponding to the sternal extremity of the clavicle. The pericardium had three ounces of straw-colored serum, and the right pleural cavity eight ounces of the same or similar fluid; some recent adhesion also existed at the front of the right lung, and signs of recent inflammation, circumscribed, at that point. A small portion of the right, lobe of the liver adhered to the diaphragm, and adhesive inflamma- tion had apparently prevented the spread of trouble in the peritoneal cavity. Paracentesis of the thorax had been contemplated during his life, but it is quite doubtful if the operation would have saved him." 1 Fallopius (Opera genuina omnia, Venice, 1606, T. II, p. 390) says: "Si vulneratus sit lien, cognoscetis ex sanguine egrediente, qui ater erit, et veluti limns, et vulnus erit sub hypochondrio sinistro: alia non solent succedere ex vulnere lienis, non dolor septi transversi, non tussioula, nee qnioquam aliud." B. Bell (System of Surg., 1787, Vol. V, p. 298) observes of the "deep red color,'' that "this is a test not to be depended on." 2 This case is reported, in a memorandum of autopsies, in the Boston Med. and Surg. Journal. 1865. Vol. LXXI. p. 110. 1")G PENETRATING WOUNDS OF THE ABDOMEN. [chap. vi. Cask 49-\—Private John Weston, Co. C 1st New York Cavalry, aged 18 years, was wounded in a skirmish near Cabletown, March 10, 1864. There is no record of the case prior to his admission to No. 1 hospital at Frederick, from field hospital, on April 6th. Acting Assistant Surgeon A. K. Gray reports, on the Case Book and Medical Descriptive List: ''" Upon examination, after admission to this hospital, two wounds, one apparently of entrance, the other of exit of ball, were observed on the left side; the wound of entrance situated over the ninth rib, four inches below and in front of the lower angle of the scapula, involving the integument only, through which a probe could be passed two and a half inches under the skin. The wound of exit corresponds to a point midway on a line drawn from the anterior superior spinous process of the ilium and ensiform cartilage, near the junction of the ninth rib with its corresponding cartilage, and passing downward and backward. The discharge from the anterior wound was profuse and fetid, welling up at every motion of patient, and has excoriated the integu- ment for a space of three inches around both wounds. The patient is much emaciated and in a very feeble condition; pulse 120, small, and irritable; ordered one ounce of milk-punch every two hours, and two grains of quinine in pill every four hours, with a good diet; poultices were applied to the wounds, and simple cerate spread over thin cloths to the integument to prevent excoriation. April 8th: general condition somewhat improved; pulse less frequent and fuller; wound less painful upon motion; discharge still profuse and fetid; continue treatment, with two grains of opium at night. April 10th: slight diarrhoea; general condition same as yesterday; appetite better; rests well at night; wound dressed with loose lint and chloride of soda solution; continue quinine and milk-puuch. April 12th: little or no appetite; no diarrhoea; pulse more frequent; discharge from anterior wound still profuse; none scarcely from the posterior wound; one ounce of whiskey every two hours. April 14th: strength failing; little or no appetite; dysphagia. April 15th: he died this morning somewhat unexpectedly, as there was no sign of dissolution at midnight, when I saw him Post-mortem: Chest: Lower lobe of left lung in contact with the diaphragm hepatized; left pleura costalis very much thickened, and the pleural cavity contained about eleven ounces of sero-purulent fluid; right side not examined. Heart: Normal size and healthy; one ounce of serum in the pericardium. The ninth rib was frac- tured near its cartilaginous insertion. The anterior and external portion of the spleen, in relation with the under surface of the diaphragm, was deeply grooved, showing the track of the ball, and in a state of ulceration. A small portion of the left lobe of the liver, near the upper border of spleen, was also involved iu the ulceration. Costal attachment of diaphragm, and that portion covering the spleen softened, ulcerated, and perforated; the ulceration at that point extending to the pleura and probably causing the empyema. Stomach, peritoneum, and intestines uninjured. Near the point of costal fracture, and a little above it, a wound of the diaphragm is observed, perforating the muscle, and indicating the passage of the ball; no perforation of chest through which the bullet entered or passed out can be found. The posterior wound, which upon admission seemed to indicate the point of entrance, did not present the characteristics of a gunshot wound, and involved integument only. A thorough search for the ball was made in the chest, spleen, and diaphragm, and the thoracic parietes, but it could not be found. Near the lower border of the eighth rib, about one inch from the posterior wound, a portion of cicatrized tissue was felt, corresponding to a faintly marked linear cicatrix, on the inner parietes of chest, indicating, it is conjectured, the point of exit of ball, from which the sinus under the integument had not yet healed." Shot wounds of the spleen are often associated with wounds of the left kidney, as in the following case : Case 499.—Lieutenant Martin K------, Co. A, 69th New York, aged 25 years, was wounded at Spottsylvania, May 12, 1864. He was conveyed by ambulance to Belle Plain, and thence by steamer to Washington, where he arrived thirteen days after the reception of the injury, and was admitted into Douglas Hospital. He died on May 26, 1864. At the autopsy the ball was found to have entered the left side one inch outside of a line falling from the nipple over the eighth rib, to have penetrated the diaphragm in two places, lacerated the spleen (FlG. 120) and left kidney, fractured the ninth and tenth ribs, and lodged in the soft parts beneath the skin, from which place it had been removed on the field. The symptoms previous to death were those due to acute traumatic pleuritis, and two quarts of bloody serum were found in the left thoracic cavity. The pleura was covered thickly with a layer of pink lymph, and the lung was compressed. The occlusion of the two openings in the inferior portion of the cavity and the retention of so large a quantity of fluid is remarkable, and indicates the necessity for ascertaining that free exits exist for such effusions. A quantity of blood was found effused into the abdominal cavity. It is remarkable that life should continue so long with such extensive injuries. Another observation worthy of notice was, that the upper portion of the left thoracic cavity was sonorous on percussion, a condition due to the compressed Fib. 120.—Posterior surface of a*r ul t^ie a*r vesicles, or to the presence of some air in the thoracic cavity compressed by the a spleen showing the lacerated increasing effusion. Upon microscopical examination, a transverse section exhibits no modifica- wound of emergence of a ninsket „ . . ball Spec. 3o27. [Reduced to tious oi the normal structure except those obviously due to congestion. The Malpighian bodies one-tlnrd.] are natural in number and distribution; the veins and capillaries are enlarged. In the three following cases, also, the left kidney was implicated : Case ;",00.—Private Henry Sherman, Co. D, 95th New York, aged 17 years, was wounded at Petersburg, March 30,1865. He was admitted to the field hospital of the 3d division, Fifth Corps, on the following day, and was subsequently transferred to City Point, and afterward to Philadelphia, where he was admitted to the Broad and Cherry Streets Hospital on April 10th. Assistant Surgeon Thomas C. Brainerd, U. S. A., in charge, reported the case as '•' Wound of the left kidney, spleen, and diaphragm, by conoidal ball; simple dressings. He died, from exhaustion and peritonitis, April 12, 1805." Ca.se 501.—Private John Fink, Co. G, 32d Indiana, was wounded at Liberty Gap, Tennessee, June 24, 1863. He was admitted to No. 1 hospital, Murfreesboro', on the 27th, and the following report of the case is given by Assistant Surgeon William P. McCullough, 7-;h Pennsylvania, in charge : "Admitted June 27th, with gunshot flesh wound of the left side and srct. in.] WOUNDS OF THE SPLEEN. 157 arm; cold-water dressings; whiskey given every four hours, and an anodyne at night. July 12th, the wound of side discharged four ounces of pus of an unhealthy appearance; patient perspired profusely; prescribed six ounces of whiskey with four drops of aromatic sulphurous acid, one ounce every four hours. July 23d, the patient was given egg-nog and poached eggs, and continued to improve until the 29th, when he sat up in bed. On the 30th, he had a severe chill, and several on the 31st, followed by fever. On August 1st, patient complained of pain in the bowels; abdomen tympanitic; pulse feeble. He died at eleven o'clock A. M. Autopsy six hours after death: Ball entered the left side; passed through, fracturing the eighth rib; passed between tbe spleen and kidney, wounding both, and passed out, fracturing tbe twelfth rib and also the spinous process of the twelfth dorsal vertebra; passed through the latissimus dorsi muscle, and made its exit four inches to the right side of the spine. There was no pus found in the abdomen; there was some burrowing of abscess in the muscles of the back, both above and below the wound." Case 502.—Surgeon C. W. McMillan, 1st East Tennessee, reports that Private H. Minnich, Co. B, 45th Pennsylvania, aged 30 years, was wounded at Blue Springs, October 11, 1863, conveyed to Knoxville on October 12th, and died suddenly on the following day, from internal haemorrhage. The ball had entered on the left eleventh intercostal space three inches from the spine, fracturing the eleventh rib, and was found at the autopsy to have passed downward, wounding the spleen and left kidney; the abdominal cavity was filled with blood. The routinists who declare that wounds of the lung are always followed by pneumonia and pleurisy, and that hepatitis is an invariable consequence of wounds of the liver, would doubtless maintain that splenitis inevitably resulted from injuries of the spleen. But the facts presented on pages 18 and 19, and in the rforegoing abstracts, teach that traumatic lesions of the spleen are not followed by anything of the nature of general parenchy- matous inflammation, unless violence is inflicted upon the whole organ. Alterations of texture are limited to the immediate vicinity of the solution of continuity; there is little tendency to abundant pus formation, unless foreign matters are confined; and the bulky exudation products of idiopathic inflammation are absent.1 The cases observed have not materially affected the questions of diagnosis2 and treatment.3 Klebs (Beitrdge zur pathologischen Anatomic der Schusswunden, Leipzig, 1872, S. 100) made the following observation at the hospital at Carlsruhe: "The spleen in Case 124 gives an instance of normal healing. The channel is closed or rather obstructed by transformed thrombical spleen tissue. The process, after shot injuries of this organ, seems to be: that the powerful muscular contraction closes the opening; if this is not sufficient, coagulated blood fills the rest. In this manner tho primary bleeding is soon arrested, and while the thrombosis advances into the injured blood spaces of the spleen, a tissue consisting of spleen tissue and blood thrombi fills the shot channel, and finally forms a deep retracted scar. We see, therefore, in this organ very little inclination toward reproduction of the substance lost by the shot injury." Dr. Klebs adds: " On the whole, shot wounds of the spleen do not seem as fatal as is generally stated in military surgeries. Observations of cases of recovery have accumulated, and the principal danger of the injury is in consequence of other and subsequent diseases cf the organ, that at last may be partly obviated." Among the few recorded cases of recoveries from shot wounds of the spleen is the following, by Pielitz (Richter's Chirurgische Bibliothek, Gottingen, 1785, B. VIII, S. 532): Shot penetration of spleen : removal of a piece of flannel, with portion of wad, and a small piece of spleen adhering thereto, followed by serious bleeding; recovery. There are other examples iu which the patients survived a considerable period, and succumbed to secondary lesions or those unconnected with the injury of ihe spleen. Thus, LOHMEYER (Die Schusswunden und Hire Behandlung, Gottingen, 1859, S. 160) cites the case of an officer who received a perforating wound of the abdomen, the spleen being perforated. The man lived over a month. Demme also (Militdr-chirurgische Studien, Wurzburg, 1861,13. II, S. 13!)) relates a case of an Austrian, "shot at Solforino, June 25,1859, in the left hypochondrium. Repeated and profuse bleeding occurred. He recovered sufficiently to be carried to the 'Osped. St. Francesco,' at Milan. * * * On July 13th, twenty days after the reception of the injury, death occurred, with signs of acute anaemia. At the autopsy the abdominal cavity was found filled with blood, probably from a rapture of the adhesions already formed. The ball, now in my possession, was found in the capsular ligament of the liver, covered with connective tissue. . The spleen was injured." And SociN (Kriegschirurgische Erfahrungen, 1872, S. 93) adduces the case of Lecrepe, who received, at Worth, an oblique shot perforation, the ball entering the left sixth intercostal space and emerging through the right eighth intercostal space, wounding the spleen, liver, and right kidney, the patient surviving the injury sixteen days. 2 DUPUYTREN (Lecons orales de clin. chir., Paris, 1839, T. VI, p. 480) remarks: "Quant aux balles qui peuvent atteindre et pengtrer la rate, il n'y a point de signes positifs qui indiquent cette l6sion. C'est par des signes negatifs de la blessure des autres visceres contenus dans l'abdomen que l'on peut etablir des presomptions sur celle de la rate. Cet organe, contenant une cnorme quantit6 de vaisseaux volumineux, doit fournir promptement un epanchement considerable dans la cavite abdominale. C'est cette hemorragie interieur, et l'inflammation qui resulte de la lesion du viscere (splenite) et celle du peritoine, qui doivent attirer l'attention du chirurgien." Iu like manner, BaUDENS (Clinique de.s plaies d'armes d. feu, p. 363) observes: "L'obscurit6 qui regno encore sur les fonctions de la rate fait qu'il est impossible d'en reconnaitre les lesions d'apres le trouble qui pourrait en resulter; les signes sont ici n6gatifs. Ainsi ce sera d'apres la direction, la situation et la profondeur du trajet parcouru par le plomb qu'on tirera des inductions plus ou moins vraies. La gravit6 de solution de continuit6 de ce viscere provient des epanchements sanguins auxquels celles-ci donnent lieu, epanche- ments souvent mortels quand la blessure est large et qu'elle a 6t6 faite par une arme blanche. Les cscarres determinces par le passage du projectile sont encore ici souvent tres salutaires pour prevenir les hemorrhagies; mais quand l'une des grosses arteres qui cntrent dans cet organe vient a etre lesee, il est fort douteux que ce bouchon puisse fermer la lumiere du tube art6riel avec assez do force pour empecher une hemorrhagic foudroyante. Lorsque la plaie n'occupe que la region dorsale et n'a entam6 que la face posterieure de la rate, les accidents sont bieu moins redoutables que si la perforation sicgeait i la face enterieure, parce que, dans le premier cas, l'6panchement sanguin se fait directement au-dehors et pent etre arret6 par le tamponnement, tandis que, dans la deuxieme hypothdse, le sang s'epanche dans l'abdomen et 6puise le bless6." 3 There is one monograph on wounds of the spleen : I'OHL, De lethalitate vulnerum lienis, Lipsia?, 1777. The articles of RlBES, Diet de Sci. Med., T. 47, p. 222, and of SAX60N, Diet de M&d. et de Chir. Prat., T. 13, p. '271, on wounds of the spleen, contain interesting observations. Mr. Grays prize essay (On the Structure and Use of the Spleen, 1&.V1) and Professor KOLLIKER'S article in the Cyclopedia of Anatomy and Physiology present full bibliographical references. Dr. EDWARDS CRIsr's Treatise on the Structure and Use of the Spleen gives the results of much laborious investigation. ASSOLASTS thesis, Recherches sur la rate, 1802, and the numerous dissertations de Liene, as those by ULMUS, Paris, 1578; by SCHNEIDER, Witteb., 1649; by SCHELLHAMMER, Kiel, 170:1; by CRAUSE (II. W.), JcnEe, 1705; by ELLF.R (J. T.), Lugduni, 1716; by QUELMALZ (S. T.), Lipsiae, 1748; and by RACHEM, Berlin, 1839, contain some scattered observations on the physical lesions of the spleen. lo.S PKXKTRATTNO WOUNDS OK THK ABDOMEN. [CHAP. VI. derie, is attested by the two following cases, of which the first corroborates also the inferences of the surgeons just mentioned, that a strangulated protruding part of this viscus may be safely excised :2 Case 503.—Assistant Surgeon J. G. Thompson, 77th New York, reports the case of ''a soldier, mime unknown, who was wounded at Cedar Creek, October 19,1864; the ball entered the right side below the ribs and emerged on tlie left side. He was removed to the Taylor Hospital, at Winchester. While straining at stool, two days subsequently, a hernia of the pancreas occurred of the size of a hen's egg. A silver wire was passed about the pedicle by which it was attached, and twisted tighter each day for about a week, until it became very small and was snipped off with scissors. The treatment consisted of light diet and milk punch, as there was some prostration. No especial unpleasant symptoms supervened, and, by the last of November, the patient was in a fair way for recovery and moving about the hospital. In December he was still doing well." Surgeon Thompson states that the specimen of the excised portion of the pancreas was left with Surgeon S. B. Knox, 49th Pennsyl- vania, to be forwarded to the Museum. No evidence of its reception or transmission can be found. Case 504.—Private William Freshwater, Co. F, G6th Ohio, received wounds of the abdomen, left forearm, and neck, at Port Republic, June 9, 1862. He was conveyed in an army wagon to Front Royal, arriving on the 13th, and on the 14th was sent by rail to "Washington, and admitted, ou the 15th, to Judiciary Square Hospital. He was placed in a ward under the charge of Acting Assistant Surgeon David W. Cheever, who states that "a ball had entered one and a half inches outside the left nipple, on a level with the seventh rib, and could be felt under the skin near the spinous process of the last dorsal vertebra. Some viscus, thought to be the lower tip of tbe lung, protruded tit the wound. He died in two days (June 17th), with symptoms of peritonitis. Post-mortem: The ball pierced the diaphragm without touching the lower lobe of the lung; there was no perforation of the intestines, but they were glued together by peritoneal inflammation. The pancreas protruded at the wound." 1 Mo.vdieue (Recherches pour servir a V histoire pathologique du pancreas, 183C>) says : "Nous ne connaissons aucun cas de plaies du pancreas; mais les experiences de Brixnkk (Ephem. nat cur., Dec. II, Ann. VII, Obs. CXXXII (1 <;««), Norimbergae, 171d, p. 243) etablissent qu'elles ne seraient pas par elles-niemes tres-dangereuses," expressions adopted by Raioe-Dei.okme, or the compiler of the article Maladies du Pancreas, in the Repertoire generate (Diet de Med.. T. XXIII, 1841, p. 68), which, if not absolutely true, justify the epigraph these writers borrow from Feknki. : Quo minus notn, eo magis exploranda sunt. Jamai.v, a very accurate writer, remarks (Manuel de Pathologic et de Clinique Chirurgicales, 2eme ed., 1870, T. II, p. i'Xif. '' Les lesions traumatiqties du pancreas sont excessivement rares; on possede quelques cxemples de ruptures de cet organe, dont la cause a et6 le plus souvent le passage d'une roue de voiture sur l'abdomen." * Attention has been called (Note 4, page 21, supra) to three cases of rupture of the pancreas without external wounds, viz: 1. S. Cooper's case (Lancet, 1839, Vol. I, p. 486), J. C-----. aged 33, struck b3' the wheel of a cart; ribs broken, "pancreas literally smashed," spleen and left kidney also lacerated; death in a few hours. 2. JL Le Gkos Clank's case (Lect. on I'riuc. Surg. Diag., Is70. p. 2E8). a lad, with other internal injuries, which proved speedily fatal. "I am not acquainted with any special sign," says this discriminating and sagacious writer, "by which this organic lesion can be identified." 'J. Devekuie's case (Med. leq., T. II. p. 44). an unknown woman, crushed by a carriage on a road in Flanders: speedy death. To these WOUNDS OF THE PANCREAS. ir,o The only cases within my knowledge, in which preparations illustrating shot wounds of the pancreas have been preserved, are illustrated by specimens 2430 and 2884 of the surgical series of the Army Medical Museum.1 These are figured in the next two wood- cuts (Fius. 122 and 12;>). It is remarkable, though such coincidences are by no means unparalleled, that these and a third case were observed at tlie same hospital during the same season: Cask 505.—Private J. Koprieau, Co. B, 51st New York. aged :W years, was severely wounded at the battle of tbe Wilderness, May 5, 1S1.4. and was at once taken to tlie field hospital of the 2d division, Ninth Corps. The records of this hospital contain only the name and military description of tbe patient, with the entry <■ gunshot wounds of arm and hip." Searches through the field memoranda, and inquiries among medical officer* under whose observation the case was likely to have fallen, have failed to procure any information respecting the early symptoms and progress of the case. As he could not speak English, and his attendants did not understand French, his own statement was not preserved. It can only be inferred that he had to undergo, with tlie other severely wounded of tbe Ninth Corps, the trying journey to Washington described in Medical Director Mcl'arlin's report, in the Appendix to Part I. Arriving there, he was placed in Lincoln Hospital. Acting Assistant Surgeon E. L. Bliss, the ward surgeon who treated the patient from May 25th, the day of his admission to Lincoln Hospital, three weeks after the reception of the wound, until his death, gives the following information regarding the case, in a report to Assistant Surgeon J. C. McKcc, which is here reproduced textually: "Doctor: I have the honor to report that Private J. Koprio, Co. B, 51st New York Regiment, on admission to my ward, May 25, 1864, was found to be suffering from a gunshot wound of the back, received on May 5th, the ball having entered about six inches to the left of the spinal column and just below the eighth or ninth rib. Upon examination, it was discovered that the ball had entered the abdominal cavity, but its subsequent course I was unable to determine. Patient's general health was apparently good, and he seemed to suffer but little pain from the injury. Appetite good, bowels regular, urine slightly suppressed and somewhat highly colored. Pulse normally full, but slightly irritable. Ordered nourishing diet, with whiskey and quinine ter. die. Two moderate doses of potassce acetas were administered, which was followed by a relief of the urinal suppression. No noticeable changes appeared for about one week, when a severe haemorrhage occurred, appa- rently venous, from the external wound, which was soon suppressed by the use of compresses and styptics. About six hours afterward a quantity of urine was voided which was thickly mixed with blood. These haemorrhages continued to recur two, three, and four times daily till death, the urinal discharge being very frequent and always bloody. Whiskey or brandy was administered every hour, more or less, as indicated, with an occasional dose of morphia sulphas; always enjoining the most perfect quiet and prescribing the most nutritious liquid diet," Death resulted June 5, 1S{>4. A post-mortem examination was made by Acting Assistant Surgeon L. Schoney, which revealed the course of the ball as follows: "A minie ball entered at the middle portion of the eighth rib, fracturing the same, passed through the centre of the spleen toward the pancreas, penetrating this also in a nearly transverse direction, and (probably a few days before death) sinking toward the splenic artery, tearing it, and lodged at its origin from the cceliac axis; the lung was found emphysematous." The specimen, shown iu the wood-cut (Fig. 122), was forwarded to the Museum by Assistant Surgeon J. Cooper McKee, U. S. A., and is a wet preparation, consisting of parts of the descending aorta and cceliac axis, spleen, pancreas, and left kidney. The ball has lodged in a pouch between tbe sloughing artery and vein. FlG. 122.—A wet preparation of portions of the spleen, pancreas, kidney, aorta, andeueliac axis, showing a musket ball embedded in the pancreas. Spec. 2430. may be added: 4. A case at St. Thomas's Hospital, under Thavers (Lancet, 1827, Vol. XII, p. 3S4), an intoxicated woman knocked down by the wheel of a stage-coach, which did not pass over her. She lived a few hours. Several ribs were fractured ; the pancreas was found completely torn through transversely; the liver was lacerated, and much blood was effused. 5. Kl.KUERG, of Odessa I Arch, fur Klin. Chir., 1868, IX, 2, S.523), relates a case of a stab in the pancreas in a discharged soldier, Anton Stepnnowitch, aged GO, who fell among thieves. Tlie protruding viscus was ligated and excised, and without subsequent fever or peritonitis; the patient left the hospital cured in twenty-one days. 6. LAlsoiiDEitiE (Gazette des Hopitaux, 1856, No. 2, p. 6) relates the case of a young girl receiving a wound in the epigastrium by falling on a knife. The pancreas is alleged to have protruded through the wound. The protruded portion was ligated and excised. The young girl recovered in three weeks. IIvrtl (Handbuch der topographischen AmU.. 15. I, S. 712) is incredulous as to the prolapsus of the pancreas in this case. 7. CALDWELL (D. C), Remarkable case, of the Protrusion of a body, supposed to be the Pancreas, through a wound between the last true and first false Rib, in the Transylvania Jour, of Med., 1828, Vol. I, p. 116. In 1816, a negro man, a slave of Judge Bibb, was stabbed in the left side, and "an oblong body, between three and four inches in length, was observed to be protruded." Drs. ROBERTS, Heaicd, and Calihyell supposed the protruded part might be mesentery, omentum, or lung substance; but, "on a more minute inspection and examination with the fingers, that opinion was changed to the belief that it was the small extremity of the pancreas. * " The loss of all that portion exterior to the constriction was inevitable, being then in a gangrenous condition. * * Extirpation was preferred; * * the bistoury was selected in preference to the ligature. * * The patient soon recovered." Eleven years afterward he was living, having "suffered no inconvenience from the loss of tho part or its unnatural adhesions.'' Drs. I'oiierts, Hkaiid, and Caldwell, " thinking it almost impossible that the pancreas could escape through a part < f the diaphragm and between the ribs," made a critical examination of the part removed, which resulted in their "thorough conviction " that the tissue removed was a portion of the pancreas. 1 Dr. Hyde Salter observes (Cyclop, of Anat and Phys., 185!), Vol. V. p. 108): " The interest that attaches to the deranged anatomy of the pancreas is the interest of obscurity—the interest of diagnosis ; 1 may add, too, the interest of situation; in fact, it is from the situation of the organ that the importance and obscurity of its pathologial relations at once result. Close to the stomach, duodenum, liver, spleen, kidney, aorta, cava, 1^0 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. vi. Some negative evidence of interest is presented by the next two cases:1 Case 506.—Acting Assistant Surgeon Thaddeus L. Leavitt reports that "Corporal Augustus B. Jones, Co. I), 5th Vermont, aged 27 years, was wounded at the battle of the Wilderness, May 10, 1834, laid out on the battle-field one day and night, was then removed to field hospital, from there carried by boat to Washington, and jolted over a rough road of two miles to the Lincoln Hospital, which he reached about two o'clock on the morning of the 23th. I mention these facts of transportation to show the immense fatigue and suffering that this patient must have sustained before he reached his destination. Saw him about six o'clock a. m., found him suffering great agony; examined his wound. The ball had entered one line to the left and below the ensiform cartilage, passing through the abdominal cavity, and making its appearance under the skin just above the crest of the left ilium posteriorly, where it was excised at the field hospital. Pulse quick and exceedingly feeble, abdomen distended and tympanitic; took food and stimuli readily, and became much easier under the free use of opium. Patient was much emaciated, and countenance ghastly and indicative of great suffering. About noon saw him again; found him much more comfortable, wounds suppurating nicely and looked well; he expressed himself as expecting soon now to get well. About four o'clock P. M. was conversing with the nurse; apparently in good spirits, without very great pain; swallowed his medicine, etc., and in about five minutes afterward was in articulo mortis. The autopsy, which was made some hours after, showed the ball to have perforated the inferior curvature of the stomach, and, strange as it may seem, although an orifice was made directly through the walls of the stomach large enough readily to admit two fingers, no inflammation or even congestion could be detected, except in the immediate locality of the wound, which was beginning to suppurate. Evidently the stomach was also uninjured in its functional capacity, as was witnessed by the recept^n and digestion of food during life. Some branches of the gastric artery were severed, and about an ounce and a half of dark uncoagulated blood filled the pelvic cavity. The pancreas was perforated at about its middle, but, except in the immediate track of the ball, gave evidence of no departure from its healthy standard; the intestines and colon were pushed aside during the passage of the ball and were uninjured; the omentum was found in a partial state of decomposition and closely adherent to the small intestines. Liver and spleen healthy. General peritonitis had prevailed, aud was undoubtedly the cause of death. In this case life was sustained for a period of fifteen days, notwithstanding the serious injury of a vital organ and the being subjected to the most unfavorable circumstances and depressing influences." Case 418.—Private William P. B------, Co. A, 44th Georgia, was wounded, near Fort Stevens, in General Early's demonstration on Washington, July 12, 1864, by a cylindro-conical musket ball, which entered below the spine of the left scapula, an inch from the shoulder joint, and penetrated the chest. He remained a prisoner on the field, and was conveyed to Lincoln Hospital, a few miles distant, being admitted on July 14th. Acting Assistant Surgeon Thaddeus L. Leavitt, the ward surgeon, noted that emphysema extended over the entire left chest, that respiration was painful, but not otherwise difficult, and that there was paralysis of motion of the left arm. Simple water dressings to the wound, and a draught with an eighth of a grain of sulphate of morphia in syrup of seneka and wild-cherry, bark thrice daily, with extra light diet and a little wine. There was little change in the progress of the case until the 18th, when the pain in the side became great, and was somewhat relieved by sinapisms. There was dulness on percussion, and absence of the respiratory sounds over the posterior left chest. Anteriorly, percussion and auscultation normal. On the 19th, there was extreme dulness in the precordial region, and the head was forced over to the right side. There was dulness, too, at the base of the right lung, with indistinct respiratory murmur. On the 20th, jaundice was very pronounced, and Dr. Leavitt enters on the register: "Can the liver be injured also?'' On the 21st, at 4 o'clock A. m., profuse haemorrhage from the nose and mouth occurred; bleeding coming apparently from the lung. The local pain was much lessened, the pulse became very weak and thready; the jaundice was extreme; chloride of sodium ordered. On the 22d there was much pain in the left side, dyspnoea, consciousness perfect, pulse failing; death at noon, July 24, 1864. At the autopsy, two hours after death, the wound was traced from the entrance in the scapula through the fractured fifth rib, the track passing downward, inward, and backward, through the Fin. 123.—Pancreas with a conoidal musket ball ' ' ° ' ' ,.-,■,• , embedded in its head. Spec. 2684. lower lobe ot the left lung, the diaphragm, the lelt lobe ol the liver, to the head of the pancreas, where the ball was found lodged in the head of the viscus, at the angle formed by the cceliac axis with the aorta. The lower lobe of the right lung was hepatized; the left lung was carnified, collapsed, and compressed by a large accumulation of black fluid blood. The pleura was freely lined with partly mesenteric glands, and cceliac axis, it finds itself in immediate relation with the great vascular, nervous, digestive, and absorbent centres of the abdomen, and may either affect them secondarily, be effected by them", or furnish a source of fallacy and doubt as to whether it be it, or they, or both, that are implicated; and while it is thus placed at the most important point in the whole range of medical anatomy, its situation almost completely precludes it from the advantages of physical diagnosis. The pancreas enjoys an immunity from disease greater than most organs, but I believe this immunity is in part real and in part only apparent; for it cannot be doubted that one reason why the records of its morbid anatomy are so scanty is that, in so large a number of post-mortems, no examination of the organ is made at all. It is the last to be got at, and, the cause of death having been ascertained, its examination is looked upon as supererogatory; besides, it is often obscured and mutilated in the removal of other organs, and its careful dissection from its situation, which is necessary to examine it satisfactorily, is troublesome and not very eas}-." ' BELL (13.) (A System of Surgery, 1787, Vol. V, p. 298) says: "As the pancreas lies deeply covered with the other viscera, wounds of it can seldom be discovered ; but as a division of the duct of this gland will prevent the secretion which it affords from being carried to the bowels, this may, by interrupting or impeding digestion, do much injury to the constitution ; and as the liquor will be effused into the civity of the abdomen, it may thus be productive of collections the removal of which may ultimately require the assistance of surgery." BOYEK (Traite des Maladies Chirurgicales, 3m0 6d., T. VI. p. 15) remarks: "Les plaies qui interessent le pancreas n'ont pas ordinairement des signes particuliers. Quelques auteurs ont indiqu6 I'ecoulement d'un liquide incolore, par 1'orifice exteneur de la plaie, comme le signe caract6ristique de cette l6sion; mais on n'a peut-etre jamais vu cet ecoulemcnt de sue pancrcatique, ct l'on a observe avec raison q'une simple augmentation dans I'exhalation pentoneale suffirait pour produire un scmblable symptome. II en est u peu pres de meme de la blessure du canal thoracique, qui, suivant quelques auteurs, laisse 6chapper hors du temps de la digestion une lymphe sans couleur, et fournit apres le repas un fluide lactiforme qui s'6coule par la plaie. Mais c'est n est pas d'apres le raisonne ment. c'est uniqucment sur l'observation qu'il convient de fonder les signes des maladies." SECT. III.l WOUNDS ok THE PANCREAS. 161 organized lymph. The heart was normal; its cavities empty, weight nine ounces. The spleen was firm, dark brown, weight nine and a half ounces. The pancreas was rather large, seven inches long; weight, five ounces (weighed with the ball embedded). There was nothing abnormal in its appearance, except the presence of tbe foreign body. The specimen was sent to the Museum by Acting Assistant Surgeon IF. M. Dean, with a memorandum of the autopsy and the clinical "descriptive list," drawn up by Dr. Leavitt. In the hitter, there is no indication of any symptoms calling attention to the pancreas during the eight days the patient was under observation. Indeed, it was not until the sixth day from the reception of the injury that the hemorrhage and jaundice led to the suspicion of the hepatic lesion. Unfortunately, the appearance of the dejections is not noted. On examining the specimen microscopically, no deviation from the normal structure is found in sections made from tissue taken from the left end or tail of the viscus, and from tbe middle part or body. In close contiguity to tbe ball is a fine network of fibrillated tissue. As hardened in alcohol, the preparation offers no indication of vascular engorgement having existed. The coats of the great arteries with which the ball was in apposition were uninjured.1 The first two ol these five observations of shot injuries of the pancreas seem to establiah that a portion of this viscus may be separated by violence from the splenic artery and other important attachments, may protrude through an external wound, and may be removed, under such circumstances, without hazardous consequences. The proximate causes of death in the four fatal cases were: in one, shock and peritonitis conjoined; in the other three, secondary haemorrhage.- In four of the five cases, the projectiles pene- trated posteriorly in the space between the angle of the left scapula and the angles of the ribs, and passed through the diaphragm and the solar plexus; in one, the ball entered anteriorly, near the tip of the xiphoid cartilage, and was believed to have passed through the stomach.2 As, in the three cases which were under treatment for twelve days or more, the lesions of the pancreas were unsuspected, its possible functional derangements were not investigated.3 The autopsies shed little light on the morbid anatomy of the organ.4 1 HlProci:.\iKS nowhere mentious the pancreas. Vesalius (De hum. corp. fab., L. V, cap. IV, ed. Basilcae, 1542, p. 494) held the opinion of the earlier anatomists, that its office was to underlie the stomach as a pillow, a view refuted by its position in birds and fish, remote from the stomach. A Baccius (Romue, 1586) maintained that it served for the transit of the chyle from the intestines to the spleen. After the discovery of the pancreatic duct, in 1642. by Wirsuxu, Yesi.ixgius (Syntagma anat, KiC4, cap. IV) held that the pancreatic fluid resembled bile, a view supported by ASELLI and Riorlan. Bartholin regarded the pancreas as the excretory duct of the spleen. A pupil of Sylvius, De Graaf (De succo pancreatico, Lugduni Bat., 1G71), extirpated the spleen in dogs to refute this view. A fifth opinion, assigned to Lindenus (Leyden, 1664), was that the pancreas excreted the effete dregs of the blood. A sixth doctrine taught that it carried off the excretions of the nerves. Sylvius CThes. 37) enunciated the true doctrine, that it furnished au important secretion of its own. After many researches by Brunxer (Exp. nov. circa Pancreas, Amsterdam, 1G83), Pechlln (Leyden, 1672), and others, IlALLEB, after exhausting himself in conjectures, could only say : Plura possunt esse officia liquoris nondum satis noti; and MAGEN'DIE, fifty years later, admitted that the function of the pancreatic fluid was unknown. In 1823, the Academy of Paris made this a prize question, and tho analyses of Tiedemaxn ami Gmf.lix, and of Leu ret and L \ssak;xe, received honorable mention, and paved the way for the great discoveries of CLAUDE BERNARD, which, however qualified by the criticisms of FRERICHS and of BIDDER and SCHMID, must stand in the main. 2In remarking, on page 49, that the statement of Dr. Leavmt in regard to the gastric laceration was "simply incredible," it was not designed to imply that the facts were intentionally misrepresented; but that the observation was probably erroneous. Many examples of supposed perforations of the alimentary canal have been sent ta the Museum, in which the donors subsequently recognized and admitted that the lacerations were made in the necropsies. In Case 50G, entered on D. C. Case Book XVI, p. (S3, and printed also by Dr. Leavitt (Med. and Surg. Rep., 1863, Vol. XII, p. 105), it is to be regretted that the pathological preparation was not preserved. 3 Of the derangements attending the arrest of the emulsifying action of the pancreatic fluid on fatty matters, or the connection between chronic diseases of the pancreas and fatty dejections from the bowels, notwithstanding the masterly researches of Dr. Richard Bright (Med. Chir. Trans., 1833, Vol. XVIII, p. 1), doubt still obtains. There are thirty-eight preparations of the diseased pancreas in the Museums of tho London Hospitals, and the evidence they present is apparently very conflicting. The possible disorders resulting from derangement cf the metamorphic action of the pancreatic fluid or starch}' matters are equally involved in obscurity. Consult BECOURT (Reaherches sur le pancrias, ses fonctions, et ses alterations organiques, Strasb.. 183'J), LLOYD (Case of Jaundice, with Discharge of Fatty Matter, in Med. Chir. Trans., 1833, Vol. XVIII, p. 57), and Et.LlOTSOX (On the Discharge of Fatty Matters from the Alimentary Canal and Urinary Passage, in Med. Chir. Trans.. 1833, Vol. XVIII, p. 67). 4 Lawrence (Med. Chir. Trans , 1830, Vol. XVI, p. 367) once found the pancreas of " a deep and dull red color," which is supposed to be charac- teristic of acute pancreatitis But very little is known of its structural changes. Axural (Pricis d'anat. path., T. II, p. 582) says that they "are infinitely rare." Baillie (Morb. Anat, Chap. XII) met with an instance of abscess of the pancreas. Portal (Cours d'anat. med., T. V, p. 351) treats of the pathological anatomy of the pancreas from speculation in place of observation, in the same manner that its injuries are described by the surgeons who, with Gooch (Chirurgical Works, 1792, Vol. I, p. 99), declare that "Wounds of the pancreas are to be concluded mortal if its duct or blood-vessels are injured, whence the succus pancreaticus or blood may be discharged into the cavity of the abdomen, and there putrefying, cause inevitable death; besides, as the situation of the pancreas is under the stomach, it cannot easily be wounded without the weapons passing through this organ also." This notion of Gooch of the pancreatic fluid escaping into the belly is probably derived from the cases given by Bonetus (Sepulchretum, Obs. LVII, et. seq.). These are very unsatisfactory, and the criticism by tho great Morgagni (Lib. Ill, I'.pist. XXX), and, indeed, his entire discussion of this subject, is little better. Vidal (Rev. Med., 1824, T. Ill) and STORCII (in his Anni Media) record examples of profuse internal haemorrhage in the pancreas. Fearnside (Med. Gaz., 1850, Vol. XLVI. p. 96) gives a case of hypertrophy. Gendrin (Hist. Anat. des inflammat, 1826, T. I. p. 2G2) gives instances of abscesses, including one opening into the jejunum. Sewall (Diseases of the Pancreas, in the New England Jour, of Med. and Surg., 1813, p. '20) collects some cases in his inaugural dissertation; but Professor GROSS (Elements of Pathological Anatomy, 2d ed., 1845, Chap. XXIV), with his usual encyclopaedic erudition, has collected nearly all the recorded observations on the subject. Consult also Harles (Uber die Krankheiten des Pankreas, Nuremberg, 1812), HOFFMANN (De pancreate ejnsque morbis, Nurembergas, 1807), Ckuveilhier (Anat. path., 1829-35, Livr. 15 and 19), COPLAND (Diet of Pract Med , London, 1859, Part III, p. 4. Article Pancreas). Clark (Case of Disease of the Pancreas and Liver, in The Lancet, 1851, Vol. II, p. 152), and KOENIG (Disquisitio morborumpancreatis, Tiibingav 1829). 21 1(>2 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI 01 Wounds of the Kidney.—Traumatic lesions of tbe kidneys present many diversities, according as they interest the cortical or tubular structures, the excretory ducts )lood-vessels, or communicate with the peritoneal cavity, or externally in the loins, or are complicated with other visceral injuries. The liability of the kidney to rupture, and examples of that form of injury, have been discussed on page 20, supra. Punctured and incised wounds of this viscus are uncommon;1 and no instances were reported during the War.2 It is well established, however, that, though dangerous, they are not necessarily mortal lesions. Shot wounds of the kidney are not very infrequent. Many alleged instances of recovery, and a yet larger propor- tion of fatal cases, appear on the returns of the War. The right kidney, lower than the left (Fig. 124), from the position of the liver, is often interested (Cases 380, 411, 452, 457) in shot perforations of the latter. The left kidney, on a higher plane, covered in front by the great end of the stomach, the spleen, and the descend- ing colou, is sometimes implicated (Cases 499, 502, 505) with wounds of those viscera. There was no case of division of the ureter alone. A missile pro- ducing this effect would be likely to interest the emulgent vessels also, and such cases rarely reach the Fig. 124.—A superficial view of the internal organs n •, i 771 i_l 111 , t , - of the chest and abdomen as seen from behind. TW hospitals. r or the same reason, probably, sympathetic duced from SlDSOX's Medical Anatomy, PI. XII.] i • i r 1 1 r ^ ■ 1 disturbance ot branches ot the spermatic plexus, from mechanical derangement of the renal plexus, was comparitively infrequent. The majority of the cases recorded in this group were complicated, and instances in which the symptoms observed were referable solely to renal injuries were very few. Examples of wounds of both kidneys appear only among the fatal cases. The practice which Larrey and Dupuvtreii enjoined, of freely enlarging the lumbar orifices of wounds of the kidney to prevent tlie infiltration of urine internally, or into the dorsal muscles, does not appear to have been at all followed. There were but few references to the formation of urinous abscesses, and no examples of persistent urinary fistulae. Nephrotomy was not practised. 1 11i:xxp.\ remarks (Princ. Med. Surg., 3d ed., p. 425): " The cases on record of recoveries after wounds of the kidney are not numerous. The excellent Haller gives us one in his Opuscul. Patholog., Obs. 69; and BOURIEXXE furnishes another in the Journal de Medecine, tome xlii, p. 554. There is also a case of Dr. Borthwick, in Duncan's 'Annals of Medicine' for 1799, where a wound was inflicted by a sword, and the patient recovered. Wounds of this part are treated of by almost all the systematic writers. A special dissertation on them was published by GlTTLER, at Leipzic, so far back as 1596, the only monograph with the existence of which I am acquainted." 2 The old writers give some instances of recovery from punctured and incised wounds of the kidney. Thus, FALLOPIUS (De vuln. cap., c. XII) writes: "Vidi renem sinistrum pugione vulneratum sanari: quia parenchyma, scilicet sanguis ille crassus concrevit in carnem." MOXTFALCON (Art. Reins, Diet des Sci. Med., 1800, T. XL, VII, p. 425) says that VALLERIOLA records a successful case. SctlENCKlUS (Obs. Med. rar., 1644, p. 461) quotes a case from DODOXJEUS (Med. obs. exempla, Hardewyck. 1621, cap. XXXII), a woman stabbed in the loins; bloody urine; wound in kidney healed, "quern (renem) vulneratum fuisse, particula ejus e vulnere exempta ostendit." LAMOTTE (Traiti complet de Chir., 3me 6d., 1771, T. II, Obs. CCXLVII, p. 129) gives a remarkable recovery from a wound of the kidney. In his notes to BECK (Elem. of Med. Jurisp., 5th ed., 1835, Vol. II, p. 218), DUXLOP refers to a case related by Dr. KNOX, of Edinburgh, of a boy at the Cape of Good Hope, who received a deep wound in the left kidney from a butcher knife, but speedily recovered. In ScilMinT's Jahrbiicher for 18G8, B. 140, S. 29!», what appears to be the same case is reported by Dr. ScnusTEK (Oesterreichische Zeitschrift farpralct. Heilkunde, 1868, B. XIV, S. 12), who cites from Herr Lorinser's division, the instance of a butcher boy, aged 14, who had received a stab wound, three inches deep, on the right side, immediately below the twelfth rib, three inches from the spine; considerable haemorrhage; urine, mixed with blood, passed for three days; on the seventh day, slight icteric coloration of skin; a copious light-brown fluid, which proved to be urine, escaped from the wound; recovery in fifty days. BECK (Chirurgie der Schussverletzungen, 1872, S. 543; cites a case related to him by Dr. SCHELLDOKF: M. F-----. in January 1868, fell backward upon a scythe, which caused an incision four and a half inches long, through which the right kidney, slightly wounded, protruded. The bloody effusion was removed and the kidney returned, and ice applied; bloody urine passed during eight days ; the patient recovered completely. Bouim'XNE (Jour, de Med. Chir. Phar., etc., Juillet-Decembre, 1774, T. XLII) recites a case of SECT. 111.] WOUNDS OF THE KIDNEY. 163 Fig. 125.—Section of a kidney with a shot perforation from before backward. Spec. 1773. Gunshot Wounds.—Shot wounds of tho kidney are often associated with wounds of tlie stomach, liver, spleen, diaphragm, intestines, or spine. Many examples have already been adduced. The case which furnished the preparations of shot lesions of the duodenum and of the liver, represented by Figures 13 and 106, of which some details arc recorded on page 134 (Case -k>2). afforded also an illustration of a shot perforation of the kidney, which is represented in the adjacent wood-cut (Fig. 125). Other examples are enumerated further on. Such cases were usually speedily fatal from shock, or from shock and haemorrhage conjoined. The least complicated instances are observed when a ball enters in the lumbar region and penetrates the cortical substance. Then it is inferred that the kidney is implicated, by the depth and direction of the wound, bleeding,1 pain in the renal region (according to most writers, though Hunter says, op. cit., p. 545: "the sensation will be trifling"), and pain and spasmodic retraction in the testis. If the wound extends to the tubular structure, usually urine mixed with blood escapes by the external wound, and there is hsematuria. When the peritoneum is also wounded, urine escapes into the cavity of the belly, and fatal peritonitis is almost inevitable. The instances of recovery from shot wounds of the kidney reported during the War, though not infrequent, are generally wanting in such details as would establish them as unequivocal.9 Case GOS.—Private Samuel M. Haldeman, Co. K, 4th Pennsylvania, aged 32 years, received a perforating wound of the abdomen at White Oak Swamp. June 30, 1862. He remained in the field hospital until July 25th, when he was transferred to McKim's Mansion Hospital, Baltimore. Surgeon L. Quick, U. S. V., in charge, states that the "ball entered above the crest of the ilium, passed through the left kidney, and out at the lumbar region." On September 19th, he was transferred to West's Buildings Hospital, and was discharged from service December 27, 1862, and pensioned. Pension Examiner Thomas B. Reed, of Philadelphia, reported, May 8, 1837: "The ball passed in about the ninth rib, right side, fractured it, and came out near the spine on the same level. The kidney was wounded, and he had haematemesis for several days after the injury. He is unable to stoop or lift a weight, or do any sort of labor for any length of time. His general health is somewhat impaired." The Pension Examining Board at Philadelphia reported, May 19, 1873, that " stooping or lifting still causes pain. He suffers from nervousness, caused by the injury to the spinal nerves, but has no trouble with his kidneys at this time." Case 509.—Private W. Norris, Co. E, Davis Legion, was wounded at Aldie, June 21, 1863, and made a prisoner. Assistant Surgeon E. A. Dodson, 1st Maryland Cavalry, states that a pistol ball passed in to the right of the spine and through the kidneys and lodged. The inflammatory symptoms were great; the catheter was used for ten days.- There was afterward pain on the passage of the urine, which was mixed with pus corpuscles; the wound was still discharging on July 16th, with less pain on micturition. He was afterward paroled. bayonet wound in the side, penetrating the kidney; severe pain, vomiting, distension of abdomen, and convulsive retraction of the testicle followed; on the second day blood passed per urethram ,■ recovery in twenty-four days. Mr. VERNON (Saint Bartholomew's Hosp. Rep., London, 18G6, p 124) records that W. M------, aged 14, fell from a height of forty feet, and received a wound of the soft parts, immediately above the right iliac crest, through which protruded the lower end of the right kidney; a piece of its substaiice had been chipped out, leaving a gap, which would admit the finger end; tenderness of abdomen; discharge of small quantities of blood-stained urine by the urethra, and free discharge of urine from wound; recovery in three weeks. Mr. ACKERLEY, of Liverpool (Observations on Wounds of the Abdomen, in London Med. Gaz., 1837, Vol. XX, p. 549), relates the case of J. K-----, aged 30, wounded in two places by the extended blades of a pair of tailor shears, the one entering the abdomen about two inches above the anterior superior spinous process of the ilium on the left side, and from which about four inches of the omentum were protruding; the other just beneath the last rib on the same side, and near the spine. Copious discharge of urino from the latter for two days. Protruding omentum removed with a pair of scissors and the several gastric-epiploic arteries secured by ligature, which was left hanging from the wound; recovery in fourteen days. Dr. Pepper (Am. Jour. Med. Sci., N. S., 18(18, Vol. LVI, p. 150) records the case of R. S------, aged 26, stabbed in the upper part of the left lumbar region; urine bloody and highly albuminous; the amount of blood in the urine steadily diminished; pleurisy of left side, and considerable effusion on the tenth day; death on the twenty-third day. The progressive improvement in the condition of the urine and the post-mortem appearances of the kidney lead to the belief that the wound of this organ had almost entirely healed. 'JOHN' Bell (Discourses, already cited, p. 100) says truly: "Bleedings from wounds of the mesentery—kidney—emulgent vein, or any smaller vessel, are often slow and gentle, and are not known by the common signs of inward bleeding." 2 M. Legouest records an instance of reparation in a shot wound of the kidney (Chirurgie d'Armee, 2d 6d., p. 403): "Les coups de feu, outre la blessure constitute par leur traj6t, semblent quelquefois faire eclater le rein et determinent des dechirures etendues. Sur un soldat russe, bless6 a Inkerinann (Crimie, 1855), de deux coups de feu, l'un aux reins, et I'autre au genou gauche, ct qui sucoomba & cette derniere blessure, nous piimes constater la guerison de la plaie du ruin: traverse d'avant en arriere et vers le milieu de sa hauteur, I'organe avait beancoup diminufe de volume et presentait au centre, sur ses deux faces, une cicatrice d6prim6e, fibreuse et solide a laquelle venaient se ioindre commo les rayons d'uno 6toile, cinq autres cicatrices irrfegnlieres." 164 PENETRATING WOUNDS OF THE ABDOMEN. ICIIAP. VI. The following history of a recovery from a shot wound of the left kidney was communicated by Assistant Surgeon R. J. Perry, P. A. C. S.f to the Confederate States Med iced and Surgical Journal. It is printed at page 75 of the first volume of that periodical, copies of which are so rare that it is often desirable, instead of citing articles contained in it, to quote them at length: Cask f>10.—"The records of military surgery show that gunshot wounds of the kidney are almost always fatal, and being so considered, the unfortunate victim is too often left to his fate without proper attention. The following case presents several points of unusual novelty and interest, and teaches the important lesson that the surgeon should never abandon, as hopeless, any case of injury, however unpromising it may seem. Patients do occasionally recover from wounds of the kidney as well as from lumbar abscesses caused from renal calculi, and should therefore always be treated with proper care throughout. Lieutenant A------, 2d Tennessee Infantry, in perfect health, of robust constitution and abstemious habits, was wounded in the battle of Shiloh, on April 6, 18(32, by a minie ball, entering immediately below the heart, and passing out through the upper portion of the left kidney. There was considerable haemorrhage, causing excessive prostration. In this condition he was captured by the enemy and removed to Pittsburg Landing, on Tennessee River, several miles distant from the battle-field, where he remained for six days without any attention, not even the removal of his bloody clothing or dressing of his wounds. He was then placed upon a transport and conveyed to Louisville, Kentucky, and sent to hospital for treatment. During the month of July following, while his wounds were still discharging profusely, he was attacked with typhoid fever, and a large abscess formed in the lower part of abdomen, about one inch to the left of the linea alba, which caused great pain. Tlie second or third week in August he was removed from Louisville to Camp Chase, by way of Cincinnati. Several days after his arrival at Camp Chase, very much enervated from the prolonged attack of fever, the abscess above referred to opened outwardly and discharged an immense quantity of dark sanious fluid mixed with urine. This greatly alarmed him, and the extreme mental anxiety, added to his fearful nervous prostration, came near proving too formidable for the unfortunate victim; but all of these difficulties were combated by a good constitution and the inflexible determination of a veteran soldier to such a degree that, when an exchange of prisoners was effected, he was able to proceed to Vicksburg, Mississippi, where he was released about the first of October. lie commenced his journey homeward (Lynchburg. Virginia), travelling only during the day, resting at night, suffering much from his wounds and abscess, which still continued to discharge an admixture of unhealthy pus and urine. In about two weeks he reached Knoxville, Tennessee, at which place I was then on duty, manifesting symptoms of very great nervous prostration. The second day after his arrival at Knoxville I was called to see hiin, at the house of his sister, at nine o'clock A. M., and found him with a severe chill, followed by high febrile reaction. On examination, I found the anterior wound entirely healed and cicatrized; the posterior wound and abscess very irritable, manifesting no disposition to heal, and both discharging, though not profusely, a thin sanious fluid mixed with urine. He complained of severe excruciating pains in lumbar region, passing but little urine through the uretha—secretions generally deranged. I ordered warm stimulating poultices to wound and abscess, and administered one grain of extract of hyoscyamus. I visited him again at four o'clock P. AI.; found him restless, looking pale, anxious, and alarmed; pulse irritable and frequent; administered anodyne for the night. I saw him the succeeding morning at nine o'clock; rested rather comfortably during the night; still suffering from pains in lumbar region, but much more composed; pulse regular but frequent; continued warm applications to wound and abscess, and anodynes to relieve pain. For several days subsequent he was annoyed with rigors simulating intermittent fever, but which gradually subsided, leaving him much debilitated and troubled with night-sweats, which were overcome by the use of elixir vitriol, tannin, and sponging with stimulating lotions. I then placed him upon nutritious diet and tonics, such as iron, tincture of bark, and quinine. The discharge of urine and unhealthy pus continued for some sixteen or eighteen days, when the discharge of urine ceased and the pus became more laudable. Simple lint and sweet-oil dressings were then substituted for the warm applications. The second or third week in November the wound was almost entirely healed, with but slight discharge, and about the loth of December he resumed his journey to Lynchburg, and in a short time was entirely restored, with some little impairment of general health. I met Lieutenant A------in October, 1833, in perfect health, with the exception that upon too frequent exercise or exposure he was annoyed with some uneasiness and pain in lumbar region." Case 511.—Private M. Selvoir, Co. E, 5th New Hampshire, aged 27 years, was wounded at Farmsville, April 6, 1865, by a round ball, which entered at the left ninth rib anteriorly, five inches from the median line, passed backward, and emerged half an inch to the left of the spinous process of the twelfth dorsal vertebra. He was conveyed to the field hospital of the Second Corps, thence, on the 19th, by the hospital transport State of Maine, to Washington, entering Finley Hospital. Acting Assistant Surgeon Dusenbury1 reports that the patient stated that for a number of days after the injury he was confined to bed, and complained of severe pain in the left testicle. There was slow, steady haemorrhage into the pelvis of the kidney, which found its way out with the urine, partly discolored and partly coagulated. After the subsidence of the haemorrhage some pus was observed with the urine, which soon disappeared, with other troublesome symptoms, when the wounds healed rapidly, so that by July 1st they were entirely healed, with slight tenderness over the cicatrices. The patient was able to go about without inconvenience, and on August 1st did guard duty about the hospital. August 29th, he was transferred to Concord, and mustered out of service September 6, 1865. He is not a pensioner. Cask 512.—Private T. A. G. Hunting, Co. H, 34th Massachusetts, aged 47 years, received a shot wound in the left lumbar region at Piedmont, June 5, 1864. He was made a prisoner, and appears at the Confederate prison hospital at Staunton ; was afterward paroled, and, on August 24th, sent to hospital at Annapolis, thence, on September 22d. to Camp Parole, thence to Dale Hospital, Worcester. February 7th. He returned to duty March 21,1865, and was discharged the service on May 23, 1865. A certificate of Assistant Surgeon Charles G. Allen, 34th Massachusetts, states: "Gunshot wound in the back, which fractured 1 Iil>kxbury (H.). Cases of Gunshot Wounds of the Abdomen involving Viscera, in Am. Jour. Med. Sci . 1865, N. S.. Vol. L, p. 400. SECT. III.] WOUNDS OF THE KIDNEY. 165 one of the ribs; he has partial paralysis of one leg, besides considerable disturbance of the urinary organs." Examining Surgeon Oramel Martin, of Worcester, reports, November 18, ]K65: ''Hall passed into left side, just above the ilium, about four inches from the spine, and passed inside of spine and out about the centre of the right side. He says blood passed with his urine about twenty-one days, and that the wound pains him in stooping or exercising; the scar has adhered to the skin and muscles. Tbe motions of the body, I think, are impaired; disability three-fourths and permanent." This pensioner was paid March 4, 1873. Cask 513.—Private James Ford. Co. G, 10th Infantry, was wounded at Chancellorsville, May 3, 1863. He was treated in the field till May 9th, then was transferred to Finley Hospital; on June 20th, to Christian Street Hospital, Philadelphia; on August 4th, to Turner's Lane Hospital; and. on September 18th, to the Citizens' Volunteer Hospital. The case appears upon the records of these different hospitals as a "gunshot wound of the left shoulder." and, at Turner's Lane, a fracture of tbe left clavicle is noted. On September 26th, the patient was transferred to St. Joseph's Hospital, Central Park, New York, where the following notes appear in the case book: "The ball entered, while he was stooping, over the outer portion of the left clavicle, passed through the lung of the same side, and lodged in the region of the left kidney. It was extracted on the tenth day, together with fragments of fractured bone. After the injury occurred he had hematuria, which continued eight or ten days. He has had cough and haemoptysis from the beginning. The examination made on admission to this hospital reveals the follow- ing facts : 'Dulness and tenderness on percussion on the left side; respiration feeble all over the left lung posteriorly, and, at some situations, is entirely absent; over the anterior portion of the lung there is heard an occasional subcrepitant rale and sibilant rbonchus. >*o distinct evidences of a cavity present themselves; the urine contains albumen, granular uriniferous tube-casts, and blood corpuscles and pus globules in abundance.' October 10th, the haemoptysis continues; the patient is failing in strength and becoming more emaciated. The treatment while in this hospital was quinine and aromatic sulphuric acid." This soldier was discharged from service October 16, 1863. Pension Examiner F. F. Burmeister, of Philadelphia, reported, June 18, 1866: "A minie ball fractured the left clavicle and passed out on the left side of the back. The pensioner suffers with pain in the shoulder and partial paralysis of the left arm, interfering with its use." lie was last paid in June, 1873. Cask 514.— Corporal William H. Leach, Co. F, 1st United States Sharpshooters, aged 21 years, received a gunshot wound through the body at Gettysburg, July 2, 1863. He was removed to the Seminary Hospital, and, on July 26th, to the Cotton Factory Hospital, at Harrisburg. Acting Assistant Surgeon Lewis Post states that "the ball passed through the left hypochondriac region, between the two lower ribs, and fractured tbe lower rib of the right side and injured one or both kidneys. He complained of much pain in the back, and for eighteen days after the reception of the injury voided bloody urine. Cooling application- were still kept to the back, and the wounds dressed with simple cerate twice each day The bowels moved regularly without medicine, and pulse was soft and natural. An opiate was occasionally administered at night. By August 1-lth, the wounds had nearly healed and the urine was natural; the patient complained of nothing but slight weakness in the back. August 24th : For three days the patient has been restless, and during the night passed pus from the bowels, and again voided bloody urine. Rest, sedatives, and mucilaginous drinks were ordered, and by September 16th he was able to walk out and was considered doing well." Leach was discharged from service January 6, 1861, and pensioned. Pension Examiner T. B. Smith, of Washington, reported, January 15, 1884: "The ball entered the abdomen over the middle third of the crest of the left ilium, passed through the loins, and emerged over the middle third of the crest of the right ilium. Another ball entered the abdomen below the edge of the second floating rib, three inches from the mesial line, and is supposed to be embedded in the muscles of the spine. This wound probably connected with the cavity of the intestine, as pus aud sanious matter is found in the stools. He is disabled by reason of much difficulty in flexion of the spinal column, probably owing to rigidity and contrac- tion of its muscles. The discharges of pus, etc., from the wound give rise to occasional attacks of diarrhoea, which temporarily disables him for labor. His general health is good, and he will improve slowly, but, I think, permanently." This pensioner was paid in May, 1873. Case 515.—Acting Assistant Surgeon L. L. Tozier reports that "Private James Brady, Co. C, 10th New York, aged 23 years, was admitted into the Ladies' Home Hospital, New York, June 8, lSiJ4. having been shot while attempting to desert. A pistol ball entered the back, passed through the upper part of the left kidney, and lodged under the skin, in the eighth left intercostal space. When admitted he was much prostrated, his pulse was feeble aud frequent, and his urine very bloody. Cold- water dressings were applied to the wound, and stimulants and a diuretic given, with extra diet. On the 11th, the ball was extracted through an incision. The urine was not as highly colored, and the patient was improving slowly. June 25th, the stimulants have been discontinued; the wound in the side has healed; that in the back nearly so." Brady was returned to duty June 27, 1864, but does not appear upon the Pension Poll, which is probably due to the circumstances attending the reception of the injury. Case 516.—Private W. S. Weaver, Co. E, 100th Indiana, aged 20 years, received a wound of the abdomen at Missionary Ridge, November 25, 1863. He was removed to the field hospital of the 1th division, Fifteenth Corps, thence to Bridgeport, to Cumberland, Nashville, whence he was furloughed January 18, ISfil. On lYbruary 26, 1864, he entered the City Hospital at Indianapolis, suffering with diphtheria. On March 6th, he was transferred to the Soldiers' Home, and, on the 11th, to the hospital at Madison. Previous to his admission to the latter place,^the injury was not supposed to have implicated more than the abdominal walls. Surgeon G. Grant, U. S. V., at Madison, states that "the ball entered the left side about one inch above the anterior superior spinous process of the ilium, perforated the left kidney, and was cut out of the back nearly opposite its entrance. The wounds are apparently healed, but he complains of much pain in the left renal region, and goes around with his body flexed in that direction, and says that he has had frequent hajmaturia. His urine does not show it at this time." Weaver was discharged from service April 21. 1S(>4, and pensioned. Examining Surgeon George YV. Mears, of Indianapolis, reported, April 22, 1864, that "the ball entered the abdomen in the left hypochondriac region and passed downward and backward, and is supposed to have lodged against the body of the third lumbar vertebra. Bloody urine was constantly passed at first, and, recently, occasionally passes. His back is very weak, and he cannot straighten it without great pain about the region of the kidney; his left leg is very weak, and walking a short distance disables him." Pension Examiner Louis Humphreys, of South Bend, reported, June 16, 1870: "The ball penetrated the left side, seven inches anterior to the spine, at the inferior border of 166 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. the lower rib, passed backward, and lodged against the vertebral body opposite the crest of the ilium, from which it was subsequently extracted. The wound healed tardily. From injury of some of the nerves of motion given off from that portion of the spine, partial paralysis exists of the lower left extremity, so as to render him quite lame at times. Walking or standing produces pain in the lumbar region and in the entire left lower limb. Hence he is unable to perform manual labor." Cask 517.—Lieutenant F. C. Hume, Aide to General Cary, was wounded near Deep Bottom, July 27, 1864, by a conoidal ball, which entered the body three inches to the right of the median line and two and a half inches above the umbilicus, escaping at a point directly opposite, the same distance from the spinal column. He was taken at once to the Receiving and Wayside Hospital, Richmond. The register states: " July 28th : The patient has excruciating pain in the region of the right kidney; the urine, yesterday, was bloody, and to-day there is inability to pass it; twelve grains of hydrate of chloral and two grains of extract of hyoscyami given. July 29th: Bowels irritable; vomiting and tympanitis; enema of castor oil and water. July 30th: Condition improving; two grains of hydrate of chloral and one-half a grain of opium was ordered every two hours. He was transferred August 27, 1864, with every prospect of recovery." Case 518.—Private George Davis, Co. D, 18th Illinois, was admitted into the depot general hospital at Cairo, July 14, 1832, with a "shot Avound of the left kidney, received at Fort Donelson, February 15, 1882." Assistant Surgeon S. Hamilton, U. S. V./further states that Davis was discharged from service August 15, 1862, and that his right leg Avas disabled. Dr. W. Q. Burke, of Cairo, also certified that there was a "gunshot wound in the region of the right kidney, Avhich disabled the right leg." A claim for pension was rejected for Avant of evidence that the disability occurred in the line of duty. Cask 519.—Private J. A. Stewart, Co. H, 101st Ohio, aged 25 years, wounded at Stone River, December 31, 1862, by a shell fragment, was treated first in the field hospital of the 2d division, Fifteenth Corps, then at Nashville, then at Louis- ville, then at Jeffersonville, then at Madison, then at Camp Denison, Avhence he was discharged from service. The diagnoses are very varied, but they all agree that there Avas a severe wound in the left lumbar region, Avith dysuria. Some reference to nephritis or gravel appears in several of the hospital reports. Surgeon WT. Varian, U. S. V., is very definite in pronouncing the case a recovery from a shot wound of the kidney. Besides the foregoing twelve eases of recovery from shot wounds believed to implicate the kidney,1 among the recoveries from wounds of the liver there were six instances in which the kidney likewise was supposed to be interested. These were the cases of Galloway (380), Little (387), Patterson (393), Sharer (397), Searle (402), and Williams (404). In the cases of Adams (289), who had stercoral fistula, and of Stanley (298), who voided a ball at stool, the left kidney in the former, and, in the latter, the right kidney, were reported to have been implicated. The only additional information obtained of the case of Private Groff, Co. D, 61st Pennsylvania, recorded.in the preliminary report in Circular jSto. 6, page 27, as a possible recovery from a shot wound of the left kidney, shows that he is not a pensioner. There were five other instances of recovery from shot wounds believed to involve the kidney: Cases 520-524.—Sergeant W. H. Penn, Co. E, 13th Iowa, Avounded at Atlanta, July 22, 1864. Acting Assistant Surgeon J. M. Adler diagnosticated an injury of the right kidney. Pension Examiner J. Windell, of Des Moines, says: "Shot wound of back, Avith congestion of kidney." Pension last paid March 4, 1873.—Private James Fraser, Co. H, 22d Illinois, wounded at Stone River, December 29, 1862, was discharged and pensioned April, 1883. Acting Assistant Surgeon T. W. Colescott states that the wound Avas "in the lower outer border of left hypochondrium, the ball passing through the left kidney and out close to 'Recoveries from shot wounds of the kidney are quite frequently recorded by modern writers on military surgery: Thus, BAUUKNS (Clin, des Pla ies d'armes a feu, 1836, p. 346) gives three examples from the campaigns in Algeria: 1st, Ben-Gil-Ali, an Arab, shot wound of diaphragm, left kidney, and descending colon. 2d, Sergeant U------, of the Zouaves, oblique perforation in the left flank, April 1, 18:16, with fracture of the tenth rib. Haemoptysis and haematuria; no pain or retraction of the testis. The haematuria began to subside after the third day, and the urine was clear in a week. 3d, Corporal S------, 17th Light Infantry, was shot through the left lumbar region, April 15, 1833. Free haemorrhage from the exit wound. Forty days after, a probe catheter entered six inches aud evacuated an accumulation of pus. Dysuria, retracted testicle, but no haematuria. The patient was convalescent. Beck (Chir. der Schussverletzungen, 1872, S. 543) records two fortunate cases in the Franco-Prussian war of 1870. Bn.MtOTH (Chirurgische Briefe, 1872, S. 188) records a recover}-, Case 31, Lieut. Ciffre, 74th French infantry. SOCIX (Kriegschirurgische Erfahrungen, 1872, S. 96) records the case of Ernest Krause, wounded at Gorze, August 16, 1870, by a ball, which entered eight centimetres to the right of the spinous process of the eleventh dorsal vertebra, injuring the right kidney, and probably the liver; recovery in about six months. STEOMEYKU, (Maximen, u. s.w., S. 639) relates the case of a Danish officer shot in the right side under the short ribs, the ball passing out near the spine, just below the twelfth rib; on the next day bloody urine, and on the fifth da}- urine, passed from the wound of exit; a concrement the size of an orange kernel passed, two months after the reception, per urethram, while the patient suffered severe pain; recovery. Dr. A. B. COOK (Louisville Medical Gazette, 1859, Vol. I, p. 99) reports a recovery from a pistol shot through the body, in the case of John D------, an athletic Irishman, aged 23. The ball was believed to have passed through the border of the left lung, the diaphragm, and the external border of the left kidney. Haematuria came on suddenly on the ninth day, and it was inferred that a slough separated at that date. There was acute pain in the left testicle, and along the corner of tbe wound. Dr. S. B. Paksons, an homoeopathist, records (Western Horn. Observer and Chicago Med. Investigator, 1865, ATol. II, p. 51) a recovery from a pistol shot in the abdomen, in the case of James D------. aged 22, the kidney being supposed to be injured. Dr. J. W. BKOOKS records (Chicago Med. Observer, 1872, Vol. XXIX, p. 519) the case of W". C------, aged 30, who recovered after being shot through the body with a Derringer ball. Shock, with haematemesis. and haematuria followed, which, with the direction of the ball, were supposed to ''point unmistakeably to the cutting of the stomach and left kidney by the ball." It is also mentioned that "after the first sixteen hours he had no pain whatever." Pendlkton (New Orleans Journal of Medicine, 18H8, p- 707) relates a recovery from a pistol shot wound of the kidney: G. H. P------, shot in December, 1868, in the right side about two and a half inches from the umbilicus. Haematuria for several days. On the seventh day the patient voided about a gill of pure red blood, with little or no urine. He continued SKCT. III.] WOUNDS OF THE KIDNEY. 167 the left side of tbe fourth lumbar vertebra; there is some abdominal effusion." Pension Examiner C. T. Jones states, in May, 181)7, that the pensioner seems to have recovered his health, but complains of suffering from bloody discharges on slight exertion. This pensioner was last paid .March I, 1S73.—The three others are not on tho Pension Poll: Private Joel IL Simpson, Co. D, 4th Minnesota, reported by Surgeon J. (i. V. Holston, U. S. V., as having received a shot wound of the left kidney at Iuka, September 19, 1S;">2.—Private M. Howe, Co. D, 34th Massachusetts, wounded at Piedmont, June 5, 18.i4, reported by Surgeon T. B. Peed. V. S. V., as "a Avound of kidney.'' Discharged on expiration of service, January 20, 1S(;i;.— Private M. Arms, Co. C, 22d Illinois, wounded at Stone River, December 31, 18G2. Acting Assistant Surgeon Thomas W. Colescott states that the "ball passed just below the ninth rib and emerged at the right side of tbe intervertebral space, between the last dorsal and first lumbar vertebra;, cutting the left kidney." Private Arms applied, but his claim was rejected for want of information. Altogether some particulars are noted of twenty-six alleged instances of recovery from shot wounds of the kidney. In thirteen the right, and in twelve the left, kidney was involved ; in one case, this point is not mentioned. The details of the symptoms and progress of the case," are, for the most part, very unsatisfactory. Hematuria is reported as present in fifteen of these cases. The escape of urine by the external wound can rarely be inferred from the meagre memoranda of the attendant symptoms. Urinary fistula of long duration is reported in one case only. In a few cases, pus and phosphatic deposits in the urine were observed for considerable periods. Various forms of dysuria are referred to ; and lumbar pains, muscular rigidity, partial paralysis, and other disabilities are reported. Of the twenty-six, fifteen are pensioners. Hsematuria is the most constant sign in injuries of this group, and directs attention to the kidney in those cases of general peritonitis in which dysuria and the escape of urine by the wound, or the signs of urinary extravasation are absent; as in the following case, reported by Assistant burgeon G. A. Mursick, U. S. V.:1 Case 525.—Sergeant James A. B------, Co. I, 8th Illinois Cavalry, aged 29 years, of good constitution, was admitted to Stanton Hospital, September 25, 1862, with a shot wound of the abdomen, received on September 22d at Jack's Shop, near Madison, Virginia. The ball entered just below the margin of the last right rib. On admission, the wound presented a ragged appearance. He complained of pain in the abdomen, which was tympanitic; the bowels Avere constipated; pulse 130 and quick, respirations thoracic and 26 per minute; the expression of countenance Avas natural. His urine contained blood. He Avas ordered a grain of opium every three hours, and beef-tea at discretion, and simple dressings to the Avound. On the 26th the condition was unchanged; the dose of opium increased to two grains every two hours; the urine continued bloody. On the 27th he appeared somewhat better; pulse 120, respirations 22. On the 29th the bowels moved spontaneously; the stool contained some blood. On September 30th, in the morning, the pulse Avas 116, respirations 20. At five o'clock p. M., the abdominal pain and tympanitis had increased; pulse 120, respirations 22; his countenance expressed great anxiety. Resumed two grains of opium every two hours. On October 1st the patient was much easier; pulse 1 Hi, respirations 18; tympanitis and pain diminished. In the afternoon, he had an evacuation from the bowels containing bloed. At five o'clock P. ai., the pulse Avas 110, respirations 14. On October 2d the patient's appearance was improved, but he Avas somewhat drowsy; the pupils were not contracted; pulse and respirations unchanged in frequency. On the morning of October 3d the pupils were contracted to one-half their natural size; pulse 110, respirations 11; tympanitis slight; drowsiness marked. On the 4th, in the morning, the pulse Avas 120, respirations 12 : tympanitis increased; ordered a third of a grain of sulphate of morphia every two hours. In the afternoon, the pulse was 130 and feeble, respirations 14; tympanitis augmented since morning; pupils not contracted ; the patient was sinking. Morphine continued, with sherry added, one-half ounce every two hours. On October 5th the pulse was to void blood in smaller quantities during the second week; complete recovery. Jules LUYS (Gazette Midicale de Paris, Juin 20, 1857, T. XII, p. 404) cites the case of a patient who died at the age of 29. Nine years previously lie had received a shot wound in the lumbar region, the ball passing out in the right subspinal region. For twenty-four hours the urine passed from the wound. A large quantity of urine was drawn off by the catheter. No unusual symptoms followed. Three weeks before his death intense fever and general oedema appeared, with symptoms of acute tuberculization. At the autopsy a mass of fibrous material was found to fill the wound into the substance of the kidney. Left kidney shrivelled; right kidney enlarged. Richardson ( West. Jour, of Med. and Surg., Louisville, 1841, Vol. VI, p. 28) reports a recovery from a shot wound of the right kidney; ball entered on the right of the median line, and escaped between the last rib and sacro-iliac junction ; discharge of bloody urine on the first day; recovery in one month. EDMUNDS (J. J.) (New York Monthly Review of Med. and Surg. Sci., and Buffalo Med. Jour.. Vol. XV, No. Ill, August, 1859, p. 119): Au escaping convict was struck in the back by a ball, which is alleged to have "passed through the bowels, wounded the left kidney, and lodged in the abdominal muscles about two inches above and to the left of the umbilicus." Shock ; haematuria; peritonitis, if any, circumscribed. Complete recovery in twelve days. Dupuytkex (Lecons Orales, T. VI, p. 481) relates that a man was received at Hotel-Dieu, in July, 1800, with a shot wound in the flank, with a single orifice, through which urine escaped, and manifested no other grave symptom, and left the hospital a fortnight subsequently conva- lescent, and ultimately recovered completely. LANGENBECK (Nosologic und Therapie der chirurgischen Krankheiten. (iottingen, 1830, B. IV. S. 589) relates a case of perforation of kidney and pelvis ; urine escaped from the wound, and blood passed by the urethra, and later, pus from wound and also from urethra ; wound closed in thirty days; recovery. The details of the case cited from M. Lkooi est, in Note 2, on page 1G3, were communicated to the Societide Chirurgie, October 30, 1867: Delos, 6th regiment of the line, aged 2fi, wounded before Kebastopol, November 5,1855, one shot comminuting the left thigh, a second perforating the left hypochondrium. Death, January 10, 1855. The cicatrix in the left kidney was as described in the note. Other examples will be noted further on. 1 Lideli. (J. A.). Injuries of the Abdominal Viscera by Firearms, etc., in Am. Jour. Med. Sci.. 1867, Vol. LIII, p. H56. l(vS PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. vi. 12^ and feeble, respirations IS, and much embarrassed ; morphine continued; allowance of Avine doubled. At six o'clock i\ Ai., pulse 136 and scarcely perceptible; respirations 22. He died at midnight. Autopsy eighteen hours after death: The body emaciated; the abdomen protuberant; a large ragged Avound about one inch in diameter, in the right hypochondriac region, immediately below the margin of the ribs. On opening the thorax. the heart and left lung appeared normal but forced somewhat to the left by a large effusion of blood into the right pleural cavity The lower lobes of the right lung were compressed and flattened, and sections immediately sank in Avater. Both the pulmonary and costal pleurae Avere covered Avith a thick layer of Avhitish-yellow recent lymph. An abscess which had formed betAveen the oblique and transverse abdominal muscles had burroAved up under the right cms of the diaphragm and opened into the right pleural cavity. The liver appeared normal; the intes- tines and stomach distended. The great omentum and mesentery loaded with extravasated blood of a dark color. Immediately below the caput coli Avas a large abscess, Avhich burrowed along the psoas maejnus and down among the muscles of the back. It Avas lined throughout by a thick layer of false membrane, and, in its lower part, immediately against the sacrum, was found a cylindro-conical ball, somewhat flattened. It had, in its course, perforated the ascending colon and lower end of the right kidney, and fractured the transverse process of the third lumbar vertebra. The kidney presented a ragged Avound at the lower end; the surrounding cellular tissue Fio. 126.—Right kidney torn had become much thickened, and lined by a layer of lymph, forming part of the wall of the lras^flLd^cedbToiie^third^r abscess. The kidney, on section, appeared of a pale-pink hue and granular, softened and flabby, the pyramids almost entirely effaced, except one, at the upper extremity, Avhich was of a dark brownish hue; its tubes Avere distinct; the pelvis avus of a greenish color, its veins much distended with blood. In the accom- panying wood-cut (Fig. 123) the ball is-represented in the direction in which it traversed the kidney, not in the locality in which it avus found. Cash 526.—Private J. Rodgers, Co. G, 53d Ohio, at Kenesaw Mountain, June 27, 1834, was struck, by a musket ball, two inches below the angle of the left scapula. The ball penetrated the pleural cavity, and emerged through the sixth left intercostal space. Admitted to the field hospital of the Fifteenth Corps, at Barton's Iron Works, on June 30th; he breathed with difficulty, and had severe pain; his countenance Avas pale and anxious; the pulse 85. Stimulants and an anodyne Avere administered. Surgeon J. C. Hilburn, 97th Indiana, reports that, " On July 1st, the symptoms Avere aggravated by retention of urine. A catheter was introduced, and four pints of urine tinged with blood were drawn off. A lesion of the left kidney was hoav apparently demonstrated. On July 2d. the patient seemed much easier; urine passed naturally, mixed, however, with much pus and blood. On July 3d, the patient complaining of extreme pain in the chest and abdomen, emollient cataplasms were applied to the bowels; urine unchanged. July 4th, the pain becoming very severe, Avith increased difficulty of breathing, all treatment Avas suspended, and the patient died July 5, 1864." Cask 527.—Acting Assistant Surgeon A. P. Crafts reports that "Private Evan Evans, Co. F, 151st New York, aged 10 years, Avas wounded at Mine Eun, November 27, 1863, by a conoidal ball, Avhich entered at the middle third of the left seventh rib, fractured it, and passed into the body. On December 4th, he was admitted into the 3d division hospital, Alexandria. There was paralysis of the bowels, but nothing else to indicate the course of the ball or the amount of injury to the internal organs, except great prostration, with occasional vomiting. Water dressings were applied, and castor oil and injections Avere given, and stimulants and tonics were administered. Death resulted December 22, 1833. A post-mortem examination, made twelve hours after death, showed great discoloration of the bowels; the liver, lungs, and spleen were healthy. The ball grazed the apex of the kidney, passed directly through, perforated the body of the seventh dorsal vertebra, and lodged close to the spine." Case 528.—Private Henry Meyer, Co. C, Eth Wisconsin, aged 25 years, Avas wounded at the Wilderness, May 7, 1864. by a conoidal ball, Avhich penetrated the right side of the abdomen. On the 12th, he was admitted into the 3d division hospital at Alexandria. Simple dressings were applied to the wound. He died May 30, 1864. Surgeon Edwin Bentley, U. S. V., states that " the ball penetrated the right side of the abdomen, passed through the kidney, and lodged posteriorly to the duodenum, between that and the descending aorta. Death from peritonitis, caused by extravasation of urine into the peritoneal cavity." Case £29.—Private Lewis E. Tickle, Jackson's Virginia Artillery, aged 22 years, received shot wounds of the lumbar region and right arm at Tennallytown, July 13, 1864. On the 27th, he Avas admitted into Lincoln Hospital, Washington. Acting Assistant Surgeon N. A. Bobbins states that "when admitted the patient Avas in a hopeless condition. There was paralysis of the loAver extremities, and he passed both urine and faeces involuntarily. Stimulants and tonics were given, and nux vomica, quinine, and iron Avere exhibited freely. He lingered until August 4th, when he died from gradual exhaustion." Assistant Surgeon J. C. McKee notes, as the cause of death, upon the monthly report, "severe buckshot wound of the kidney." Case 530.—Surgeon John Trenor, jr., II. S. V., reported that "Private Thomas W----, Co. B, 127th New York, aged 43 years, Avas admitted into the hospital at Beaufort, December 10, 1864, Avith a perforating gunshot wound of the back, received at Pocataligo the previous day. The ball had entered to the left of the spine, opposite the first lumbar vertebra, and emerged five inches to the right of the spine. Simple dressings were applied to the wound. Death resulted December 16th. At the necropsy the ball was found to have carried away the FlG. 1~V—Sln.t laceration of the * • right kidney. Spec. :s?03. apex of the right kidney (Fig. 127). The spinal column was uninjured." SECT. III. | WOUNDS OF THE KIDNEY. KiO Case 531.—Sergeant Frederick Littig, Co. II, 146th New York, aged 25 years, was Avounded at Six Mile House, near Petersburg, August 19. 1^04. He was taken to tbe hospital of the 2d division, Fifth Corps, and was transferred to Washington on the 24th, and admitted into Lincoln Hospital. Acting Assistant Surgeon G. S. Stebbins notes a "gunshot wound of the chest, involving the kidney,'' and states that "the patient had suffered so much from the wound previous to his admission that be was very badly reduced; there was also paralysis of the bladder and lower extremities. He was constantly delirious, and had involuntary discharges for several days, both from the bowels and bladder. Stimulants, tonics, and nourishing diet Avere given, and a grain each of acetate of lead and opium was administered to control internal haemorrhage. Sulphate of morphia in solution to allay pain, and strychnine to overcome the paralysis of the bladder, were also given. He continued to fail in strength rapidly, and died on September 5, 1864, from complete exhaustion." The injury was on the right side. Cask 532.—Sergeant F. S. Moyer, Co. K, 51st Pennsylvania, aged 34 years, was Avounded at Spottsylvania, May 12, lS.il, by a conoidal ball, which entered above the crest of the ilium and lodged. He was taken to the hospital of the 3d division, Ninth Corps. On the 26th, he was removed to Lincoln Hospital. Assistant Surgeon J. 0. McKee notes the injury as a "shot wound of tbe left kidney, the ball lodging in the organ," and states that pyaemia Avas developed June 10th, and, although tonics and stimulants Ave re freely administered, the patient died June 16, 1864. Case 533.—Private A. Wolf, Co. H, S7tb Pennsylvania, Avounded tit. Mouocacy, July 9, IH54, entered hospital at Frederick on the 10th. Acting Assistant Surgeon W. S. Adams reports that the matter discharged from the Avounds had the odor both of laves and of urine. On the 11th, there was slight tympanitis, but no tenderness on pressure; the bladder Avas empty. A discharge of urine and faeces from the wound continued until death, July 1!, 1864. An autopsy, ten hours after, showed that the ball, passing through the left gluteal hiuscles, thence through the sciatic notch, the bladder, tbe ileum, the ascending colon, and right kidney, lodged against the spinal column. The patient Avas much prostrated on admission, yet survived this terrible series of lesions five days. C.VSE 534.—Private G. W. Kyerson. Co. F, 9th Maine, aged 20 years, received a shot wound of the left side at Petersburg, June 30th, was taken to the base hospital of the Eighteenth Corps, and died July 9, 18f>4. Surgeon C. H. Carpenter, 14dth New York, thus describes the necropsy: "External examination showed the chest full and resonant; no difference perceptible on either side; no more than the usual amount of dulness as the spine or dorsal region was approached. A penetrating wound was seen passing through the tegument between the eighth and ninth ribs, midway between the sternum and spine, fracturing the ninth, from which the omentum was protruding nearly one inch. BetAveen tbe sixth and seventh ribs, and nearly two inches anterior to a line drawn from axilla to trochanter, was a punctured wound entering the cavity of the thorax. On opening the thoracic cavity the lungs were found uninjured. Slight adhesion had taken place above the point of puncture and of penetrating wound through the diaphragm. On opening the abdomen, tbe intestines were found to be intact, the liver extending three inches to the left of the median line; the left kidney torn from its seat, and nearly reduced to a pulpy mass; the ball passing onward, downward, inward, and backward, until it rested beneath the psoas muscle just below the crest of the ilium, one and one-fourth inches to the left of the last lumbar vetebra."1 Thus the patient survived a very grave lesion of the kidney nine days. Case 535.—Private Edward II. Kichard, Co. K, 51st Pennsylvania, aged 24 years, received a wound of the chest and abdomen at Petersburg, August 19. 1864. He was treated at a field hospital for a few days, and was transferred to Washington, entering Lincoln Hospital on the 24th. Acting Assistant Surgeon G. S. Stebbins states that "on admission the patient, of a naturally weak constitution, Avas very much reduced in strength, from exposure and suffering. Tbe ball entered the left thoracic cavity, penetrated the diaphragm, wounded the left kidney, and emerged immediately over the spinal column. Internal haemorrhage occurred, and continued for several days. Acetate of lead aud pulverized opium were given, with topical applica- tions of ice-cold Avater, to control the haemorrhage. On September 8th, the wound became gangrenous ; nitric acid was applied, and morphia? Avas administered, and stimulants and tonics were given freely. The gangrene extended, finally involving the spinal cord and its investments, and causing death on September 10, 1864." Case 533.—Private S. N. Daily, Co. F, 11th Infantry, aged 19 years, was wounded at Gettysburg, July 2, 1863. He was taken to the field hospital, Avhere the injury was recorded as a "gunshot Avound of the hip; fracture." On the 24th. he was admitted into the Cotton Factory Hospital, at Harrisburg, where Acting Assistant Surgeon Lewis Post reports: "Tbe ball entered the right side, fractured one of the floating ribs, passed anterior to the spine, and injured the left kidney. On admission, there was considerable prostration, Avith fever, and much tenderness in the region of the left kidney. There was also inconti- nence of urine, Avith painful and bloody discharges; pulse frequent. August 10th, the course prescribed was strictly antiphlo- gistic, with rest. The bowels were kept soluble with oil or sulphate of magnesia. Mucilaginous drinks were given, with opiates at night when necessary. For a feAV days past there has been considerable suppuration, with a feeble pulse. The febrile bymptoms have entirely subsided, and he is now under a tonic course and is allowed a more liberal diet, which is doing good work. August 24th, the wounds are doing well. Healthy granulations are being formed. The pulse is more full and less frequent. The suppuration is diminishing, and he sleeps well. September 26th, there is but little suppuration from the wound, and the patient continues to improve. He sleeps well tit night, and occasionally walks out. No medicines are given, and but light dressings are advised. On September 29th, he had a severe chill, followed by fever and congestion of the left lung. Antiphlogistics and counter-irritants Avere at first resorted to, followed with sedatives and tonics. He gradually failed, and died October 4, 1853." Cask 537.—Private Elden Townsend, Co. F, 7th Maine, aged 19 years, received a wound of the left side at Spottsylvania, May 12. 1854. He was removed to the hospital of the 2d division, Sixth Corps, Avhere the injury Avas treated as a flesh Avound. On May 25th, he Avas transfeired to Lincoln Hospital, Washington. Acting Assistant Surgeon E. L. Bliss reports that "the ball had entered just beneath the eleventh rib and six inches from the spinal column. From the first, the patient suffered great mental depression, which continued until his death. The pulse was full and hard, and the skin dry and parched. The tongue was coated and inclined to redness about its edges; tbe bowels were constipated, and the appetite very poor. These symptoms 1 CARrEXTEii (C. H.). Boston Med. and Surg. Journal, 18fi5. Vol. LXXXI. p. 112. 22 17») PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI continued Avithout change until about July 23d, Avhen they all became gradually aggravated, with the exception of the pulse, which w as Aveak and rapid. This course continued until the skin Avas excessively husky, the tongue red, dry, and cracked, and the stomach so irritated that food and medicine were constantly rejected. Death resulted, from exhaustion, July G, 1S64. No tympanitis nor tenderness of the bowels Avere present at any time. The treatment Avas tonic and stimulating." An autopsy was made 1>v Acting Assistant Surgeon H. M. Dean, who furnishes the following record: " The patient Avas very much emaciated; post-morlriu rigidity well marked; the ball on entering had opened the diaphragm at its attachment, slightly injured the lower lobe of the left lung, passed behind the left kidney, lacerating it somewhat; it then coursed backward and a little dowmvard, breaking off the left transverse process of the first lumbar vertebra, and was found with its apex between the spinous processes of the first and second lumbar vertebrae; the lower lobe of the right lung Avas slightly engorged, but was otherwise healthy; the left lung Avtis healthy, with the exception of the laceration by the ball, above referred to; weight of right lung, twelve ounces; of left, ten and a half ounces; the heart Avas flabby, and in the right side was a medium-sized fibrinous clot; the left side contained a smaller one; the valves were healthy: the heart weighed nine and a half ounces: the spleen was softer than usual, and weighed eight ounces; liver anaemic, weight sixty-six ounces; the right kidney Avas partially congested, and weighed seven and a half ounces; the left kidney Avas very anaemic, and had a laceration across its posterior surface, near its middle, and Avas much smaller than its fellow; it weighed five and a half ounces." The comparative frequency of the association of wounds of the liver and of the right kidney has already been adverted to, and six instances have been noted among the recoveries from shot wounds of the liver. These lesions were conjoined also in nine of the fatal cases that have been enumerated, as in three cases detailed on page 134; the cases of Corporal Coffin (424) and of Bugler William B-----, figured on page 136; and four others enumerated among the fatal complicated cases of wounds of the liver, viz: Case 415.—An autopsy reported by Surgeon C. W. McMillan, 1st East Tennessee, in the case of Corporal Bailey, 45th Pennsylvania, Avounded at Blue Spring, October 12,1863, showed that a conoidal musket ball entered the right sixth intercostal space, passed through the anterior portion of the right lobe of the liver, Avounded the right kidney, and lodged betAveen the bodies of the tenth and eleventh dorsal vertebrae. The patient died six days after the reception of the wound. The abdominal cavity was filled with coagulated blood and serum. The peritoneum and bowels presented a dark appearance.----Case 429.—Assistant Surgeon H. R. Silliman reports that Corpora] S. B. Davis, 8th Tennessee Cavalry, Avas shot by a sentinel, April 12, 1864, at Fort Delaware. The ball entered the right lumbar region, per- forated the right kidney and the liver. Death from internal haemorrhage followed in a few hours.----Case 450.—Serg't S. L. Lynn, 7th New Jersey, received a shot perforation of the chest and abdomen, November 6, 1864. First treated at the Second Corps hospital; he was transferred to Armory Square, at Washington, where Acting Assistant Surgeon T. H. Stuart states that the ball, entering the right seventh intercostal space anteriorly, passed backward and downward through the lung, diaphragm, liver, and kidney, "as Avas indicated by the difficult breathing, profuse discharge of bilious matter, and bloody urine," and emerged to the right of the second lumbar vertebra. The surface Avas icteroid. Death, December 15,1864.---- Case 481.—Private J. Woods, 10th New York Cavalry, on April 24, 1863, was struck by a carbine ball, Avhich entered on the chondral junction of the right seventh rib, passed downward and backward through the lobe of the liver and the right kidney, and emerged two inches from the spinous process of the third lumbar vertebra. Assistant Surgeon L. W. L'liss, 10th New York Cavalry, reports that this wound was fatal in twenty hours. In cases that Avere fatal on the sixth and thirty-ninth days, respectively, there were no evidences of efforts toward reparation of the renal lesions. Indeed, pathologists generally have found little to say on this subject.2 On page 156, examples of associated lesions of the spleen and left kidney have been noticed. Two analogous cases may be found in the First Surgical Volume, pages 446 and 589. The six cases thus complicated were fatal, though one patient lingered for five weeks. 1 This illustration, in which the right kidney is higher than it is usually represented, was photographed on wood from the copperplate opposite page 402, in the Leyden edition of VESALIUS. of 1725. The original wood-cut drawing, according to tradition from Titian's pencil, is on page 370 of the Basel edition of 1542. ■i KLEBS (Beitrage zur pathologischen Anatomic der Schusswunden, Leipzig, 1872, S. 100) observes: "Itpgarding shot injuries of the kidneys, I have little to say, as I have not observed any cases of recovery. In the two fatal cases at Carlsruhe. after fourteen and eighteen days, respectively, no interstitial ne'v formations were found." Tig. 128.—.Some of the relations of the kidneys, spleen, and blond-vessels. [After A'ESALIUS, Figura vigesima— quinti libri.]' SECT. III.] WOUNDS OF THE KIDNEY. 171 Avounds of the kidney conjoined with wounds of the intestines, already exemplified by Oases 424, 4o2, 457, 529, 533, supra, were observed also in the two following cases : Casks 568 and 539.—Surgeon George C. Bennet, 1st New York Mounted Rifles, reports that " Sergeant G. F. Wilson, Co. E, was wounded, January 9, ISO:?, by a conoidal leaden ball, which entered the hypogastric region, passed upward, back- ward, and to the right, and lodged on the external surface of the quadratus lumborum muscle. The intestines were much lacerated, and faval matter issued from the orifice of the wound. The urine Avas satiguinolent. The ball passed through the right kidney, and was extracted from immediately beneath the cellular tissue. The patient was brought into camp and died ten minutes after."—Surgeon St. ,1. W. Mintzer, U. S. V., reports that "Lieutenant George A. Hosmer, 2d Kentucky Cavalry, was admitted into the hospital at McMinnville, October 5, ISti:?, Avith a penetrating shot wound of the abdomen, the ball passing through the small intestines and the right kidney. He was in a moribund condition and died the same day." Shot wounds of the kidney are not infrequently complicated with fractures of the vertebral column, as Surgeon John A. Lidell, U. S. V., in the instructive paper1 on injuries of the spine, already cited, records the particulars of the following case : Case 540.—Private J. W. Smith, Co. K, HGth Pennsylvania, aged 19 years, received a shot wound in the right lumbar region, at Salem Church, May 30, 1864. Admitted to Stanton Hospital June 4th. There Avas ischuria renalis, Avith partial paraplegia. He died June 14, 1864. The ball had traversed the bodies of the second and third lumbar vertebra? and perforated the right kidney, Avhich Avas almost disintegrated. Tlie peritoneum Avas everywhere highly inflamed, the intestines almost gangrenous ; the bladder was tilled with bloody pus. Similar complications have been noted in Gases 501, 525, 527, and 529.2 The frequency of fractures of the lower ribs in connection with renal injuries has also been exemplified. The following is another instance : Cask 541.—Acting Assistant Surgeon A. II. Halbertstadt reports that " Sergeant Charles Clyde, Co. K, 20th Pennsyl- vania Cavalry, aged 25 years, was admitted into the post hospital at Pottsville, December 17, 1863, having been wounded at Pottsville the same day. A buckshot had passed through the tenth rib two inches to the left of the spine, the upper portion of the kidney, and lodged under the skin in front of the chest. Another ball had passed through the head of the tibia and opened the knee joint. The missile was removed from under the integument. Quinine, tincture of opium, and stimulants Avere administered, and nourishing diet ordered. Pyaemia developed December 25th, and death occurred January 6, 1864. The post-mortem revealed the course of the ball as described. Pus had collected in the left pleural cavity, and there were metastatic abscesses in the left kidney." Nineteen other fatal cases of shot wounds of the kidney appear on the returns. Six of the patients succumbed in the first few days, from shock or haemorrhage; two lingered for seven and nine months, and died worn out by protracted suppurations. The dates of injury and of death are enumerated in the following list: Cases 542-561.—Pt. H. Bacon, Co. E, 9th Kentucky, Murfreesboro', January 1st, wounded through both kidneys ; died January 5, 1863. Pt. T. Boardman, Co. F, 64th New York; Reams's Station, August 25, 1864; prisoner; paroled; died March 28. 1865. Pt. W. W. Booty, Co. F, 112th New York; Cold Harbor, June 3d; died June 13, 1864. Pt. W. S. Bruce, Co. H, 6th Iowa Cavalry; Aldie, June 17th; died June 21, 1863. Corp'l D. Brown, Co. I). 165th New York; February 21st; died February 21, 1833; Pt. W. Cochran, Co. K, 14th Pennsylvania Cavalry; Ashby's Gap, December 17th; died December 28, 1864. Pt, I. Eaton, Co. B, 10th Pennsylvania; Gettysburg, July 2d; died July 3, 1863. Pt. M. Holder, Co. B, 11th Georgia; Knoxville, November 29th; captured; died December 16, 1863. Pt. 1). Howard, Co. C, 17th Infantry; Wilderness, May 8th; ■LIDELL (J. A.), On Injuries of the Spine, including Concussion of the Spinal Cord, in the Am. Jour. Med. Sci., 1864, XLA'III. p. 314. 2 In a note on pages 162-3, eleven examples of recoveries from alleged punctured or incised wounds of the kidney are enumerated, to which may be added a twelfth, recorded by Purrmann (Lorbeer-Krantz, u. s. w., 1692, S. 416): a soldier, Miiller, of Captain Kettwich's company, received a stab- wound of the left kidney; retention of urine; finally bloody urine ; which escaped with great force on the fifth day ; complete recovery in six weeks. Another case is found in Korestus (Obs. et Cur. Med., Francof.. 1614, Lib. XXV, Obs. 20): a youth of twenty, stabbed in the right kidney, had retention for six days ; after hot fomentations, he passed a quantity of bloody urine, with clots, and had a rapid convalescence. An interesting case by Dr. Dupuv, of New Orleans, is recorded in the sixty-fourth volume of the Journal geniral de medecine of Sedillot and A'aidy : A man stabbed with a sharpened foil in the right lumbar region ; had acute pain, and voided nearly pure blood from the urethra ; acute circumscribed peritonitis and nephritis followed; he recovered under an energetic autiphlogistic treatment. On pages 166-7, sixteen recoveries from supposed shot wounds of the kidney arc cited ; it is not difficult to adduce others, and it is surprising that Dr. Hamilton (Lectures, Am. Med. Times, Vol. IX, p. 14, and Treatise on Mil. Surg., p. 3G7) should instance M. Legolesi's ease at Sebastopol as the only example within his knowledge. IIexnkn's fifty-ninth observation (op. cit, 3d ed., p. 422) is of unquestionable authenticity, and has been pronounced the most singular on record as illustrating the whole series of symptoms of injuries of the kidney: An officer, shot through the right side of the body, December 9, 1813; was in extreme agony, and voided bloody urine. lie soon became delirious, and venesection was practised several times. He suffered intense pain in the right shoulder. In seven weeks he was removed to England. Fever was again lighted up, and a tumor formed at the site of the posterior wound. The swelling was punctured a fortnight after, and discharged six ounces of pus of a urinous odor. The pain shifted to the testicle and afterward to the penis. The flowing of matter continued great and savored of urine, and there was much suffering from frequent and painful micturition. In July, a piece of cloth was discharged from the urethra. After this, complete recovery ensued. Deiime (Mil.-Chir. Studien, 1861, B. II, S. 151) says : " One of my colleagues at the Ospedale San Francesco observed a case of shot wound of the kidney, in which a piece of cloth from the soldier's uniform passed by the urethra ; examination proved the cloth to be impregnated with epithelial detritus." Oberarzt Tuske (Sciimidi's Jahrbiicher, 1866, TS, 129. S. 213) relates the case of a man wounded by three buckshot, the third entering two inches from the spine and an inch below the right twelfth rib, perforating the peritoneum twice, wounding the kidney, and bruising the intestine; recovery in two and a half months. 172 PHNETKATINU WOl'NDS OF THE ABDOMEN. [CHAP. VI. died May 22. lSil. Pt. 1). Macfagan, substitute; in deserting. November 2-tli : died November 29, IHC4. Pt, II. MacXeil, Co. C. 54th Ohio; Shiloh, April Gth; died May 23, 18 12. Pt. J. Markham, Co. I, 70th New York ; Williamsburg, May 6th; died May 23, lrs,;2. Pt. J. Morlock, Co. K, 37th Indiana; Murfreesboro', January 3d; died January 1G, 1^63. Pt. P. Mower, Co. M. 1st Pennsylvania Cavalry; Culpeper, September 13, 1863; died July 3, 1864. Pt, S. H. Parcells, Co. L, 12th New York Cavalry; Moseley Hall, N. C. March 30th; died April 17, 1865. Pt. A. Perkins, Co. I. 11th New York Cavalry; Memphis, March 15th ; died March 15, 1865. Corp'l L. Specknagle, Co. B, 26th Ohio; Murfreesboro', December 31, 1862 ; died January 1, 1sii3. Pt, J. Sperry, Co. K, 141st Pennsylvania; Chancellorsville, May 3d; died May 19, 1863. Lieut. W. E. Weyrick, adjutant 44th Illinois; Dallas, May 26th; died July 7, 1864. Though there were several instances of lodgement of balls in the kidiie}r, and cases of laceration without communication with the peritoneal sac, there appear to have been none in which the attendant circumstances were thought to require nephrotomy or to warrant the operation of extirpation of the kidney.1 Urinous infiltration in the lumbar cellular tissue does not appear to be common after shot wounds. The reason probably is, that the eschars, lining the track, protect the parts until a limiting wall of inflammatory exudation has taken place. Hence it seems unwise to enlarge the exit wounds at first; but later, the free incision of the phlegmonous accumulations likely to form in the loins constitutes a most important part of the treatment.2 The possibility of retention of the coagula in the bladder should be an object of solicitude, and a large catheter and vesical injections should be used early, if indicated. That the kidney may recover from any very considerable lesions, if the complications can be averted, is now well established. Professor Socin and Mr. Fayrer have recently furnished additional proof/' 1 Professor BILLROTH (Chirurgische Briefe aus den Kriegs-Lazarethen zu Weissenburg und Mannheim, 1870, Berlin, 1872, S. 205) remarks: KlMON gave it as his opinion, "that it might be advantageous, in uncomplicated cases of injur}' of the kidney, where the latter suppurated—cases almost invariably fatal—to extirpate the injured kidney. * * * I would not hesitate to perform this operation, should an opportunity offer." The successful case on which Professor Simon based his opinion, is recorded in the Deutsche Klinik, 1870, S. 137: A woman of 46, who had undergone ovariotomy eighteen months previously, had a renal fistula. On August 2, 1869, at Heidelberg, Professor G. SlMOX extirpated the left kidney. The patient was able to leave her bed in six weeks. Dr. J. T. GlLMORE, of Mobile (Am. Jour, of Obstetrics, May, 1871), removed, in December, 1870, an atrophied kidney from a negress, aged 33, five months advanced in pregnancy. The organ was fed by a single small vessel, which was ligated. The woman recovered without aborting. These, and six other cases, are collated in the American Journal of the Medical Sciences for January, 1873, Vol. LXV, p. 278, viz: Dr. Pkaslee's case (Peaslee, On Ovarian Tumours, 1872, p. 158), the extirpation of a solid renal tumor, April, 1868; death from peritonitis fifty hours afterward. Dr. Schetelig's case (Archiv fur Gynakol, 1870, S. 146), quoted by Peaslee (I.e., p. 158). Dr. Meadow's case (British Med. Jour., 1871. Vol. II, pp. 66, 73), a renal mistaken for an ovarian cyst and extirpated; death from haemorrhage from the pedicle on the sixth day. Mr. Durham's case (Brit Med. Jour., 1870, Vol. 1, p. 565), a woman of 43, who had undergone nephrotomy for suspected calculous disease two years previous]* was not relieved of haematuria, severe pain, etc., and on May 14, 1872, at Guy's Hospital, the right kidney was extirpated and found to be healthy; the patient died. Dr. Peters's case (New York Med. Jour., 1872, Vol. XVI, p. 473), William S. B------, aged 36, had purulent discharges from the bladder, with a tumor in the right loin, and was supposed to have calculous pyelitis ; the kidney was extirpated May 7. 1872; death in sixty-five hours afterward. Professor Von Brlx's case, reported by Dr. Lixseu (Wurtemberg, Correspondenz Blatt 1871. B. XLI, No. 14), of a man with urinaiy fistula following a shot wound received December 2, 1870; a portion of the left kidney was extirpated, March 23, 1871, and death resulted ten hours subsequently. The viscus was so bound down by adhesions that its complete removal was impracticable. The right kidney was found gravely diseased. The editor, for some reason, does not include the case of Dr. E. B. Woi.COTT, of Milwaukee, reported by Dr. I'llAttLES S. Stoddard, (>*) of tlie pi-eroding volume,1 the ball, after fracturing the ninth right rib, traversing the left lung and diaphragm, lodged in the left supra-renal capsule. The patient lived four weeks, although both the pleural and abdominal cavities were opened. iVs he survived so long, it is to be regretted that a more detailed clinical record was not made, that it might be possible to decide how far the icteroid discoloration of the skin and other symptoms, referred to pvcemic infection, may have been associated with pigment deposit in the skin, or the bronzing described by Dr. Addison;2 or if the destruc- tion of one capsule was attended by the retention in the circulation of some poisonous substance, which, as Dr. Brown-Se'qiiard3 suspected, it mav possibly be the office of these organs to remove. But the most careful pathological observation is unlikely to reveal functional rela- left w'dney^ith aconoidai .. Till I i' l -it musket ball lodged in the tions that have eluded the researches ot the most practiced and suprarenal capsule, spec. 1 2425, A. M. M. sagacious physiologists. Case 562.—Private H. C. H------, Co. B, 1st Maine Heavy Artillery, wounded at the Wilderness, May (i, 1864, was sent to Washington, and entered Lincoln Hospital on May 26th. The symptoms are described only on the 30th and on June 2d: "A musket-ball wound, one inch below the inferior angle of the left scapula, enters the pleural cavity; there is no exit wound; the patient is very weak; the wound is unhealthy in appearance; a probe passes readily for FlG. ±30.—Section of ninth right rib, from which more than two inches of the body of the bone were driven into the left lung by a conoidal musket ball. Spec. 2423. [Half-size.] long distance through the wound; there is pyaemia; the respiration is hurried; there is consid- erable dulness on percussion over the left side; several sequestrse were removed from the scapula." On June 2d, there was "bloody oozing from orifice of the wound; no haemorrhage from the mouth or bowels." Death, June 3, 1864, twenty- eight days after the reception of the wound. At the autopsy, " a central portion of the ninth left rib, about two and three-fourths inches long (FlG. 130), was found broken off and driven into tlie substance of the left lung, having become firmly adherent to the lung by fibrinous bands (FlG. 131). The ball penetrated the left lung and diaphragm and was found flattened but concealed, because entirely encysted in the supra-renal capsule over the left kidney." It is erroneously stated in the minute in the First Surgical Volume that the ball penetrated both pleural cavities. The thoracic and abdominal were the two cavities penetrated. The lower lobe of the left lung was partly hepatized, partly carnified. The pulmonary and costal pleurae were greatly thickened by profuse layers of lymph and false membrane. There had been liDemothorax, and the level of the dark decomposing grumous fluid was mapped out by stains on the serous sac (FlG. 131). The fragment of rib driven in upon the lung exactly supplies the loss of substance from the shaft of the bone. The three specimens were forwarded to the Museum by Assistant Surgeon J. Cooper McKoe, with the following memorandum: "Specimen '24-23 exhibits the two extreme portions of the fractured rib; 2424 shows the middle portion of the rib attached to the left lung, which it has penetrated; 2425 is the upper part of the kidney with the supra-renal capsule, containing the ball itself, yet undisturbed. The ball penetrated the left lung and diaphragm and was found flattened and concealed, because entirely encapsulated in the supra-renal body." 1 See First Surgical Volume, Chap. V, p 569, Fig. 229. In this very remarkable case there was no hcernoptysis, not much oppression cf breathing, scarcely any haemorrhage, no disorder of the uropoietic functions, and comparatively little shock at the outset, the reverse of what would be anticipated from Kolliker's observation, that the supra-renal capsule is more highly supplied with nerves than any other glandular structure, and that the nervous branches are derived from the sympathetic, pneuinogastrio, and phrenic nerves. The patient died of pyaemia. The dissection was made by Dr. Schoney, detailed by Dr. McKee to make autopsies at Lincoln Hospital. 2 Addisox, On the Constitutional and Local Effects of Disease of the Supra-renal Capsules, London, 185G ; HAKLEY, An Experimental Enquiry into the Function of the Supra-renal Capsules, Med. Chir. Rev., Am. ed., 1858, Vol. XXI, pp. 169, 389 ; WlLSOX, Diseases of the Skin, 4th ed., p. 557; Lister, Proc. Royal Soc., No. 27; HUTCHINSON, Med. Times and Gaz., 1856, Nos. 297, 299 ; Vulpian, Gaz. Hcbdomadaire, Mars 8,1858. 3 Bno\vx-S£QUARI>, Jour, de la Physiologic, Vol. 1,1858, p. 160 ; PHILIPPEAUX, Comptes Rendus de I'Acad. des Sciences, 1856,1857 ; G katiollt, Comptes Rendus, ] 856. FlG. 131.—Left lung, with a portion of the ninth rib embedded in it. The thickened pleura is cut away to expose the cavity in which altered blood was effused. Spec. 2424. 171 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. Wounds of the Omentum, Mesentery, and Blood-vessels.—Those cases of pene- trating wounds of the abdomen in which the most important lesions are limited to the serous membranes or blood-vessels rarely come under treatment. Some observations that might be included in the first group have been recorded under the head of penetrations without visceral injury (p. 35). The cases in which lesions of the blood-vessels were the most important feature have not been well studied or classified, for the obvious reason that most of the patients perish before help can be accorded, and are left with the slain on the field. Moreover, the pernicious doctrine of Jourdan,1 that surgery is powerless in lesions of the blood-vessels of the belly, had too much currency, and most surgeons felt exonerated from exposing and securing wounded vessels within the abdomen, and at liberty to "rely on general measures," or to employ tents and styptics. The evils of such teinporization will be more fully indicated in treating of haemorrhage and of abdominal effusions. On page 38, supra, the distinctive symptoms that Ravaton ascribed to wounds of the omentum are quoted. Few other authors2 attempt to separate them from the phenomena common to cases of traumatic peritonitis. Apart from the numerous instances of protrusion of the unwounded omentum, which will come up for consideration under the head of complications of penetrating wounds of the abdomen, the returns of the War present at least one remarkable example of a shot lesion of the omentum, the penetration being probably a secondary accident: Case 5(i3.—Private L. S. P------, Co. E, 3d North Carolina, received wounds of the left ankle and left side, at Antietam, September 17, 18G2. He was treated at the field hospital, and, on the 29th, was transferred to hospital No. 1, Frederick, under the care of Assistant Surgeon I. H. Searle, 20th New York, who states: "The first hall inflicted a transverse wound in the left ankle; the second entered just anteriorly and below the twelfth rib on the left side. Amputation above the ankle was deferred only on account of the patient's weakness. He had tenderness over the abdomen to some extent, and constipation. He was treated with stimulants, tonics, and opiates, with "cold-water dressings to the wound. He died October 29, 1832." A post-mortem examina- tion was made twelve hours after death, and Acting Assistant Surgeon W. W. Keen, jr., obtained three specimens: "The ball which wounded the abdomen had passed between the internal and external oblique muscles to the other side of the abdomen, two and a half inches to the right of, and above, the umbilicus. It had there probably ulcerated through the walls of the abdomen, since there was a small abscess and the walls of the abdomen and peri- toneum were firmly glued together. There were also, at this point, as well as over the diaphragmatic surface of the liver, some traces of the effects of peritonitis. The ball was found in the left lumbar region posteriorly (the patient lav mostly upon the left side), iu the fold of the omentum, lying in about one-half an ounce of serum, and was surrounded by some peritoneal bands. The folds of the omentum when lifted hold the hall most beautifully within their grasp." The specimen, imperfectly represented in the wood-cut (FlG. 133), is described by Assistant Surgeon Woodhull3 as "a portion of the omentum magnum, in the folds of which is lodged a conoidal bullet slightly misshapen from having glanced against the brass plate of the soldier's waist-belt." The second prep- aration, sent by Dr. Keen, and very imperfectly represented in FlG. 132, consists of a rectangular portion of the integument from the right (?) lumbar region, exhibiting a circular depressed smooth cicatrix an inch in diameter, composed of granulation tissue, with a thin, shining, epidermal covering. "The ball was found," Dr. Keen writes, "in the left lumbar region. I am under the impression that it entered in the right lumber region, but I am not sure. My memorandum simply says: 'Skin of Fig 132.—A portion of integument from the loin, including a circular shot cicatrix. Spec. 852. [Re- duced to one-half 1 Fig. 133.—Conoidal ball held in the folds of the omentum magnum. Spec. 1926. 1 JOURDAX, Diet des Sci. Med., T. II, p. 317. See First Surgical Volume, p. 521, note. 1 The dissertations of Riyixis (De omento, Lipsiae, 1717J Rebmanx (De omento sano et morboso, Argent., 1753), Halder (De morbis omenti, Gottingen, 178i;), and VALLOT (De morbis omen64.—Private Lewis Vetter, Co. I, 1st New York Artillery, aged IS'2 years, was wounded at Chancellorsville, May 3, 1S63. He remained at the field hospital until the 7th, when he was transferred to Finloy Hospital, Washington. Here, Assistant Surgeon William A. Bradley, U. S. A., recorded the injury as a "shot wound of the right side." On June 2d, the man was transferred to Satterlee Hospital. The following notes of the case appear upon the case-book: "Gunshot wound of the anterior wall of the abdomen; the ball entered about one inch above the crest of the right ilium. The patient states that a portion of omentum protruded about six inches from the wound, and that the protrusion was tied and replaced. The ligature still remains. Sulphate of copper dressings. June 16th, traction on the ligature was commenced by adhesive strips, and water dressings were applied to the wound. On the 18th, the ligature came away. The patient had some diarrhoea on the 19th. On the 20th, cerate dressings were applied." The case appears to have progressed favorably, and on July 27th Vetter was returned to duty. He is not a pensioner. A remarkable example of protrusion of the omentum through a shot wound is related by Assistant Surgeon Sternberg, at page 250 of Circular No. 3, 1871. The protrusion took place through a ragged orifice in the left hypochondrium, caused by the oblique impact of a ball at short range. After a three-days journey of over a hundred miles, the officer who received this injury arrived in camp. The epiploon was then covered with florid granulations, and bathed in pus, and adhered to the margins of the orifice. It was removed by Dr. Sternberg with a wire e'eraseur, and recovery ensued without an unpleasant symptom. The specimen, Avhich weighs three °^fam' Spet' 5524' [Half ounces, is represented in the wood-cut (Fig. 134). Instances of ruptures of the blood-vessels of the abdomen have been referred to on page 24, supra, and examples of wounds of the mesenteric, epiploic, and epigastric arteries have been mentioned1 on pages 9, 10, 42, 62. Wounds of the mesentery are commonly disregarded in presence of the lesions of the intestine to which it is attached, or of the vessels it serves to distribute.2 Figure 49, page 71, supra, shows how it may share in perforations of the bowel. Specimen 505 of the Medical Section of the Museum is "a piece of mesentery, in which an opening has been formed, through which several feet of the lower part of the ileum passed, and subsequently became strangulated."3 In an interesting case, reported by Surgeon W. S. Edgar, 32d Illinois, the division of both epigastric arteries could be recognized in a patulous shot channel above the pubes. There appears to have been no bleeding: Case 565.—"John D. Murphy, a prisoner of war, was wounded while attempting to escape the guard. The ball entered at one inguinal region and emerged at the other, cutting through the entire abdominal wall, from one side to the other, about half an inch above the pubes. It severed the epigastric artery on either side, and produced a gaping wound about eight inches in length, exposing plainly the pelvic viscera. The patient was admitted into the post hospital at Cairo on June 30, 1864, and returned convalescent to the military prison on July 21, 1864." It will be more convenient to continue the subject under the succeeding head. FIG. 134.—Portion of excised 1 Consult also Miung (Preussische Vereinszeitung, 1844, No. 8) and EMMERT (Lehrbuch der Speciellen Chirurgie, Stuttgart, 1862, S. 248). 2Morgaoni (De sed et cans., Patavii, 1765, Epist. LIV, art. 35, p. 282) relates that a foreigner was stabbed in the ahdomen with a sharp thin sword; he died on the fifth day. Of the autopsy MORGAGNI remarks: "And the wound had reached to the intestine colon, ahout four inches below the spleen, but had injured it only superficially; and from thence, without injuring any other intestine, it had reached to the mesentery, which, for this reason, was not only found to be wounded, but tumid." 3 Woodw^aud (J. J.), Catalogue of the Medical Section of Ihe Army Medical Museum, 18G7, p. 55 : Case of Private C. C----, A. 8lh Wisconsin. 176 PENETRATING WOUNDS OF THE ABDOMKN. Complications.—Penetrating wounds of the abdomen may be attended by the following complications, viz: haemorrhage, foreign bodies, visceral protrusions, abdominal effusions, and traumatic peritonitis: Hcemorrhage.—The bleeding which attends penetrating wounds of the abdomen may proceed either from the vessels which supply the walls, from the parenchyma of the viscera, or from the great vessels, in which event the cases rarely come under treatment, and from the secondary branches which supply the viscera. Enthusiasts have cherished and proclaimed the conviction that the surgi- cal lessons of the War, deduced from a great wealth of materials, would embrace solutions of many of the higher surgical problems; but the thoughtful reader, while not disregarding those grave subjects, on which experience was acquired on so large a scale, will, per- haps, look for some of the more important teachings in provinces that rarely engage the attention of sys- tematic writers. In treating of wounds of the chest, we saw that the abandonment of rigid antiphlogistic treatment in such injuries, though sanctioned, was not brought about by the experience of our War, but was only a part of general professional progress, while the practical acquisitions really resulting from our expe- rience were to be sought in our better knowledge of the limits of operative interference with fractures of the bony case, with thoracic effusions, and with lesions of the contained parts. In wounds of the belly, like- wise, we must look for improvements among matters of detail, to which didactic authors devote but little space. In the First Surgical Volume,1 a series of cases was adduced which displayed, in a very impressive manner, the dangers of regarding bleeding from the internal mammary and intercostal arteries as a trivial affair. Not less than twenty-one instances were detailed of recurrent bleeding from these vessels, and seventeen of these cases terminated fatally. The cases recorded with wounds of the abdomen furnish other instances: Case 566.—Surgeon John Drye, 6th Kentucky Cavalry, reports that "Private John T. Minor, Co. I, 6th Kentucky Cavalry, was wounded while on picket at Hopkinsville, Kentucky, December 21, 1864, by the accidental discharge of a Spencer rifle. An elongated ball entered one inch to the right of the umbilicus, passed inward through the intestines, and out close to the spine, dividing the lowest intercostal artery. He died the same day, from internal haemorrhage." Case 567.—Private C. IT. S------, Co. E, 2d Michigan, aged 17 years, was wounded at Petersburg, June 17, 1So4, and was taken to the Ninth Corps Hospital, where it was found that a ball had entered two inches above and to the left of the ensiform cartilage, and passed out in the left hypochondriac region. The injury was regarded as a flesh wound, and the patient was sent to "Washington, entering Emory Hospital June 24th. Acting Assistant Surgeon E. 13. Harris reports that "he was much exhausted, on his arrival, from hiss of blood and exposure in transit to this point. Pulse 98 aud feeble; skin hot; bowels constipated; urine scanty and high colored. There was slight haemorrhage when the patient arrived in hospital, and extensive ecchyinoses and swelling of the left side, extending to the axilla [interstitial haemorrhage], attended with some difficulty of breathing." * * "The patient was bathed and cleansed, and placed in bed, with the wound in a depending position and dressed with iced water. The bowels were opened with sulphate of magnesia; spirits of nitric ether, witli a nourishing diet and stimulants, and an anodyne at night, were directed. On June 25th, the patient had slightly improved. having rested quietly during the night; bowels opened; cold-water dressings continued, with laxatives. On June 27th, the wound was discharging slightly a very offensive matter. On June 30th, the wound discharged pus with slight traces of blood; 1 < )n pages 523, 52."). and 548-552. Fn;. 135.—Posterior view of the viscera of the thorax and abdomen, designed specially to show the relations of the blood-vessels. [After Siuson, Med. Anat, PI. XIV.] sect, in. 1 COMPLICATIONS—H^RMORRHAOF. 17.7 no abatement of swelling in the gide ; breathing more free. On July 1st, the swelling of the side was less, the breathing easier; the cold-water dressings were continued, and nourishing diet and stimulants were given. On July 2d, the wound discharged pus and blood; treatment continued, with anodyne at night. On July 3d, in the morning, the patient was apparently improving. At two in the afternoon, secondary haemorrhage set in profusely, and was supposed to proceed from branches of the internal mammary art on ; patient lost considerable blood; his countenance was sunken, with a haggard expression; breathing short and hurried; bowels tympanitic, and the meteorism rapidly increasing; pulse ]'J) and feeble; ice-water dressings were applied, and sponges saturated with the solution of the persulphate of iron were passed into each wound, and compresses applied over them ; stimulus was given and the patient kept on his back." [Those measures appear not to have controlled the bleeding.] Dr. Harris resumes: "On July 4th, no particular change; some haemorrhage again; no change in treatment, save repeating the compression and persulphate of iron to suppress the bleeding; gave a mild laxative to open the bowels in hope of removing the tympanitis, which was accomplished, with relief to the difficulty of breathing. On July 5th, on exposing the wound, there was no bleeding; gave stimulants, with nourishing food, and an anodyne at befltime. On July Cth, at three in the morning, haemorrhage set in, and the patient expired in a very few moments. 1'ast-inortem: The ball had made furrows through the cartilages of the fourth, fifth, and sixth ribs, and, passing down, had carried away portions of the seventh and eighth ribs, and passed out opposite the spleen. Found that the haemorrhage must have been produced from the musculo- phrenic and superior epigastric arteries, as their mouths were exposed. Found the pericardium altered from the diseased parts contiguous to it, and also partially filled with blood. Also found the transverse portion and upper part of the descending colon were gangrenous; also a portion of the peritoneum contiguous to the wound and diseased parts. There was extensive inflam- mation of the soft parts extending to the axilla. The lower part of the left lung and parts contiguous were highly congested. There were traces of a nutmeg appearance in the left lobe of the liver, which was slightly inflamed. The stomach, heart, right lung, and the upper part of the left lung were normal in appearance. There was also found a mass of coagulaj, pus, spiculac of bone, and pieces of cartilage in a sac between the points of entrance and exit of the ball." A preparation of the anterior extremities of five ribs, the fifth to the ninth inclusive, with the costal cartilages, was forwarded to the Museum by Surgeon N. R. Moseley, aud is mounted as specimen 280i». "The seventh and eighth ribs are fractured at their extremities, and are necrosed."—(Cat, p. 77.) It is difficult to conceive of a more perplexing conjunction of circumstances than was here presented. The propinquity of the ball-track to the pericardium, the hazard of displacing the shattered fragments of the ribs in such vital relations, might well arouse the gravest solicitude of the most experienced surgeon. The excellent Goyrand tells us1 that the ligation of the internal mammary "may be done with facility in the first three intercostal spaces, presents some difficulties in the fourth, is very difficult in the fifth, and nearly impracticable in the sixth." It is quite possible that, in this case, the difficulties of ligating the vessel at the seat of the wound might have proved insurmountable. In this event, it would have been proper, upon the recurrence of the bleeding, to tie the artery in the third intercostal space. But the urgent indications for ligation were obviously unheeded, and the skilful anatomist in charge of the hospital was not, appar- ently, consulted. The disastrous results of reliance on Monsel's salt in serious arterial bleeding were, once more, conspicuously exposed. Here is another instance : Case 568.—Assistant Surgeon E. McClellan reports that "Private W. Bacchus, Co. E, 142d New York, aged 36 years, wounded at Bermuda Hundred, May 12, 1864, was shot through the abdomen. The ball entered posteriorly in the left lumbar region, two inches from the spine, and passed obliquely forward and inward, and was extracted from beneath the skin on the right side. He was treated at the Tenth Corps Hospital till May 19th, and was then admitted to Hampton Hospital. . From June 7th to 11th, there were lost from twenty to twenty-five ounces of blood from recurring bleeding from an intercostal artery. The bleeding was each time arrested by plugging the wound with lint and styptics. Death, June 12, 1864." It is essential to have correct views in this matter. In treating of wounds of the walls of the belly, on pages 9 and 10 of this Chapter, I have earnestly insisted on the dangers of trusting to palliative measures in bleeding from the epigastric, circumflex, iliac, mammary, and lumbar arteries, and have adduced a deplorable series of six fatal cases (Cases 34-39) in exemplification of the perils of temporizing with such accidents. These positive examples are more impressive than any language. Haemorrhage from these vessels is not common, it is true, after division by shot. We have seen, in Case 565, how both epigastrics may be torn across without consecutive bleeding; and know that much larger trunks, as the • brachial, or even the femoral, when divided by shot, are sometimes as completely occluded ' GOYRAND (d'Aix). Cliniqvt Chirurgicale, 1870, p. 223, and Mem. de I'Acad. de Med., 1832. 23 17* PENETRATING WOUNDS OF THE ABDOMEN. [eii.u•. vr. as if treated by torsion. But this natural hsemostasis is not uniformly brought about in. shot wounds, and, in punctured or 'incised wounds, seldom; and when bleeding does take place, it must not be trifled with. In 1790, Dr. James Carmichael Smyth enumerated, in the Society for promoting Medical Knowledge, ten cases in which death resulted from haemorrhage, in consequence of the epigastric artery, or some branch of it, having been wounded in the operation of paracentesis.1 . Mr. South and Professor Hamilton'- have also adduced examples in illustration of this accident. The disastrous results of wounding the epigastric artery in the course of the operation for strangulated hernia are well known. I cannot approve the course of Lawrence and of some other writers, in representing that the dangers of this accident have been exaggerated.3 The recent works on ovariotomy by Dr. Peaslee and by Mr. Wells contain several examples of haemorrhage4 succeeding that operation, which instructively exemplify the importance of exposing and of directly securing the bleeding points. The sixty-eighth and sixty-ninth observations of Sanson's monograph5 on traumatic haemorrhages are instances in which the fatal results of division of the' epigastric artery by stabs might readily have been arrested by the ligature. C J. 1 Smyth, Medical Communications, 17G0, Vol. II, p. 482. Dr. Smyth encountered this accident in his own practice, and mentioned it to Dr. Wn.uam Hunted, who said it was new to him. A twelvemonth after, Dr. Smyth observed a second instance, and, on enquiry, learned that Mr. Watson, cf the Westminster Hospital, had seen the accident three times; Mr. Howard, cf tho Middlesex Hospital, twice; and Mr. Howard, of Argyle street, twice ; and that a patient had recently died at fjt. Thomas's Hospital from the same cause. The editor of the Communications remarks that two cf the above cases had been related by Messrs. Ford and Pearson, and had been the subject of public conversation at meetings of the society several years previously. The St. Thomas's Hospital case may have been that related by fjouTii, in his additions t.) Chelius (op. cit, Am. ed., Vol. Ill, p. 207). Including two referred to by Dr. Thomas Watson (Lcctures'on the Principles and Practice of Physic, Vol.11, p. 309), South groups together five cases ; but it is net practicable to determine whether cr net they are identical with these enumerated by SMYTH. = Dr. Hamilton's patient recovered; but the case illustrates impressively the serious nature if this accident (see p. 9, note 2, supra) and the importance of fixed rules of treatment. The operator relates the circumstance as follows: "* •' But when the trocar was nearly withdrawn, its distal extrem- ity having escaped from the cavity of tbe peritonaeum, but still remaining beneath the skin, a stream of arterial blood, nearly filling the canula, flowed from its open extremity. Alarmed, and uncertain how to proceed, I per- mitted the canula to remain in this position until nearly a pint of blood had escaped, thinking it better that it should flow outwardly than inwardly, and hoping that it would cease spontaneously. In this I was disappointed ; and, finally, I thrust the canula farther in, and the bleeding at once ceased. Preparing then a graduated compress, the trocar was again slowly with- drawn, and, arresting its extremity where it had been arrested before, the phenomenon was repeated—the blood flowed in a full stream. Removing it entirely, blood continued to trickle quite freely over the skin. The com- press and a firm bandage were then applied, and the bleeding ceased altogether. The recovery was as complete and rapid as usual in such cases; and, several months later, having occasion to tap her again, I dis- covered that my first operation was made three or four inches to the right of tho median iine.'' * * The Principles and Practice of Surgery, by frank Hastings Hamilton, A. M., M. D., LL. D., 1872, p. 765. "We desire to mention, however, that we have once wounded the epigastric artery while operating for the relief of ascites, and that the haemorrhage was made to cease by pressure. * * The instrument, a trocar, was inadvertently carried about two inches to the left cf the median line— a few inches below the umbilicus. The water escaped freely and without being colored with blood. As the canula was being slowly withdrawn, however, and when its extremity had fairly escaped from the peritoneal cavity, but was still held by the muscles and skin, a clear, bright-red stream of lilocd began to flow through the instrument. The stream nearly filled the canula. It was at once apparent what had happened, but an occurrence so unexpected left us for a moment undecided wThat course to adopt. Push- ing the canula fairly into the cavity again, it was observed that the stream of blood ceased at once, and that colorless serum again escaped. This, happily, confirmed our suspicion that the vessel was lying so far from the peritoneum in the substance of the rectus muscle that it had not emptied itself into the peritoneal cavity, and perhaps might not if the canula was withdrawn. While we were deliberating, and before the canula was carried back into the belly, the patient had lost over a quart cf blood. The instru- ment was now withdrawn, and the external bleeding at once ceased almcst entirely. A graduated compress was prepared and laid directly over the wound, and this was secured in place by a broad and firm bandage. On the following day a slight bleeding occurred, from the bandage having become displaced while the patient was asleep, but it never returned;" A Treatise on Military Surgery, by F. H. HAMILTON, 18C5, p. r>74. The following are accepted rules, as formulated by Mr. POLLOCK, Vol. II, p. 4:79, Holmes's System, 1861 (the italics are the author's): "We would lay it down as a rule, firstly, that in punctured wounds cf the abdominal wall, if any haemorrhage be present, but not sufficient in amount to justify or indicate an enlargement of the wound fcr the purpose of applying a ligature to the bleeding vessel, the exit cf the flowing blood through the orifice of the wound from the injured artery or vein should not be checked by outward applications. By far the least of two evils will be rather to allow the blood an escape externally, than by external appliances to insure its accumulation in the tissues surrounding the wound. We would lay it down as a rule, secondly, that if haemorrhage be at all free, the wound should be enlarged sufficiently to allow tbe bleeding vessel to be secured, and no dependence should be placed on pressure to restrain such haemorrhage.'' Whether the puncture in this case cited, of the operation termed by Mr. Erichsen "the simplest in surgery," was " two inches to the left'' cr "four inches to the right cf the median line;" whether the haemorrhage amounted to "nearly a piet." or to "over a quart;" whether the operator was "fur a moment undecided," cr "alarmed, and uncertain how to proceed," far an indefinite period,—the employment of a compress, involving the hazard of internal or cf interstitial haemorrhage, should not be held up for imitation. 3 Lawrence (^1 Treatise on Ruptures, 5th ed., 1838, p. 270) and Sharp (Critical Enquiry, etc., 1754, p. 31). BOYER, also (op. cit, T.VI, p. 256), thought lightly of this accident, but had occasion to modify his opinion; for VlDAL (Path. Ext, T. IV, p. 251) relates that he saw him subsequently divide the epigastric in herniotomy on two cccasicus, succeeding, it is true, in arresting the bleeding. But SCARPA (SulV ernie, p. 41) gives a fatal case ; A. COOPER (op. cit, p. 53) another, in Mr. STERRY's practice : and a case by Mr. Davie, in which the patient recovered after being reduced very low. Glnz (Observationes ar.atomico-chirurgicx de herniis, Lipsiae, 1744) tells us that he heard cf two fatal cases in Paris. Hey (Pract Obs. in Surgery, 3d ed., p. 161) gives an instance in which he had great difficulty in controlling the bleeding. Arnaud (Memoires de Chirurgie, etc., 17C8, T. II, p. 781) invented a special tenaculum for this accident. Fcr general observations on its dangers, without specified cases, consult Bertrandi (Traiti des operations, 1781. p. 29), ElCIITER (Anfangsgriinde der Wundarzneykunst, Gottingen, 1801, B. V, S. 309), and Leblanc (Precis d'operations de chirurgie, Paris, 177.", T. I, p. 51). 4Pla-LKE, Ovarian Tumors, their Pathology, Diagnosis, and Treatment, especially by Ovariotomy, New V< rk, n.S7.D. p. 497. Wells, Diseases of the Ovaries, their Diagnosis and Treatment, Xew York, 1673, p. £70. "In Mr. WELLS'S eleventh case, very free haemorrhage took place on the tenth day. from a small artery that had apparently been wounded in passing the lowest suture. He applied a ligature, and the bleeding ceased." B.Sanson", Des hemorrhagies traumatiques, Paris, 18:14, p.284. sect. 111.I COMPLICATIONS--FOREIGN BODIES. 1/J M. Langenbeck relates an instance of fatal haemorrhage from a slight stab in the belly, where the bleeding was found to proceed from the ascending branch of the left colic artery. The treatment had consisted in the application of a broad body bandage.1 Malgaigne encourages" a reliance upon direct compression in punctured wounds of the blood-vessels of the abdominal wall. But an examination of the evidence must satisfy the reader that there is ample foundation for the prudent counsels of Professor Gross and Mr. Pollock, who advise ligation or acupressure as the only safe resources. Foreign Bodies.—Examples have boon adduced of the lodgement of balls in almost all parts of the abdomen, in the vertebra), muscles, and connective tissues, in the stomach., intestines, liver, kidney, pancreas, supra-renal capsule, and omentum.u Here is an additional illustration (Fig. P>6), contributed by Surgeon J. A. Lidell, U. S. V. In most instances these missiles have been removed after death. The old precept of LeDran, that when balls are lost in the capacity of the belly, one need not amuse himself by hunt- /IG; 13f-rBa" <>x1tra.cted„ r . v > J after il(;ith from the hody of ing for them, was corroborated by Percy's statement that projectiles ^xdaysaftcruhadtravereed ,• • i i - i -it - i -, -i the forearm left thorax, dia- are sometimes innocuously encysted in the abdominal cavity, and some- Phragm,_and left kiduey.- times harmlessly eliminated by stool, and has remained a rule generally observed. But Baudens earnestly contested its validity, and adduced instances in which he succeeded in extracting balls lodged in the psoas muscle or the vertebra?, and maintained that, in this region as elsewhere, the removal of foreign bodies when practicable should be the rule. M. Legouest adheres to this opinion, and those practitioners who permit the introduction of the finger for exploration of shot wounds of the belly cannot well refuse to sanction the removal of foreign substances that may be detected in such examination. The two following examples of the lodgement of foreign bodies in the abdominal cavity are somewhat remarkable : Case 569.—Private W. Billinger, 19th New York Battery, aged 24 years, was wounded at Spottsylvania, May 12, 1834, by a minie ball. He was taken to the field hospital of the 2d division, Ninth Corps, and on May 26th was transferred to Lincoln Hospital. On June 2d, pyaemia developed, and resulted fatally on June 9, 1864. Iron and quinine, alternated with brandy, constituted the medicinal treatment. At the necropsy it was found that the ball had struck between the posterior border of the acetabulum and the lesser sacro-ischiatic notch, passing obliquely upward and forward, fracturing the acetabulum, and, rebounding from there, flattened and bent down in an unciform fashion at its apex. It was found hooked in a mesenteric pouch below the duodenum. The omentum was disorganized, and the small intestines were covered with grayish exudations; the mucous membrane of the stomach was congested. This case furnished specimen 2493 of the Museum, and there will be occasion to revert to it in treating of fractures of the pelvis. Assistant Surgeon J. C. MeKce reports the case. Case 570.—Private J. Ives, Co. I, 158th New York, aged 20 years, received a lacerated wound of the gluteal region by the explosion of torpedoes at Bachelor's Creek, ^l-jy 23, 1S34. He was admitted to Foster Hospital, at New Berne, on the same day. He was supposed to be only slightly wounded until the sixth day, when blood and pus passed with his urine. On the tenth day, faecal matter escaped from the wound. The bowels had moved freely, and without pain, from the first. On the twelfth day, profuse haemorrhage occurred. The wound was plugged with lint saturated in a solution of persulphate of iron, but the haemorrhage escaped through the rectum, and continued at intervals until death, June 8, 1864, fourteen days after the injury. At the autopsy, ten hours after death, it was found that, from sloughing of the wound, two branches of the gluteal artery were opened about half an inch from the bifurcation ; the canal or track of the wound passed through the great sciatic notch, and a fragment of a splinter, five and a half inches long, which had been broken off, was found lying within the abdominal cavity, having penetrated the descending colon about twelve inches above the rectum and passed out three inches higher, and was forced against the inner wall of the pelvis, on the right side, with such force as to broom up the end about half an inch, wounding the sciatic nerve in its course, in which situation it remained, transfixing the colon and lying behind tho bladder, without giving rise to inflammation of the colon or peritoneum. The bladder was much thickened and inflamed, and contained considerable pus; death seemed to have resulted from secondary haemorrhage, and not from the wound or the presence of the foreign body. The case is reported by Surgeon C. A. Cowgill, U. S. V. 1 Langenbeck (C. J. M.), Nosologic und Therapie der Chirurgischen Krankheiten, 1830, B. IV, S. 595. 2 Malgaigne, Manuel de Medecine Operatoire, Teme 6d., 18G1, p. 560. 3 In the vertebra. Cases of McDonald, Hogan, Flaherty, and Joseph R------, pp. 441-4, of the First Surgical Volume, and Cask 49G, p. 155, supra; in the muscles, Cases 186, 197, 200, 302, 499, 445, and 324, pp. 47-141, supra ,■ in the fascia and connective tissue, CASES 305, 307, 47-1, 414, 330; in the stomach, Case ICG; in the intestines, Cases 294, 295, 29G, 297, 298, 299, 3C0, and Case A2 on page 101; in the liver, CASES 199, 318; in the pancreas, Cases 505, 418; in the kidney Cases 525, 532; ia the suprarenal capsule. Case 5G2 ; and in the omentum. Case 563, supra. I SO PENETRATING WOUNDS OF THE ABDOMEN. [chap. VI Visceral Protrusions.—Being subjected to a constant equable pressure by their muscular walls, the abdominal viscera, when these are divided, follow the line of least resistance and are liable to protrude. This condition is of such importance that generic distinctions are determined, in the classification of penetrating wounds of the abdomen, by its presence or absence. It is especially common in incised and large lacerated wounds; comparatively infrequent in punctures and in shot wounds. Still, it has been seen that even the lixcd viscera occasionally protrude through the orifices made by shot. Examples have been adduced of protrusions of wounded portions of the liver, spleen, and pancreas, and it was observed that, in the case of these solid viscera, adhesions formed speedily at the orifice, intra-peritoneal extravasation was avoided, and the injured part being removed by sloughing or excision, the complication might be regarded as a favorable one. The intestines and epiploon protrude more frequently, especially the latter. The mode of dealing with the protruded gut is tolerably well settled; but much discussion, with which the reader is probably familiar, has arisen regarding the proper management of the protruded omentum. Sometimes, with a recumbent position and relaxation of the abdominal muscles, the protruded parts return without difficulty. If not readily reduced, the general surgical practice is in accordance with the precept of Boyer,1 to return the omentum wdienevcr it is intact, and to enlarge the orifice if necessary to accomplish this purpose. Ravaton taught that it was very bad practice to cut off the protruding omentum, "a deadly and cruel manoeuvre, contrary to reason and experience."2 Pipelet has collected a few instances of its ill effect,3 but I find more in which it has been practised with impunity.4 Larrey advises that the protruding omentum Should not be returned, and 1 BOYElt, Traiti des maladies chirurgicales, 5e ed., T. VI. p. 38. 'J Ravaton, Pratique moderne de la Chirurgie, 1776, T. II, p. 210, and Chirurgie d'Armee, 17C8, p. 48G. s PirELET, Memoire sur la ligature de I'epiploon, in Mem. de I'Acad. de Chir., 1757, T. Ill, p. 394. 1 1. Galenls (Omnia quiz extant, Frohen, 1567, T. I, Lib. IV, p. 274, de usupartium, &.c.) remarks: " Sicut et nos id (omentum) alignando fere totuni abscidimus illud gladiatori ita vulnerato. file vero homo sanatus est cito." 2. FORESTUS (Obs. et cur. chir., Francofurti, 1611, Lib. VI, Obs. 7, p. 13); a youth, A. J-----, in December, 1562, was stabbed with a knife in the left side cf the abdomen ; the protruding omentum, without being ligated, was cut off by a young, inexperienced surgeon, "ad quern cum venissem, objurgavi temerarium chirurgum ob crassam ejus ignorantiam;" recovery in about two months. 3. IUcn;En (Eph. nat. cur., Dec. II, Ann. VI, 1687, Obs. CXCVI1I, p. 395) relates that he was called to see a peasant, Hering, aged 50, who had been stabbed iu the left h}rpogastrium. The protruding omentum had been cut off before his arrival by a surgeon of the village Osthoven. "Ipsum vehementer objurgavi, quod non omni conatu repcsitionem tentasset, vel ad minimum ante abscissionein, ut solet fieri in simili crsu. ligasset." The patient recovered entirely. 4. Laeeet (Mem. de Chi. Mil. et Comp., 1812, T. Ill, p. 261) relates that the dragoon, Bernard, received a sabre wound in the right inguinal region; hemorrhage from epigastric, and protrusion of omentum; the protruding portion was extirpated; recovery in six weeks. 5. AckerlVs case (London Med. Gaz., 1857, Vol. XX, p. 549) has been cited in note 2, pp. 162-3, ante. 6. HOHBEUG (RlCHTEk's Chir. Bibliothek, Gottingen, 1779, B. V, S. 152) records the ease tf a young man, aged 15, stabbed in the abdomen. A large piece of omentum protruded and was cut off two hours after the reception of the injury; recovery in four weeks. 7. Neumax (American Med. Intelligencer, 1841, p. 164); a negro, Loven, on February 25, 1840, received a stab wound in the abdomen an inch and a half below the navel; a portion of the omentum, protruding nearly two inches, was ligated and cut off; recovered iu a few weeks. 8. Coates (Med. Gazette, N. S., Vol. V, 1847, p. 933) records that J. Allen, aged 14, was stabbed, on October 14, 1847, in the abdomen, between the ninth and tenth ribs. A ragged portion of the omentum about three inches in length protruded, and was cut off; the wound healed in ten days. 9. Gusiiee (Boston Med. and Surg. Jour., 1847, Vol. XXXV, p. 80) relates that a man, aged about 36, cut himself in the abdomen, seized the protruding omentum and cut off a portion measuring one hundred and forty-four square inches. "At the eud of four weeks the patient was up and well."' 10. Hewson (Medical Examiner. 1851, Vol. VII, p. 567) records the case of a colored woman, Lloyd, aged 21, stabbed on June 21, 1851, in the left groin. A piece of the omentum, the size of the palm of a hand, protruded; a double ligature w;is passed through the mass, which was then cut off close to the integuments; recovered in six weeks. 11. COLEGHOVE (Boston Med. and Surg. Jour., 1859, p. 249) cites a case cf removal of the entire omentum by Dr. Stauxton. A German woman, aged 30, was, on June 30, 1858, attacked by a cow, the horn cf the animal penetrating the abdomen two inches above and to the right of the umbilicus; the bowels protruded, and also the torn and lacerated omentum ; the latter was removed; recovered in less than three months. 12. MlLIAER (New Orleans Jour, of Med., 1869, Vol. XXII, p. 177) was called, on May 27, 1853, to see a negro, Alick, who had been stabbed in the left iliac region one inch above the anterior superior spinous process of the ilium ; the omentum, severely lacerated, protruded six inches ; a ligature was passed around and the protruding portion cut off; recovery in one month. 13. Wii.laud (Med.'and Surg. Reporter, 1870, Vol. XXIII, p. 281) cites the case of a patient of Dr. Oai;i:etso.v, who had been stabbed in the abdemcu ; a portion of omentum protruded and was afterward torn and bruised; it was cut off and allowed to remain in the wound; recovery. 14. HOWE (The American Med. and Surg. Jour., August 1855, Vol. VII, p. 331) relates that, on May 13, 1855, James C-----, aged 23, was stabbed above and a little to the left of the abdomen; a portion cf the omentum, much lacerated, protruded; the lacerated portions were chipped off, one piece being twelve inches long and four inches broad; recovery in two weeks. 15. Kl.O.UAN (Phil. Med. Times, November, 1872, Vol. Ill, No. 55, p. 101) states that a boy, aged 10, fell upon an iron railing, one point penetrating the abdomen ; in disengaging tbe boy a piece of the omentum, considerably lacerated, was dragged fr. m the wound; protruding portion ligated and cut off; recovery. 16. GlBBES (Transactions of the South Carolina Med. Ass.. 1872, and Am. Jour, of Mi d. Sci., 1873, Vol. CXXIX, N. S., p. 200); knife wound in the left hypechondrium, through which omentum protruded; ligation and excision of six inches of protruding omentum; recovery in about forty days. 17. Baldens (I.e., p. 346); case of Ben-Gil-Ali, cited in note on page ICG, supra,- a portion of the omentum protruded and was removed. 18. Mr. NUXXELEY (Medical Times and Gazette, 1860, Vol. I, p. 432) showed, at the meeting of. the Pathological Society of London, March 20, 1860, a portion of omentum which had been euccessfully removed after protrusion SECT, ill] COMPLICATIONS—VISCERAL PROTRUSIONS. 181 Guthrie, Robert, and Baron II. Larrey have earnestly sustained this precept.1 Many illustrations in favor of either view might he adduced,2 and the circumstances attending particular cases will determine the practitioner's conduct in adopting the one or the other. If the protruding omentum is intact and readily reducible, it should be returned; other- wise, it is safer to leave it protruding than to enlarge the wound in the peritoneum for its reduction, or to incur the hazard of intra abdominal effusion from its lacerated vessels. Left externally, the epiploic protrusion'will generally shrivel gradually and waste, and will be apparently retracted within the abdominal cavity. Sometimes, on the contrary, the mass heroines tumefied and is invaded by suppuration or gangrene. It may then be advantageously incised, or partially removed by the dcraseur or the knife. This operation is not dangerous if deferred until adhesions at the orifice have formed a barrier to the extension of inflammation. Cases 2oG and 276, of Lieutenant Deichler and Private Marker, on pages 77 and 91, and the instance from Dr. Sternberg's practice, referred to on page 175, exemplify the advantages of deferred inteiference. Except in extended lacerations, amounting to eviscerations almost, epiploic protrusions are as rare after shot through a wound of the abdomen. 19. There is also a ease reported by Saviard (Nouveau recueil d observations chir., Paris, 1702, p. 102): A woman, aged 31, was wounded with a sword on the right side of the hypogastric region ; omentum and seven inches of ileum protruded ; gut returned, omentum ligated and a piece of the size cf a pullet's egg cut off; the wound healed, but the woman died shortly afterward of diarrhoea. At the autopsy the omentum, intestine, and peritoneum were found united together. 20. Dr. Dewes (Med. Times and Gaz., 1862, Vol. I, p. 611) relates a successful case of ovariotomy, with removal of large portion of omentum. 1 Larrey (D. J.), Clmique chiinrgicale, T. II, p. 467; Guthrie, Wounds and Injuries of the Abdomen, London, 1847, p. 15; Robert (A.), Mem. de I'Acad. de Med., 1845, T. XI, p. 664 ; Larrey (IL), Bull, de la societe de chir., seance, Avril 17, 1850, T. I, p. 620. 2 Guthrie (On Wounds and Injuries of the Abdomen, etc., 1847, p. 12) cites four instances: 1. Evan Thomas, aged 17, stabbed September 1, 1828, immediately above the umbilicus; the protruding omentum was returned; the wound united in a week. 2. A soldier, wounded with a lance at Albnhera, in the right lower part of the belly; the omentum protruded and was reduced, and a ligature applied to the epigastric; recovered. 3. A Spanish soldier, stabbed at Madrid, in 1812, near and below the umbilicus ; the protruding omentum was reduced ; the wound healed. 4. A Spanish soldier, shot at the battle of Toulouse ; a small ball perforated the abdomen and carried with it a portion of the omentum ; the latter gradually diminished, and finally 4, by a revolver ball, which entered the left iliac region two inches above Poupart's ligament and one and a half inches to the right of the anterior superior spinous process of the ilium, passed backward, and emerged between the body of the fifth lumbar vertebra and the posterior superior spinous process of the ilium. He was removed to the. Cavalry Corps Hospital, where he remained until October 29th, when he was transferred to the hospital at Cumberland. Acting Assistant Surgeon S. B. West reports that "a considerable piece of the omentum protruded and sloughed off." His health was good, and the wound was discharging healthy pus and healing. He was returned to duty January loth, and discharged from service July 24, 1835, and pensioned. Pension Examiner David Clarke, of Flint, Genesee County, Michigan, reported, in .\faivh, 1870, that " in consequence of the wound the patient suffers from a partial paralysis of the left leg and weakness of the back. The left leg is somewhat smaller than its fellow. The power of rotating the body on the hips is impaired, and the response of the muscles in rising from a sitting posture, or in attempting to lift, is uncertain, causing him to fall if thrown out of a perpendicular line." A single example of early excision of a portion of protruded omentum is presented by a fatal case; and the unfavorable result, if not expedited, does not appear to have been retarded by the operation: • Case ;">?'2.— Acting Assistant Surgeon T. II. Stuart reported that ''Private (1. Webster, Co. E, 6th Maine, aged 23 years, was admitted into Armory Square Hospital, Washington, November 9, 1353, with a penetrating wound of the abdomen, received at Rapidan Station on the 7th. The ball entered one inch to the left of and a little above the umbilicus, passed inward and backward, and emerged from the loins one and a half inches from the spine. A portion of the omentum, half the size of the hand, protruded and was strangulated so that it could not be returned, and was removed with a scalpel at three o'clock in the afternoon. He died at six o'clock on the same day." Ill most of the cases of shot wounds attended by protrusion of the omentum, there were other grave or mortal complications. In the histories of the four following cases, fatal at the end of two or three days, the epiploic protrusions are prominently mentioned: Case 573.—Private Calvin Drury, Co. D, 30th Ohio, was wounded at Mission Ridge, November 25, 1833, by a conoidal ball, which penetrated the right side of the abdomen. Surgeon John Moore, U. S. A., states that he was admitted into tho field hospital of the 2d division of the Fifteenth Corps. "The omentum protruded, and was returned and the opening closed. He died November 28, 1833." Case 574.—Acting Assistant Surgeon W. M. Dorran reports that "Private Henry Eggemyer, 4th Ohio Battery, was admitted into the Union Hospital, Memphis, September 28, 1863, having been accidentally wounded the day previous by the explosion of a shell in a caisson, on wrhich he was seated while the battery was disembarking. On examination it was found that one fragment had entered the right chest and fractured the eighth rib near its_ junction with the cartilage ; another pene- trated the abdominal cavity a little to the right of the median line and about two inches above the umbilicus, permitting the protrusion of a portion of the omentum about the size of a Avalnut. There was also a fracture of the left ulna and a contused wound of the right thigh, il he patient had suffered great pain iu the chest for two hours after the reception of the injury. When admitted his breathing was labored, respiration about 50 per minute, and pulse 120. Morphine was given to ease the pain, and, through the night, one grain of opium and one-eighth of a grain of tartar emetic were given in a pill every three hours. September 29th, respiration labored; he suffers no pain, but speaks in monosyllables and with difficulty. Death resulted September 30, 1863." Cask 575.—Private James Howard, Co. F, 43d U. S. Colored Troops, was admitted into the field hospital of the 4th division, Ninth Corps, July 30, 1864, with a shell wound of the abdomen, received at Petersburg the same day. The omentum protruded from the wound. Simple dressings were applied. He died August 1, 1834. The case appears upon a list of casualties signed by Surgeon James P. Prince, 36th Massachusetts. Case 576.—Assistant Surgeon J. G. Murphy, U. S. V., reports that " Captain R. B. Kellogg, Co. A, 15th Iowa, aged 28 years, was admitted into the Officers' Hospital at Beaufort, January 14, 1885, with a shot wound of the abdomen, received on the skirmish line, near Port Royal, the same day. The ball entered on the left side, about four inches posterior to the crest of the ilium, passed transversely through the ilium and peritoneum, and emerged one inch to the left of and two inches below the navel, carrying out through the exit wound a portion of the omentum. Simple dressings were applied. This officer was much prostrated by the shock of his injury, and died January 16, 1835, from its effects." Five other cases, in which this complication is mentioned, terminated fatally within twenty-four hours: Cases 577-5-1.—Surgeon J. M. Woodworth, 1st Illinois Light Artillery, records the following two cases of protrusion of the omentum upon the list of casualties at the battle of Ezra Chapel, Atlanta, July 28, 1334 : 1. Major T. J. Ennis, 6th Iowa, shot » wound, from the loins through the abdomen; omentum protruding; simple dressings; he died eight hours after the reception of the injury.—2. Captain T. S. Elrick, Co. D, 6th Iowa; shot wound of belly; large mass of omentum protruding; death the same day.—3. Surgeon f^arrettson L. Carhart, 31st Iowa, reports that "Private Thomas Darnell, Co. E, 13th Illinois, was admitted into the hospital of the 1st division, Fifteenth Corps. June 30, 18(33, with a shot wound of the abdomen, received at Vicksburg ihe SECT, in.] COMPLICATIONS'---VISCERAL PROTRUSIONS. 183 same day. The omentum magnum largely protruded. He died July 1, 1S3:>."—4. Surgeon John A. Spencer, 09th New York, reports that "Private Patrick Sheridan, Co. A, C9th New York, was wounded near Petersburg, June, 1H31; the ball comminuted the left elbow joint, fractured the seventh rib, and lodged in the abdomen; the omentum protruded; death, June 17, 1834."— 5. Assistant Surgeon J. S. Billings, U. S. A., reports that "Sergeant M. Gaynor, Co. ]>, 88th New York, was wounded at the Wilderness, May 6, 1834; the omentum protruded from the wound; death resulted tbe same day." In the treatment of protruding intestine, the rules of practice are well settled. Unless disorganized, it must be replaced, the exit wound being enlarged for the purpose, if requisite. If it is wounded, recourse must be had to enteroraphy. Protrusion of the bowel after shot wounds is uncommon; but some remarkable instances have been cited.1 The four following are examples of recovery after this complication: Cask. [-,82.—Corporal Leroy Jordon, Co. C, 110th Ohio, was wounded at Cold Harbor, June 3, 18o4, by a conoidal ball, which entered the right side at a point between the iliac and umbilical regions. lie was treated in hospitals at Washington and Columbus, and discharged from service May 12. ls,i". Pension Examiner Samuel S. Gray reported, June 15, 1835, that "the missile cut through tbe walls of the .abdomen, allowing the bowels to protrude. The wound has healed, leaving a large cicatrix; the wall of the abdomen is weakened and tender." Cask 583.—Private Daniel Miller, Co. E, 63th New York, received a wound of the left side of tbe abdomen at Antietam, September 17, 1862. Surgeon C. S. Wood, Goth New York, states that "the missile opened the cavity of the abdomen so that tbe meso-colon protruded. Cold-water dressings were applied." He was transferred to the hospital at Frederick, September 23d, where, without information of Dr. Wood's observation, tbe case was regarded as a flesh wound in the left flank. The patient convalesced rapidly, and was discharged from service January 20, 1863. His name does not appear on tbe Pension Roll. Cask 584.—Private Patrick Powers, Co. E, 28th Massachusetts, received a shot lacerated wound of the abdomen a little above and to the right of tbe umbilicus, at Bull Run, August 30, 1882. On September 4th, be was admitted into the 3d division hospital at Alexandria, under the charge of Surgeon Edwin Bentley, U. S. V., who reports that "the bowels protruded from the wound. They were replaced, and adhesive straps, compress, and bandages applied. He was discharged December 13, 1862, at which time an unnatural opening in tbe muscles still existed." Pension Examiner S. L. Sprague, of Boston, reported, March 7, 1858: " He has hernia at the place of the wound, the tumor being now the size of a small hen's egg. The scar is an inch long, and, on feeling with tbe finger, is depressed in a ring whence the intestine protruded. Lifting or coughing increases the tumor. He cannot labor or do anything requiring much effort. Disability three-fourths and wholly permanent." Cask 585.—Sergeant B. Vincens, Co. C, 6th Georgia, was admitted into the Receiving and Wayside Hospital, Richmond, September 30, 1834, with a wound of the right side of the abdomen, received at Fort Harrison the day previous. The following notes of the case appear upon the hospital case-book: "A conoidal ball entered two inches above Poupart's ligament, and one inch internal to the ilium, and lodged. When admitted, the patient was cold and pale; the bowels protruded through the wound to the extent of one and a half inches; no lesion of the gut could be detected. The intestines were replaced by manipulation without enlarging the wound, and the orifice was closed by sutures and adhesive straps. Stimulants and opiates were ordered. October 1st, no action of the bowels has taken place since the reception of the injury; urine passed freely and without paiu. October 2d, an enema of warm water and castor oil was given, which produced three or four evacuations; abdomen somewhat swollen. On the 6th, tbe wound commenced suppurating. Fetid matter escaped, and there was considerable gastric disturb- ance but little fever. October 9th, some improvement; fetid matter continually escaped from the wound; no natural evacuations. On the 2'2d the patient felt better; his appetite was improved, and the edges of the wound had assumed a healthy appearance. Opium, quinine, and bismuth had been given at different times. On October 25th, he was transferred." After the bowel is replaced, the abdominal wound should be securely closed. The quilled suture, as recommended on page 4, supra, accomplishes this effectually; but the button suture, devised by Dr. Bozeman,2 answers still better. In cases of this group, if anywhere, the plan advocated by Drs. Chisolm, Michel, and Howard, of refreshing the edges of shot wounds and seeking union by first intention,3 may be advantageously instituted. In most instances, however, the extent of internal injury will preclude any fig. i37.-Bozeman's button hopeful interference, as in the following cases: Cases 586-589.— Lieut. B. E. Kelley, Co. G, 1st Rhode Island, Chancellorsville, May 3, 1863; Pt. H. Richardson, Co. C, lst.Connectieut, Petersburg, August 17, 1834; Pt. J. W. Slider, Co. A, 13th Ohio, Petersburg, August 21, 1864; Serg't H. Burt, Co. A, 77th New York, Cedar Creek, October 19, 1884. In these four cases the bowels protruded after shot wounds and were replaced and retained by strapping, death resulting within a day or two. __________ 1 The cases of Major Power, CASE 163, page 34, and that of Lieutenant Carter, CASE 2S4, page 94, are examples of recovery. Cases 228 and 229 (pp. 72 and 73) are instances of protruding wounded intestine treated unsuccessfully by enteroraphy. Case 231, page 75, is also an instance of protruding wounded intestine. 2Bozeman (N.), Account of a New Mode of Suture, in the Louisville Review, 1856, Vol. I, p. 75. 3 Consult the references in note * to p. 514, First Surgical Volume. 181 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. Hcrni't.—The liability to ventral hernia involved by wounds of the abdominal parietes hfjve been discussed in the First Section of this Chapter, and exemplified by Casks 92-0."). Fewer examples are observed after penetrating wounds; because the recoveries from those injuries are not numerous, and because the peritoneal adhesions inseparable from reparation are an obstacle to protrusion. It is proposed to consider the general subject of hernia as a cause of disability, discharge, and pension, in a chapter in the Third Surgical Volume;1 but it is of interest to notice here some specific examples of traumatic hernise, and, if not strictly relevant, to adduce the nine instances of kelotomy and two operations for the radical cure of hernia that appear on the returns. Case 590.—Private W. W. Wilbur, Co. D, 7th New York Heavy Artillery, was wounded at the Wilderness, May 5, 1834, by a musket ball, which struck to the left of the umbilicus and inflicted a furrowed penetrating wound. He was sent to the Ira Harris Hospital, at Albany, August 25, 1834. The wound healed readily, but the walls of the abdomen were so much weakened that a ventral hernia formed. Professor J. H. Armsby had prepared and sent to the Museum a plaster cast, which admirably shows the1 condition of the parts. It is imperfectly illustrated in the adjacent drawing (FlG. 138). In a case of intestinal obstruction, of which the nature was not determined during life, the dissection after death (Plate X) referred the symptoms to the strangulation of a small knuckle of the jejunum, which had protruded through a fissure at the margin of the left rectus, where the con- joined tendon had been weakened or divided by the passage Fig. 138.—Ventral hernia consequent on a c E 11 shot-wound. Spec. 2279. [Plaster-cast,] 01 a Dail. Case 591.—Corporal John F------, Co. D, 2d New York Cavalry, was wounded at Aldie, June 17, 1833, and admitted into the Mansion House Hospital, Alexandria, on the next day. Acting Assistant Surgeon W. Leon Hammond reports: " On admission he complained of severe headache; his pulse was frequent and hard, his tongue clean and moist. He passed his water freely, but stated that he had had no evacuation of the bowels for several days. The ball had entered in the left inguinal region in front of and a little above the external ring, had severed the pectineus muscle, struck the body of the pubic bone, glanced, and was lost in the body, its direction and course being unknown. Pressure of the hand over the abdomen developed no pain. There was tenderness over the lumbar region, which the patient attributed to bruises received when he was thrown from his horse on receiving the wound. A dose of castor oil was ordered. June 18th, no evacuation of the bowels had taken place. The cephalalgia was increasing; there was much heat about the head, and the face and cheeks were red and hot. To be more sure of the diagnosis before venturing on further treatment, I examined the rectum, but found no faeces or obstructions. I then injected the rectum myself in order to ascertain the nature of the complication. The first pint of water was retained; the second pint remained also; but a third overflowed, and was free from any admixture of faeces or blood. June 19th: In the afternoon the patient began to be troubled with hiccough and nausea; paregoric was given and quiet enjoined. June 20th: Hiccough and nausea somewhat abated; in the afternoon, vomiting set in, first of water, then of bile; laudanum was ordered, to be repeated during the night. June 21st: The laudanum was not given, through the interference of a female nurse. The injury was now thought to he in the abdomen, and that tlje intestines were ruptured, and opium, with absolute abstinence from food and drink, was directed. June 22d: Has paroxysms of hiccoughing, and vomited faecal matter. On the morning of the 23d, he seemed to rally, and asked for some stimulants, and took a draught of brandy and iced-water; he relished it and appeared more quiet; the vomiting and hiccough continued, and patient became very much prostrated and slightly delirious. During the evening of the 24th, the pulse ran up veryliigh; hippocratic face. Death resulted June 25th, at eleven o'clock A.M. At the autopsy, the hall was found embedded in the body of the pubis or horizontal ramus, close to the cotyloid cavity. A portion of the jejunum protruded through a fissure at the base of Hesselbach's triangle, constituting an internal inguinal hernia, and was strangulated. This hernia was small and made no tumor perceptible to the touch; no correct diagnosis could be made before death/' The preparation from this remarkable case, Specimen 1604 of Section I of the Museum, is represented by Plate X. the photo-relief print opposite. 1 TABLE CT, p. C46, of the First Medical Volume, gives the number of discharges of white soldiers for hernia as 9,002, and TABLE CXII, p. 717, reports .'158 discharges fcr the same cause from the colored troops, a total of 9,360 cases. This is believed to be much less than the real aggregate of discharges for this cause, net only because of the incompleteness of the reports from which the consolidations were made, but because the 27,141 unclassified discharges doubtless include many in which hernia was the unspecified disability. Commissioner J. H. Bakkr (Report of Com. of Pensions, lt-71. p. S) states that "the whole number of pensioners paid on account of hernia is 3,183," and adds that ''it is not improbable that a considerable proportion , by a musket ball, which penetrated tho left wrist and the lower part of the left chest. He was taken to the hospital of the 2d division of the First Corps The details of the progress of the case are not recorded further than by indications that, after grave symptoms from fracture of the ribs and pulmonary lesions, the patient slowly convalesced, and recovered sufficiently to be transferred for modified duty in the Veteran Reserve Corps. He was attached to the '.'.'Mi company of the 2d battalion. On November 11, 1S6;>, he was admitted into Lincoln Hospital, at "Washington, for remittent fever. Tbe case was attended by anomalous symptoms which are not described in detail, and terminated fatally November 15,18(53. Acting Assistant Surgeon H. M Dean gives the following account of the post-mortem examination: "Autopsy sixteen hours after death : Height, five feet eight inches; rigor mortis well marked; body not much emaciated. Parts in situ: Kight lung extended from clavicle to fifth inter- costal space, and lacked one and a half inches of meeting tbe median line; left lung, a small portion only visible, extending from first to second ribs, and lies directly in the median line; both lungs well adapted to the costal surface of the thorax; the rest of the thorax of left side was filled with the stomach, which was greatly distended with air, and extended one and a half inches to the right of the median line; on removing the sternum, it bulged up an inch above the level of the thorax; apex of heart one- half inch to the right of the median line; liver extends two and a half inches to the left of the median line; fundus of the gall- bladder visible; small intestines collapsed and contained little or no air; spleen highly injected, of a dark purple-reddish color; colon unusually distended with flatus. Brain perfectly healthy; little or no fluid in tbe lateral ventricles; weight, forty-nine and a half ounces. Oesophagus purple color throughout; trachea filled with a very tenacious, blackish-gray sputa; bronchi tilled completely with this secretion. The apex of the first lobe of tbe right lung was the seat of gray tuberculous deposit; the whole lung was of a uniform dark-red color; crepitated under pressure, permeated with air throughout; this lung performed the whole aeration of the blood; weight of right lung, fifteen ounces. The left lung was very much compressed, the upper lobe being five lines thick, the lower, nine lines; both were everywhere of a dark flesh color on section, with the exception of the border of the first lobe, which was of a light flesh color; a section of it sank in water; weight of left lung, eight and three-quarter ounces; the left lung was firmly united to the ribs and diaphragm by very firm fibrinous adhesions. Pleura not thickened; no trace of pus anywhere. The eighth, ninth, tenth, and eleventh ribs were fractured about three and a half inches from their corresponding cartilages; these were all, but the eleventh rib, ununited. The heart, four inches long by three and a half inches wide at base, somewhat pyramidal in shape—the apex being at the root of the pulmonary artery; the base behind the two sides was formed by the right and left ventricles; the organ had evidently beeu much compressed during life; no clot in the right side; the left side contained a very small venous clot and a small quantity of venous blood; the right ventricle, two and a haY lines thick; the left ventricle, nine lines thick; peri- cardial fluid, two drachms. The stomach was of a large dimension, being eleven inches long, six inches wide, three inches deep; it was entirely contained in the left thorax, with the exception of the cardiac extremity, which, was in the abdominal cavity; the tumor was of a globular shape, owing to the manner in which the stomach had been forced through the opening of the diaphragm ; this opening was opposite to the eighth rib, and in close proximity to it; the opening was two and a half inches long in a line with the transverse horizontal diameter of the body, and embraced, besides the cardiac extremity of the stomach, two portions of the transverse colon—a large horse-shoe loop being contained in the thorax. The liver, ten and a half inches long, eight inches wide, two and a half inches thick; intense dark-blue color, with a slight shade of purple; acini almost obliterated, the organ having a dull flesh color on section ; intensely injected with dark venous blood, a large quantity of which flowed out on pressure. (Bronze liver.) The bile in the gall-bladder measured ten drachms, of an intense black color in mass, but of a dark brown when poured out; no sediment; very viscid. The spleen, four and a half inches by three inches; unusually firm—taking some force.to push the linger through the paren- chyma; darkish-purple mulberry color; weight, four and a half ounces. Pancreas, nine inches by one and a half inches at head; flesh color; weight, two and a half ounces. Kidneys: Eight kidney, four and a quarter by two and a quarter inches; intensely congested; weight, five ounces; left kidney, four and a quarter by two ajid a quarter inches; same appearance as right; weight, four and three-quarter ounces. Intestines greatly congested throughout, as seen from the peritoneal surface; of a stone color; mucous membrane dark-purplish red; solitary glands not enlarged. Peyer's patches inconspicuous. In the large intestine the mucous surface was of a dark purple; the glandular organs were not diseased. The ball entered on a level with the sixth rib on the left side, two inches below the nipple, traversed the diaphragm, and passed out two inches lower down, and six inches posterior to the wound of entrance." The weight of the viscera, on lifting the preparation from the alcohol in which it is immersed, withdraws them from the thoracic cavity. Hence, in Figure B59, drawn from a photograph of the preparation, the relations of the parts are but imperfectly represented. ■In the Museum of the British Army Medical Department, preparations 1152 and 1153 represent diaphragmatic hernias (Williamson's Cat, p. 155). At St. Bartholomew's, Specimen 74 of Series XVII is an example (Cat., p. 334). At the New Vork Hospital Museum, Specimens 40C and 407 are both examples cf traumatic phrenic hernia (Cat, p. 160). In the Boston Medical Improvement Society's Museum, 493, a dry preparation, is ahernia, though an old stab wound of the diaphragm (Cat. p. 141). 2-1- FlG. 130.—Preparation from a case of dia- phragmatic hernia.—Spec. 1789. 1>») PENETEA/ING WOUNDS OF THE ABDOMEN. [CUAP.vi. Herniotomy.—Nine operations for strangulated hernia were reported. The protru- sions were all inguinal or scrotal—five left, four right; nearly all were old reducible hernias, getting down and becoming strangulated through carelessness. In all the operations the sac was opened, and the stricture was generally found at the neck. In one instance, a branch of the epigastric was cut; in another, the gut was punctured; in both, ligatures were applied; but in the case of the wounded intestine the ligature slipped, and there was fatal intra-abdominal effusion. Five operations resulted successfully, one being for the relief of an inflamed epiplocele: Case 593.—Private W. Chase, Co. M. 2d Wisconsin Cavalry, aged 23 years, was admitted to Gayoso Hospital, Memphis, January 2, 1865, with symptoms of strangulation from a direct inguinal hernia, which was ascribed to a strain received in a fall from a horse, June 4. 1864. There was intense pain in the tumor and over the belly, and, without unnecessary delay, Acting Assistant Surgeon W. D. Hall decided to operate. Chloroform being given, an oblique incision, five inches in length, was made over tlie sac, through the integument, superficial fascia, intercolumnar fascia, conjoined tendon of transverse and internal oblique cellular tissue. The protrusion was still firmly held by annular folds of peritoneum. After much hesitation, and a renewed careful attempt at taxis, a probe-pointed bistoury was passed through the peritoneum and an incision half an inch in length was made, which permitted the reduction of the protruding intestine, which was much engorged, but not in an unfit condition for replacement. The patient was kept on low diet, and aconite and veratrum viride were administered in small doses. The pulse, which had been at 90, was reduced to 60. Eecovery was rapid, and in twenty-eight days complete. Case 594.—Private P. Fountain, Co. B, 8th Louisiana (afterward 47th U. S. Colored Troops), on August 17, 1863, was brought to the regimental hospital with strangulation of a right scrotal hernia, that had existed for nine years. The tumor was of the size of a cocoa-nut. Taxis, under chloroform, being unavailing, Surgeon N. N. Horton,1 8th Louisiana, performed kelotomy, opening the sac, which contained omentum and knuckles of small intestine somewhat congested. The stricture being divided, the protrusion was readily returned. The wound was closed by five stitches, and dressed with a T-bandage, and full doses of opium were administered. No untoward symptoms ensued. The wound healed rapidly, and on September 1, 1863, the patient was returned to duty. Assistant Surgeon L. P. Fitch, 8th Louisiana, reports that he was discharged at Vicksburg, June 15, 1834, on account of hernia. Case 595.—Discharged Private W. H. Herrington, Co. K, 32d Wisconsin, on May 28, 1865, was admitted to the general hospital at Hilton Head with symptoms of strangulation, that had lasted for four days, of an oblique right scrotal hernia. Assistant Surgeon C. T. Eeber, U. S. V., administered chloroform, and, failing in taxis, proceeded with the operation, as the abdominal tenderness, vomiting, hiccough, and other symptoms were too urgent to admit of delay. The sac was opened; a knuckle of small intestine extended to the bottom of the scrotum, and was tightly strictured at the internal ring. The stricture being divided, the protrusions were replaced without difficulty. The external pudic branch of the epigastric artery was ligated The threatening symptoms were at once allayed, and the patient convalesced without any untoward circumstance, and was returned to duty June 18, 1865. Case 596.—Corporal F. Markle, Co. M, 2d New York Heavy Artillery, was admitted to hospital at Camp Nelson, Ken- tucky, October 5, 1834, with symptoms of strangulation from an irreducible tumor in the left inguinal canal. The tumor was inflamed and painful; the abdomen was tender. Surgeon Daniel Meeker, U. S. V., proceeded, on October 6th, to give chloro- form to practice kelotomy; the sac being opened, the protrusion was found to he omental. It was replaced, the grave symptoms subsided, and the man returned to duty January 17, 1865. • Case 597.—Private J. A. Tracy, Co. D, First Veteran Eeserves, aged 29 years, was admitted to Armory Square Hos- pital, March 14, 1864, with strangulated hernia. The left side of the scrotum was distended by a tumor and was very painful on pressure. Efforts at reduction by taxis, already vainly essayed by the medical officer at Camp Eush, were renewed under chloroform, without success. As the vomiting and abdominal tenderness had mitigated after the anajsthetic and the administra- tion of a dose of morphia, it was decided to await the arrival of the surgeon in charge. The next morning, March loth, Surgeon D. W. Bliss, U. S. V., had the patient placed in a warm bath for half an hour, and then, under chloroform, again employed persevering taxis, unavailingly, and then proceeded with the operation of herniotomy. An incision, four inches long, was made over the long axis of the tumor, extending to the course of the spermatic cord, and the various coverings of the sac were successively divided. The point of stricture was found at the internal ring, and was relieved by a slight incision, which was followed by the descent of a considerable loop of intestine, somewhat discolored. The protrusion was carefully replaced within the abdominal cavity, and a few sutures and straps were applied, and maintained by a T-bandage and compress. The patient was placed in bed and ordered an opium pill every three hours. Except from abdominal pain, which was relieved by enemata containing sulphuric ether, there were no untoward symptoms. The patient was kept on a farinaceous diet, with opiates, and on the sixth day had a dose of castor oil, which operated kindly. After this convalescence was uninterrupted, and on April 21st the patient was discharged on furlough, and on July 1, 1834, was returned to duty. He was discharged July 14, 1^35, and pensioned. Examiner J. S. Beck, of Lancaster, Ohio, reported, August 17, 1869, that the hernia was reducible, but required the constant use of a truss. The pension was suspended June 30, 1873, "no response having been received from the pensioner for two years." 1 Dr HonTOX, in the Am. Med. Times, 18l>3, Vol. VII, p. t!16, gives a full account of this case, describing the hideous torture to which this hernia! protrusion was ascribed. sect. in.| COMPLICATIONS--UKRiMA. 187 Four unsuccessful operations for strangulated inguinal cnterocele were reported: Case "9S.—Private J. Z. Kivett, Co. II, 2d East Tennessee, was admitted to Jarvis Hospital, April 18, 1864, with oblique left inguinal hernia. He was convalescent from pneumonia, and presented symptoms of strangulation. The tumor extended well down in the scrotum. Symptoms of strangulation were very urgent, and ether being administered, and taxis unavailing, Acting Assistant Surgeon B. B. Miles laid open the sac, May 11, 1864, divided the stricture, which was very tense, and replaced the protruding gut, which was indurated and congested. Traumatic peritonitis supervened, and was treated by opium, with stimulants. Death, May 17, 1864. At the autopsy, the colon was found thickened, and perforated about eighteen inches from the ileo-caecal valve. Cask 599.—Private X. Moore, Co. 125, 2d battalion, Veteran Boserve Corps, was admitted to Main Street Hospital, Covington, with oblique right inguinal hernia. On May 5th, Surgeon A. M. Speer, U. S. V., found the tumor immensely large—at least six feet of intestine in the scrotum, besides a mass of omentum. The symptoms of strangulation being very grave, chloro- form was administered, aud the usual operation was performed, the stricture being found in the neck of the sac, opposite the external ring. On May 8th, the tumor again protruded during a fit of coughing, and was replaced with some difficulty. On May 9th, alarming signs of traumatic peritonitis arose, and the ease terminated fatally on the following day, May 10, 1864. Cask COO.—Private J. A. Bobbins, Co. 1, Mod Pennsylvania) under l>r. J. M. Da Costa's care for a functional cardiac disorder, at Filbert Street Hospital, January 12, 1S64, presented the symptoms of strangulated hernia. Acting Assistant Surgeon A. D. Hall was summoned at eleven o'clock at night and found a moderate-sized irreducible inguinal hernia. The patient had worn a truss habitually, but had carelessly left it off. His legs were drawn up, but his countenance expressed little pain. Taxis under ether had been tried. Gentle efforts were again made by Dr. Hall. Then the man was ordered two grains of opium, and an operation was deferred till morning. The further progress of the case is described by Dr. Hall: "At nine the next morning the same state of affairs existed, and, assisted by Dr. E. L. Duer, I proceeded to operate. Tbe incisions were made layer by layer carefully. On opening the sac, quite a mass of omentum was found in a healthy condition. There was trifling effusion in the sac, and no adhesions. About twelve or fourteen inches of intestine were in the sac, of a ruby color, merely deeply congested, without any signs of inflammation or sphacelus; the external ring was enlarged by an incision directly upward. At the internal ring the stricture was so tight as to admit with difficulty the tip of the little finger on which to cut as a director. This stricture had to be incised several times before it would permit the return of the bowel. A slight puncture of the bowel, not penetrating more than the muscular coat, was discovered. It bled quite freely, and a ligature was put around it It was supposed that the bowel must have been injured by riding up under the knife in the tight stricture. The stricture being relieved, the bowel was returned first, and followed by the omentum. At one stage of the operation tbe ether produced alarming symptoms; suddenly the face became livid, the respiration gasping, and then almost ceased. Asphyxia being imminent, the tongue was pulled forward; ammonia applied to the nostrils, artificial respiration put into practice, and galvanism applied to the cervical spine and praecordia. The patient slowly rallied; the edges of [he wound were brought together with silver sutures, a compress and spica bandage were applied, and one hundred drops of laudanum ordered after the effects of the ether had passed off. The operation occupied about an hour. The patient was made comfortable in bed; it was enjoined that his diet should consist of a tablespoonful of arrowroot every third hour, and nothing else. Four hours after the operation he was quite comfortable, had no pain, was unaffected by the opium, had been dozing a little, pulse 114. good; face expressive of ease and relief. He was to have the opium in doses of twenty-five drops of the tincture every hour until sleep was produced. At half- past nine in the evening he was doing well. No pain in abdomen, felt quite easy; had not slept much; pupils showed no evidence of being affected by the opium; did not seem sleepy, and had slept but little, although lying quietly. At half-past three in the morning I was called up to see him, as he had had a convulsion, followed by rigidity. I found him in a comatose condition, with labored respiration. He had talked to the head nurse at two o'clock and said that he felt very comfortable, and a half hour later he had the convulsive attack. He continued to sink, and died at five in the morning. At tbe autopsy eight hours after death, the membranes and veins of the cerebral sulci were found much congested. The lateral ventricles contained yellowish serum; each choroid plexus congested; the right lung was pale externally, congested internally; the left lung pale anteriorly, deep purplish congestion of lower lobe posteriorly—this portion yet floated in water. Bloody serum was found filling the pelvic cavity. The strangulated portion of the intestine had not recovered itself; it was still of a deep-red color; patches of fresh lymph were scattered near the mesenteric attachment; the folds of the intestine were glued together; the ligature had come away from the little wound of the intestine, and it was covered with a recent clot; the omentum was bound together in a firm globular mass by inflammation; the peritoneum about the internal ring was marked by deep spots of ecchymosis." Case 601.—Private A. Soethig, Co. 48, 2d battalion, Veteran Reserve Corps, aged 42, was admitted to Armory Square Hospital, September 21, 1864, with right inguinal hernia of two years' standing, during which period the protrusion had frequently descended into the scrotum and been with considerable difficulty returned by the patient's own efforts. There were . now symptoms of strangulation of no great severity. The man was placed in a hot bath, and taxis was unavailingly practised. The symptoms became more urgent, and on September 22d Surgeon D. W. Bliss performed the usual operation and reduced the protrusion. Opium pills and a nourishing diet. Death, October 10, 1864. The pathological preparations in these cases were not forwarded to the Museum, which possesses, however, at least one excellent illustration of the appearance of an old reducible • hernia after protracted strangulation (Fig. 140). It was contributed by Dr. L. J. Draper: Case A4.—J. W----, a negro man of 40, with reducible right oblique inguinal hernia of twelve years' standing, was unable to reduce his hernia, August 17,1839, and symptoms of strangulation soon appeared- Dr. L. J. Draper, of Washington, was summoned, and, failing in taxis under chloroform, directed the tumor to be coveted with ice during tbe night and the lower bowel to be opened by enema. On August 18th, taxis was again tried by Dr. W. Lee and by Dr. Draper, and again in the ss PENKTRATING WOUNDS OF THE ABDOMEN. [CHAP. VI Fr.J. 140.—Semi-gangrenous loop of ileum from a strangu- lated hernia. Spec. 5590. evening by tin-so surgeons, assisted l>v Dr. W. B. Drinkard. It was then decided to cover the tumor with extract of belladonna, and to give a fourth of a grain of sulphate of morphia every two hours during the night. Up to this time, nothing had been retained upon the stomach. The morphia was likewise rejected, and on August 19th, at ten in the forenoon, had made little impression on the system. Dr Draper describes the termination of the case as follows: "He was then put under the influence of chloroform, and, after a last effort at reduction by taxis, the tumor was laid bare, the sac opened, and the external and internal rings both enlarged so that the finger would pass readily into the abdomen. But one knuckle of intestine had passed into the sac, which was returned without difficulty; but the omentum of which the tumor was principally composed was so congested and swollen as to be returned only with great difficulty. It was thus much discolored, but apparently not gan- grenous, or it would have been removed. After the operation the hic- cough and vomiting continued, the latter becoming faecal; the patient sank rapidly, and died at 9 P. M. the same day. Post-mortem made at 10 A. M. the following day, and six inches of ileum removed. It was much discolored and semi-gangrenous, but showing plainly the points of constriction. The failure of the operation is attributed to the excessively hot weather, and the postponement of the operation for twenty-four hours iu the hope of reducing by taxis. Another illustration of the importance of operating early, when satisfied that it must be done." See wood-cut (Fig. 140). Two unsuccessful operations for the radical cure of reducible inguinal herniae were reported: Case 602.—Private W. P. Hayden, Co. K, 100th New York, aged 36, was admitted to hospital at Buffalo, June 25, 1864, with left direct inguinal hernia of two years' standing. Dr. Sanford Eastman, on August 24th, introduced a silver ligature through the inguinal canal, after the method of Professor J. H. Armsby, with the view of inducing adhesive inflammation and preventing a recurrence of the protrusion. Serious inflammatory symptoms ensued, but were relieved by a cataplasm of powdered elm. The ulterior result was unfavorable, the patient being compelled to maintain the hernia by a truss. He was discharged, for disability, January 19, 1865. Cask 603.—Sergeant P. O'Connell, Co. G, 2d Missouri, aged 37 years, was admitted to the Brown Hospital, at Louis- ville, May 6, 1864, with a reducible oblique inguinal hernia of the left side. His general health was perfect. On May 14th he was placed under chloroform, and Assistant Surgeon B. E. Fryer, U. S. A., operated, for the radical care of the hernia, by Svmes's method. No untoward symptoms ensued, and recovery was almost complete, on his transfer to Jefferson Barracks, July 11, 1831. Returned to duty August 16th; he was discharged September 29, 1864. The hernia appears to have returned, as Pension Examiner J. Bates, of St. Louis, reported, October 10, 1865, that there was "left inguinal hernia in the scrotum." His application for pension was rejected for want of evidence that the disability was incurred in the line of duty. An ingenious instrument, devised by Medical Inspector G. T. Allen, U. S. A., for a modification of the operation by invagination for the radical cure of reducible hernia, was presented by him to the Museum.1 Dr. Greenville Dowell, of Galveston, also donated an instrument employed by him for the same purpose.2 Abdominal Effusions.—The extravasations that are sometimes associated with pene- trating wounds of the belly may be considered in the following order: 1. Effusions of blood; 2, of bile; 3, of urine; 4, of alimentary or stercoral matters, and of entozoa; 5, of pus; (i, of gas. It has been seen, in the second section, that similar effusions sometimes result from contusions and ruptures. They are furnished by the different reservoirs contained in the abdomen, by lesions of the vessels, by morbid secretions of the serous membrane, by the ruptures of abscesses, aneurisms and cysts, and may be divided into primary and consec- utive effusions. Tbe former comprises effusions of blood and of the various gaseous, 1 These instruments are numbered 1428 and 6094, respectively, in Series XXVIII. Here also may be seen patterns of the apparatus of WUTZKR, WOOD, ROTHMUND. Parker, and others. See an article by Dr. DOWELL, in the Texas Med. Jour., 1873, Vol. I, p. 233. - For the bibliography of Hernia, the articles of Richerand and of RAIGE Delohme (Diet des Sci. Mid., XXI, p. 108. and Diet de Med., XV, p. 3CS) may be consulted. Some of the points specially alluded to in this subsection are considered by the following authors : Hes&ELBACH, Uber den Vrsprung und das Fortschreiten der Leisten- und Schenkelbriiche. Wiirzburg, 1814, p. 17; Boeiimer, De herniis abdominalibus, Halae, 1780; THURM- CIse.v. De hernia ventriculi, HumI. 1777; KIRSCU15AUM, De hernia ventriculi, Argentorati, 1749; FlELITZ, Ein Harm-und Netzbauchbruch (Enterm- piplocele centralis) nebst dessen Behandlung, in SODF.U's Journal, 1801, B. Ill, St. 3, S. 447; LAFOXD, Considirations sur les hernies abdominales, sur les bandages herniaires enixigrades, et sur des nouveaur moyens de s'opposer d, Vaneurisme, Paris, 1821; CLOQUET, Recherches anatomiques sur les hernies de l'abdomen, Paris, 1817-19; SCHMIUTMAXN, Von einem geheilten Magenbruch, in RUST'S Magazin, 1825, B. XVIII, H. I, S. 155; Wheel- wright. A case of hernia ventriculi from external violence, wherein the diaphragm was lacerated, in Medico-rhirurg. Transactions, London, 1819. Vol. VI. p. 371: PiPK'.LT. Remarque* sur les signes Hiusoires des hernies epiploiques, in Mem. de I'Acad. Roy. de Chir.. T. V. p. 04."!. SHOT. III. | COMPLICATIONS—EXTRAVASATIONS. 189 liquid, and solid contents of the hollow organs or accidental cavities within the abdomen ; the latter are due to the morbid secretions induced by the presence of irritating matters, or result from traumatic inflammation. Essentially variable in their nature, the cases of each group of effusions must bo separately examined. Blood.—Eflusions of blood in tho abdominal cavity may be either arterial or venous, and may proceed from injuries of the aorta and its branches, from lesions of the vena cava*and portal vein and their ramifications, or from wounds of the viscera, particularly the liver and spleen. Over a score of examples may be found among the preceding abstracts.1 The following is a rare instance of extra-peritoneal extravasation from the rupture of a large traumatic aneurism : Cask 604.—Sergeant Winslow A. Morrill, Co. A, Kith Maine, was wounded at Gettysburg, July 3, 1803, by a conoidal ball, which entered the chest at the right nipple and lodged. He was taken to the field hospital of the First Corps, where the wound was dressed simply. On the 19th he was transferred to the hospital at York, whence Acting Assistant Surgeon A. E. Carothers reports that "at the date of admission the patient was in a very low condition; his pulse was rapid and feeble, skin covered with cold perspiration, tongue dry and red. There was some delirium, and the patient complained of great pain in the lumbar region, with painful and difficult urination. There were symptoms of pyaemia, but, under the liberal use of tonics and stimulants, his condition improved and hopes were entertained of his recovery. About August 1st, after the excitement of meeting his wife at the hospital, he rapidly grew worse, presenting the same symptoms as at first, and a pulsating tumor was distinguished in the umbilical region, which steadily increased in size. He gradually sank, and died August 12th, from anfemia. A slight convulsion occurred in articulo mortis. An autopsy was made nine hours after death: The ball entered at the right nipple, passed inward, downward, and backward, struck the spinal column about the eighth dorsal vertebra, passed through the diaphragm by the side of the sheath of the aorta, and lodged in the body of the fifth lumbar vertebra half an inch to the right of the median line. In the aorta, immediately above the point of lodgement of the ball, was found a large aneurismal sac. partially emptied, and there was a large quantity of coagulated blood beneath the peritoneum, on the left side of the spine, amounting to nearly two pounds. The pneumonic inflammation had entirely subsided, and the aorta elsewhere was healthy. The right ureter, which passed over the sac of the bullet, was obliterated." The doctrine of the circumscription of effusions due to the reciprocal equable pressure of the parietes and viscera, advanced by the celebrated Petit, the younger, has been the theme for much discussion,2 in which the disputants have not alwavs commanded respect for their knowledge of physical laws. This reproach cannot be addressed to the refutation of Petit's hypothesis, in Velpeau's masterly paper on effusions in the abdomen, in the first part of the dictionary in thirty volumes; where it is demonstrated, by clinical facts and by experiments, that the collection of the blood in circumscribed depots occurs only when a small quantity is extravasated and adhesions form in the vicinity, and that when ' In the First Surgical Volume, among the cases of fractures of the lower vertebras, see Cases of James S-----, p. 440; of W. A-----, p. 441; of W. B-----and John McD-----, p. 445; of J. D-----, p. 449; and, in this volume and chapter. Cases 206, 212, 221, 225, 228, 302, 304, instances of circumscribed cr diffused effusions of blood from the mesenteric veins or small arteries; Cases 311, 414, 424, 434, 455, 457, of effusions from lesions of the liver; CASES 459 and 502, of wounds of the spleen ; and Case 506. Doubtless, in many of the other cases enumerated, blood was copiously poured out, although the circumstance is not particularly specified in the reports. 2 Horlacher, De lethalitate vulnerum. abdominis cum extravasatis conjunctorum, Onoldi, 1837; JOUERT, Des collections de sang et de pus dans l'abdomen, These, Paris, 1836; Mokgagm, Opera omnia, Bat., 1765, Lib. IV, Epist. 54, Art. 14, p. 279; Boxetus, Sepulchretum, Genevae, 1700, T. Ill, Lib. IV, Sect. 3, De vulneribus, Obs. £5, p. 302 ; Rui'SCtl, Observationum anatomico-chirurgicarum centuria, Amstelodami, ^1691, Obs. 43, 84, and 85; Dlxcan, The History of a Discharge of Blood to a great Extent, by tapping, in Med. and Phil. Comment, by a Society in Edinburgh, Loiidon, 1777, Vol. V, Pt. I, p. 191; ELLEB, Niitzliche und Auserlesene Med. und Chir. Anmerkungen, u. s. w., Berlin, 1730, S. 138; PEUT, Essai sur les epanchements et en particulier sur les epanchements de sang, in Mem. de I'Acad. de Chir., Paris, 1743. T. I, p. 237, and T. II, p. 92; G AREXGEOT, Sur les epanchements dans le bas-ventre, in Mem. de I'Acad. de Chir., Paris. 1753, T. II, p. 115 ; Vaciiek, Observations de Chirurgie sur un espece d'empyeme, fait au bas-ventre avec succis en consequence d'un epanchement, Paris, 17:17; La Motte, Traiti complet de Chirurgie, Paris, 1771, T. II, p. 122, Obs. CCXLIV; Jordan*, ttpanchemens dans le sac du peritoine, en Diet, des Sci. med., en 60, Paris, 1815, T. XII, p. 420; Pelletan, Clinique Chirurgicale Paris, 1810, T. II, p. 98; LECI.ERC, Epanchement sanguin determine par I'ulceration d'un vaisseau abdominal et suivi de la mort dans lespace de ti-ois heures, in Arch. gen. de mid., 6me ann., 1828, T. XVIII, p. 281; Bell, J., Discourses on the Nature and Cure of Wounds, Edinburgh, 1795, Pt. II, p. 95; DESOER, Sur Vepanchement de sang dans l'abdomen produit par cause externe, These de Paris, 1815; Rayatox, Chirurgie d'Armee, etc., Paris, 1768, Obs. XXV, p. 498; Caurol (A.), Alphabet anatomique avecplusieurs observationsparticulieres, Genevae, 1GC2; Blaxdin, Diversm in abdomen liquid- orum effusiones, Paris, 1827; FOURCADE (L.), Etude clinique, anatomique et experimentale de Vepanchement de sang dans l'abdomen, par cause externe, Thfise de Paris, 1829; Larrey, Mim. de Ciiir. mil., Paris, J.812, T. IU, p. 334; Cruveiliuer, Anat path, du corps humain, Paris, 27" liv., p. 5; VOLLGXARD, Ex vehementi illusu abdominis lethalitas, in Eph. Nat. Cur., 1670, Ann. I, Obs. XXI, p. 82, cites a case of bloody-effusion in the abdom- inal cavity from a blow of the horns of a deer; Ehruch, Chirurgische Beobachtungen, Leipzig, 1795, B. I, S. 128; Mertexs, Diss, vulnus pectoris camplicatum cum vulnere diaphragmatis et arteriie mesentericie inferioris, Argent., 175s; Brown (Wm.), Case of fatal hsemorrhage into the abdomen, in Edinburgh Med. Jour., Vol. I, p. 852; PORTER, Case of Penetrating Wound of the Abdomen, in Edinburgh Med. Joir., Vol. IV, Pt. II, p. 1064 ; BlUKETT, Laceration of the Spleen, Death in a few hours from Internal Ibemorrhage, in Lancet, 1864, Vol. II, p. 716; Sabatier, Medecine opiratoire, Paris, 1822, T. II, p. 147; MOREHEAD, General peritonitis from a penetrating wound of the liver and effusion of blood into the abdomen, in COKBYNS'S India Journal, 1840, Vol. V, p. 206 ; VELrEAU, Epanchements dans VAbdomen, in Diet de Med., T. I, p. 187. 190 PENETRATING WOUNDS OF THE AUDOMEX. [CHAP. VI. furnished copiously by the laceration of a large vessel or of a vascular organ, it may permeate to all parts of the abdominal cavity. Commonly it gravitates toward the pelvis or the iliac fossre, the relations of the duplications of the peritoneum greatly influencing its localization. On the right side of the mesentery, the folds of the peritoneum are so arranged as to convey the effused blood on inclined planes toward the right iliac fossa; if the blood is poured out from a wound on the left side, it is more likely to run clown into the pelvic cavity. Sudden copious bleeding within the abdominal cavity is indicated by the well-known signs of haemorrhage—feebleness of pulse, faintness, pallor, cold extrem- ities, cold sweats, etc.; but alow, gradual bleeding may continue unsuspected to a dangerous or fatal extent,1 so slight are the symptoms induced by it. When the blood is principally circumscribed, partly by coagulation and partly by the compression of the walls and the viscera, adhesions form around it by the agglutination of the serous surfaces or the exudation of false membrane. Then consecutive symptoms arise, due "to the presence of the effusion 'as a foreign body. The extravasated blood may be slowly absorbed, or it may excite or aggravate traumatic peritonitis. Here is a case in which a patient survived for seven weeks a shot perforation of the abdomen with limited extravasation of blood: fjASE 605.—Private Daniel Wills, Co. D, 2d West Virginia Cavalry, aged 19 years, received a wound of the lumbar region at Five Forks, April 5, 1865. He was conveyed to the depot field hospital of the Cavalry Corps, and, on the 8th, was transferred to Stanton Hospital, Washington. He gradually sank, and died May 23, 1865. An autopsy was made twelve hours after death by Acting Assistant Surgeon W. liryan. who reports as follows: "The original wound was enlarged by an incision in the direction of the course of the ball, which had passed into the abdomen from the fourth lumbar vertebra, having opened the abdominal parietes on the right side. A collection of dark fluid, apparently blood and pus, to the amount of one pint, was found in the right hypogastric region. An incision was made over the crest of the pubis, and the ball was found lodged in the tissues." A case illustrating the diffusion of the effused blood, and the absence of peritoneal inflammation, is found in the records of Douglas Hospital: Case 606.—Private James Reed, Co. D, 1st U. S. Sharpshooters, was wounded at Rapidan, November 7,1863, and was admitted to the field hospital of the 1st division, Fifth Corps, on the same day. He was transferred to Washington, and admitted to Douglas Hospital on November 9th, and Assistant Surgeon W. Thomson, U. S. A., reported as follows: "At the time of admission he was much prostrated, but there were no symptoms of peritonitis. He died November 13, 1863. At the autopsy, the ball was found to have entered the right side three inches above the anterior superior spinous process, passed through the internal iliac and psoas muscles, and then escaped as far as the integument, whence it had been removed by incision from the sacro-iliac symphysis. The intestines were not Avounded, but were deeply stained by the effused blood. Death seemed to have been caused by the prostration of so severe a wound, as no traces of peritonitis or pyaemia were found." The following is an example of fatal bleeding from the internal iliac vein: Case 607.—Private John Dudley, 103d U. S. Colored Infantry, aged 32 years, was wounded in a skirmish in Kentucky, August 29, 1864, and was admitted to West End Hospital, Cincinnati, on August 30th, where he died on the same day. The case is reported by Acting Assistant Surgeon R. Bartholow2 as follows: ''On examination, found a wound of the right hip which was supposed to be the entrance of the ball, and another wound anteriorly in the right iliac region, supposed to be the orifice of exit. Patient was very weak; pulse rapid; respiration also rapid; skin cold and dry; the abdominal muscles were firmly contracted, and the lower extremities drawn up. He evinced great suffering when pressed upon the abdomen, and vomited freely. At 2 o'clock P. Jl. haemorrhage took place from the anterior wound, but was arrested by placing the patient on his back, but commenced again, however, when he was lying on his right side. There was also great irritability of the bladder; but no urine passed when the catheter was introduced. Morphia and one ounce of whiskey were given every four hours, and applications of warm water were made over the abdomen; he was unable to take food. Autopsy sixteen hours after death: There was considerable suggillation posteriorly and about the neck, and swelling of the neck anteriorly. Upon laying open the cavity of the abdomen, a clpt of blood was found effused on the anterior surface of the intestines, and entangled in it was the" skin of a grape. The peritoneum was red and injected, but there was no exudation of false membrane; the cavity of the abdomen was filled with blood. Upon removing the intestines and tracing the course of the ball, it was found to have entered through the ischiatic notch, divided the internal iliac vein, impinged upcm the right lateral portion of the bladder, and made its exit in the right iliac region. The ball also passed through the lower portion of the ileum about twelve inches from the ileo-caecal valve." 1 Follix, in an article replete with sound and sagacious observations, mentions an instance in which death resulted from the puncture cf some of the terminal ramifications of the mesenteric artery by a bayonet, and the haemorrhage was not suspected until revealed by the autopsy. Des Epanche- ments traumatiques de l'abdomen, in Diet encyclop. de Sci. Med., T. I, p. 171. 2BARTHOLOW (11.) Cincinnati Lancet and Observer, 1864, Vol. VII, p. 590. SECT. III.] COMPLICATIONS--EXTRAVASATIONS. 191 In the treatment of intra-abdominal bleeding, the surgeons usually adopted the general measures for combating hoemorrhage commended by systematic authors, excepting venesection and cupping over the belly: that is, absolute immobility, occlusion of the external wound, and the application of refrigerants, with sinapisms to the extremities, and, internally, cold acidulated or saline drinks, opiates, and, sometimes, preparations of digitalis, veratrum viride, or gallic acid. Phlebotomy, still recommended by leading French and German authorities on this subject, was rejected even more uniformly than in intra-thoracic hoemorrhage. When internal bleeding proceeds from the vessels of the abdominal walls, the ligature is, of course, the safe and indispensable remedy. On page 177 and elsewhere I have dwelt upon the disastrous results of neglecting this paramount resource. In this direction, I believe that operative interference should be carried to the extreme verge of the limits that prudence enjoins. Instances are not wanting in which branches of the mesenteric, epiploic, gastric, and colic arteries have been successfully ligated. Where there is protrusion of the wounded, solid viscera, with oozing from the lacerated surfaces, a ligature in mass may be requisite. If the finger, introduced into a penetrating wound in the belly, recognizes the warm jet of a bleeding vessel, the point must be exposed and secured. It would be more rational to ligate even the cava or aorta, than to stuff the wound with lint saturated with persulphate of iron, as was done in more than one mortal hoemorrhage. The cases of intra-abdominal bleeding that are not immediately mortal, from lesion of the great vessels, and that are not amenable to mechanical treatment, form a small group in which the surgeon is reduced to the general measures for combating haemorrhage already indicated. Should these means, of which rest and ice-poultices are the chief, prove successful, three additional indications arise: to promote absorption of the effused blood, to oppose the recurrence of bleeding, and, under some circumstances, to evacuate the extravasation. If the utility of such resolvents as cupping and cataplasms is not demonstrated, it is certain that the second indication may be fulfilled by maintaining absolute repose, with a light, reparative diet, of a nature to leave little residue,1 for immobility of the intestine also is essential, and must be assured by opiates. There is reason to apprehend that here, and in other circumstances in which recurrence of haemorrhage was imminent, a want of caution in the administration of brandy and other stimulants was a point open to criticism in the practice of some surgeons. The evacuation of the effused fluid may become necessary, where it forms a circumscribed tumor, augmented by inflammatory products. No example of the sort is found on the reports; but the surgeon encountering such a case may judiciously follow the practice inculcated by Velpeau, of a free incision in preference to puncture, as advised by Vacher. In this connection may be noted a few instances in which tapping was required for non-traumatic effusions, dependent on morbid secretion: Paracentesis.—Four instances only of tapping were reported; whence it may be inferred that the cases of ascites following diarrhoea or malarial fever that required this operation were comparatively rare: Case 608.—John Davidson, powder boy, Co. A, Marine Artillery, was admitted into the Ladies' Home Hospital, New York, February 28, 1863, suffering from hydropsy. The following notes of the case appear upon the hospital case-book: " Ho was on board the gunboat Picket when she was blown up, September 9, 1832, and received a fracture of the left leg with consid- erable contusion of the soft parts. He was treated at the hospital at New Berne, and was furloughed for twenty days, and came to New York in the latter part of January, remaining at a sailors' boarding house until his admission into this hospital. He had diarrhoea during all the time he was at the hospital at New Berne, and until his arrival in New York, when it ceased. On . ' Milk diet, recommended particularly by Dr. Ashhurst (Princ. and Pract. of Surg., p. 368), is excellent. \\\'2 PENETRATTNC WOUNDS OF THE ABDOMEN. |(HAP. vi admi>sion, the abdomen was much enlarged ; fluctuation was distinct, and the veins of the abdomen were turgid. He was still lame from the injury to the leg, considerably emaciated, and obliged to keep his bed from debility. There was some oedema of the lower extremities. Hydragogue cathartics were given repeatedly, with the effect of reducing for the time, to some extent, the abdominal effusion ; but the relief being only temporary, paracentesis was resorted to on March 24th, with much relief. The liquid, however, re-accumulated, so that in a few days the abdomen was as much enlarged as before the operation. The treatment, aside from tapping, consisted of muriate tincture of iron and nutritious diet. March 29th, the vertical diameter of the liver, as ascertained by percussion, appears to be normal; there are no signs of cardiac disease. It does not appear that this patient has been so situated as to be able to drink spirits to much extent, He states that he has drunk only very little occasionally. On July 22, 1863, Davidson was transferred to Lovell Hospital, Portsmouth Grove, whence he was discharged from service October 29, 1863, "because of ascites, most likely from tubercles in the mesentery, contracted in line of duty. Fracture and dislocation of left tibia." Pension Examiner R. H. Tuft, of Elkton, Maryland, reported, December 14.1868, that Davidson was " blown up by the explosion of the gunboat Picket, receiving internal injuries which resulted in debility and chronic diarrhoea. This condition has been kept up by exposure and bad whiskey." His claim for pension was rejected! Case 609.—Private John W. Tarton, Co. I, 94th New York, aged 35 years, was admitted into the depot field hospital of the Fifth Corps at City Point, March 15, 1335, suffering from dropsy. On March 23d, he was transferred to Harewood Hospital, Washington, and on April 17th to Stanton Hospital. On May 7th, Surgeon B. B. "Wilson, U. S. V., administered chloroform and performed paracentesis, removing two gallons and one pint of fluid. The patient was in good condition. Dr. Wilson, on May 28th, repeated the operation, withdrawing fluid to the amount of three gallons and three pints. The patient was rather debilitated, and required the administration of stimulants during the operation. The abdominal parietes appeared to be in good condition. Death resulted from peritoneal inflammation on June 16, 1865. Case 610.—Private John Tacket, Co. B, 14th Kansas Cavalry, aged 45 years, was admitted into the hospital at Pine Bluff, April 29, 1865, from his regiment, suffering from chronic diarrhoea. Assistant Surgeon F. J. Foster, 13th Illinois Cavalry, reports that "on June 27th, there was enlargement of the liver and abdominal dropsy. The patient was anaemic, and the abdomen was much distended with fluid. Paracentesis abdominis was performed. A tonic course of treatment was then pursued, but the abdomen again became distended. He died September 10, 1865, from dropsy resulting from hepatic disease." Case 611.—Private Titus H. Flanders, Co. K, 153d New York, aged 48 years, was admitted into the regimental hospital, April 16, 1864, suffering with acute diarrhoea. The progress of the case is not noted, but, on July 17th, he was transferred to Marine Hospital, St. Louis, whence .Surgeon A. Hammer, TJ. S. V., reported that ascites had supervened. The patient was very feeble and the abdomen much distended. On July 21st, Dr. Hammer performed paracentesis abdominis, evacuating nine pints of fluid. Diuretics, diaphoretics, and stimulants were administered. Death, July 31, 1884. Acting Assistant Surgeon Gr. P. Hachenburg transmitted a drawing of a trocar, designed to preclude the admission of air in paracentesis by a syphon attachment to the canula. File.—In two notes on page 21 the principal recorded clinical observations on the effects of extravasation of bile from rupture of the gall-bladder or of the biliary ducts are referred to, and in the series of one hundred and seventy-three shot wounds of the liver (Oases 312-484) are some illustrations of the results of effusion of bile in the peritoneal cavity, and others may be found in the works referred to in the note.1 The elevated position of the biliary reservoir and canals, and the fluidity of the secretion, and its persistence after lesions of the excretory apparatus, are circumstances that would seem to ensure the diffusion of the bile over the intestinal mass in the event of wounds or ruptures of the gall-bladder or ducts.. In a case of wound of the gall-bladder that Sabatier observed, intense peritonitis was rapidly developed; the belly swelled quickly, with great tension and pain in the hypochondrium. On the third day a prominence was noticed in the right iliac region, and Sabatier introduced a trocar and gave vent to a dark- green odorless fluid, supposed to be pure bile. Authors have repeated Sabatier's descrip- tion ; and it has been commonly held that extravasation of the acrid bile would necessarily irritate the serous membranes to a degree involving mortal peritonitis. The instances of 1 AUTENKEITH, De sanandis forsan vesiculx fellese vulneribus; E. LITTRE, Blessures des voies biliares, in Diet de Mid., T. V, p. 232 ; Harlan (G. C), On Wounds of the Liver, in North Am. Med. Chir. Rev., 1859, Vol. Ill, p. 701; Herlin, Experiences sur Vouverture de la visicule du fiel, in Jour. gin. de Med., 1767, T. XXVII. p. 463; FRYER, Extravasation of Bile into the Cavity of the Abdomen, etc., in Med. Chir. Trans., 1813, Vol. IV, p. 330, and Medical and Phys. Jour., 1815, Vol. XXXII, p. 152; MAYER (L.), Die Wunden der Leben und Gallen-Blase, Miinchen, 1872, Sn. 47, 61, 77; AviCEXXA, Canon medicina, Venetiis, 1700, Lib. Ill, Fcun. 14, Tract. 3, p. 14; PETIT, Sur les tumeurs formees par la bile retenue dans la visicule du fiel, et qu'on a souvent prises pour des absces au foye, in Mem. de I'Acad. Roy. de Chir., Paris, 1743, T. I, p. 170; Blasius, Observationes med. rariores, Amst., 1677, P. II. n. 4 ; Le GROS Clark, Cases illustrative of Injuries of the Abdomen, in Lancet, 1864, Vol. I, p. 698; WiLKS, Laceration of the Liver, with Formation of an Abscess between it and the Diaphragm, perforating the latter, in Lancet, 1864, Vol. II, p. 716; PORTAL, Cours d'anatomie midicale. Paris, 1803, T. V, p. 121 ; LlEUTAUD, Historia Anat-med., Parisiis, 1767, Obs. 910-911, p. 211, refers to cases related by Salmuth and HOKFMAXX ; SABATIER, Med. operatoire, Paris. 1822, T. II, p. 153; STUART, The Use of Bile in the Animal (Economy, in Phil. Transactions, Abr., &c, by Eamks and Makiy.v. Loudon, 1734, Vol. VII. p. 571 ; CALLISEN, Syst Chir. Hodiernre. Vol. I, p. 718. SECT. Ill ] COMPLICATIONS--EXTRAVASATIONS. 193 recovery recorded by Fryer and Frank are contested by Chelius and others, and it baa been sought to explain the exceptional case of Parroisse, referred to on page 137, by supposing that the ball gained admission to the gall-bladder by ulceration. Callisen pointed out that extravasation might be pro vented in wounds of the gall-bladder by previous accidental' adhesions of the organ to the peritoneum, a suggestion practically applied in the operative treatment proposed for biliary calculi. The experiments on animals by Horing and Herlin and by Oampaignac indicate that the intensity of the irritant action of bile effused in the peritoneal cavity has been overrated,1 and some of the facts observed during the War point in the same direction. In the complicated case of Coffin (Case 421, p. 136), hyperacute peritonitis terminated fatally in fifteen hours; but in the cases of Alleger and Kingsbury (Cases 408, 419), with equally.extensive extrava- sation of bile, life was prolonged for five and eight weeks. In .the following case the patient survived twenty davs : Case 61'2.—Private Haywood Painter, Co. A, 24th North Carolina, was wounded at Petersburg, March 24, 1835. He was admitted to field hospital at City Point on the following day, and on March 29th was transferred to Washington, where he was admitted to Lincoln Hospital on the 30th. The history of the case up to the time of death was reported by Acting Assistant Surgeon N. A. Eobbins, and the autopsy by Acting Assistant Surgeon I. P. Arthur, as follows: "Gunshot wound of back, ball entering near the crest of the right ilium, and probably penetrating into the cavity of the abdomen. He suffered a great deal of pain from time to time; the wound also suppurated pretty freely; he grew weaker daily, and finally died, from tbe consequent exhaustion, on the 13th of April, 1SC5." Autopsy record : " Height, five feet ten inches; external appearance very much jaundiced; ball entered three inches to the right of the spine on a level with tbe crest of the ilium, passed forward through the muscles of the back, penetrated the cavity of tbe abdomen, and ruptured the gall-bladder; tbe ball was found lying loose posterior to bladder; lower lobes of both lungs very much congested; pleural adhesions on right side; heart healthy; abdominal viscera very much discolored by bile; intestines not wounded." In the case of Green (Case 436, p. 139), a shot perforation of the right lobe of the liver, with division of a large branch of the hepatic duct, though there was generalized peritonitis, and probably an incessant escape of bile, the patient survived forty-four days. In such cases, Campaignac advised ligation of the ducts, and Herlin extirpation of the gall- bladder, adducing the results of experiments on animals in support of these propositions.2 Bohn and Kaltschmidt3 held that life might be extended for some length of time without the cystic bile, and that this, when effused in the abdomen, did not of itself bring on any immediate danger; but the view promulgated a centur}*" later by Sabatier has prevailed, and subsequent facts appear to modify it only as to the intensity of the inflammation resulting from extravasation of bile. It has been stated that the report of a recovery from a shot wound of the gall-bladder in Circular 3, page 50, was a clerical error; in the recovery recorded on page 140 (Case 316), in which this lesion was alleged, the diagnosis was probably erroneous. Urine.—The absence of examples of urinary extravasation in the cases of wounds of the kidney or ureter, that come under treatment, has been adverted to on page 162. This complication is so rare that, according to Velpeau, Morgagni could cite only the example adduced by Piccolomini. Instances of extra-peritoneal urinary infiltration are adduced on page 20. That the effusion of urine within the peritoneum is more irritating ' In a case of rupture of the gall-bladder observed by ROGERS (GROSS'S Elera. of Path. Anat, 1845, p. 665), the patient survived the escape of the fluid sixty hours. In one recorded by DRAKE ( Western Jour, of the Med. and Phys. Sci., 1834, Vol. VII, p. 5120), death took place at the end of the third day. In four of tho cases recorded in LESUEUR'S thesis, life was destroyed in a few hours; the fifth survived four days. A case described by SKEETE (London Med. Jour., 1785, Vol. VI, p. 274), terminated fatally at the end of the sixth week. TRAVERS (Inquiry, etc., op. cit, p. 72) mentions two fatal cases, without specifying their duration. See cases in Morgaoxt's Epistolve Anatomical, Ep. II, Art. 96, Op. omn., Patavii, 1765, T. II, p. 85, and in Van SwiETEX, Comm. in Boerhaave, Parisiis, 1755, T. I, p. 475. 2 The certainty of an inevitably fatal result from expectation may justify extreme surgical boldness, and, with FOLL1N, I would refrain from censuring this proposition; but, as that excellent surgeon remarked, it is to be feared that the damage inflicted by the bile already extravasated would render interference nugatory. 3BOH\, De vulnerum renuntiatione, Lipsiae, 1689, cap. 4. KALTSCHMIDT, De vulneribus hepatis, Jena, 1735. 2."> 194 PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. than the extravasation of any other secretion is unquestioned. Such an accident is almost uniformly fatal in from two to twelve days. Yet, in thirty-seven cases collected by Houel,1 there were two instances of recovery. The subject will be reverted to in treating of injuries of the bladder. Fojces, etc.—Escape into the peritoneal cavity of the alimentary, stercoral and gaseous matters ordinarily contained in the digestive tube, and occasionally of lumbrici and other entozoa, are complications resulting from ruptures and spontaneous perforations of the intestines as well as from wounds, so frequent as to come under the observation of every practitioner. The relations to the extravasation of the form and extent of the solution of continuity, of the state of repletion or vacuity of the intestine, of the formation of adhesions, and of the interposition of epiploic laminae, have been exemplified by cases of ruptures and of wounds (pp. 22 and 62). It has been contended that after wounds of the intestine this extravasation "takes place much less frequently than might have been expected."2 Two instances of multiple shot wounds of the intestine are adduced by Mr. Erichsen, in which no fsecal effusion took place, although the intestines contained much stercoraceous matter, and were largely lacerated, and the patients survived two days. One or two such exceptional instances (Cases 225 and 226, p. 71) are found on the reports of the War. Sometimes the subject is passed over in silence; but a multitude of such examples as the following appear: Case 613.—Sergeant Daniel H. Bird, Co. 1,1st West Virginia, was wounded at Murfreesboro', September 11, 1863, while sleeping in his tent. He was treated in regimental hospital until he died, on September 13th. Surgeon D. Baguley, 1st West Virginia, reported: " Ball entered the left lumbar region and passed to the right side, from whence it was extracted, having perforated the intestines in its course. The contents of the intestines were extravasated into the abdominal cavity and fatal inflammation resulted." If, by the fortunate adhesions or occlusion by interposition of the omentum or of contiguous viscera, fsecal effusion was temporarily arrested, it was liable to be provoked by moving the patient, as in the following case : Case 614.—Private John Piercefield, Co. H, 91st Ohio, aged 33 years, was wounded at Winchester, July 20, 1864, by a conoidal ball. He was treated in a field hospital until the 24th, when he was admitted to hospital at Cumberland, where he died two hours after admission. The following report of the case was made by Acting Assistant Surgeon C H. Ohr: "The ball entered near the sternal end of the cartilage of the tenth rib, at the upper edge on the right side, and, passing down through the abdomen, lodged in the muscles of the right hip three and a half inches below the crest of the ilium and three inches behind the tip of the great trochanter, whence it was extracted immediately after his admission here. The patient had been some four or five hours delayed on the road from Martinsburg, without even the necessary supply of water. His skin was cold and clammy; pulse 96, small, weak, and thready; voice hoarse and weak; respiration laborious, short, and hurried; bowels con- stipated; ejects stimulants immediately after swallowing; extremities cold. The extreme prostration of the patient prevents the acquisition of any information as to his previous treatment, and, from the disposition to emesis with the near approach of death, nothing was administered but a little whiskey and water, winch was not retained. Autopsy, fourteen hours after death, showed the abdomen tensely swollen, peritonitis with adhesion of the bowels, and the peritoneal sac extensively studded with patches of pus and freely covered with faecal matter from the numerous perforations of the intestines. The tediousness of separating the adhesions and the offensive condition of the subject prevented a minute tracing of the track of the ball or preser- vation of portions of the perforated intestines." Case 224, on page 71, is another instance of delayed extravasation, the symptoms of intense peritonitis coming on during transportation, and terminating fatally on the eighth day. There is yet another group of cases, wThich John Bell has admirably described, in which the patient goes on well till the eighth or tenth day, the intestines having only been bruised in the rapid passage of the ball, and then the hurt part sloughs off, and the 1 HOTEL, Des plaies et des ruptures de la vessie, Paris, 1857, p. 50. The recoveries were reported by Syme (Lancet, 1848, Vol. I, p. 289) and by Dr. Walter, of Pittsburg (Med. and Surg. Reporter, 1862, Vol. VII, p. 153). 2ERICHSEN, Tlie Science and Art of Surgery, Cth ed., 1872, Vol. I, p. 508. The case of Dunn, p. 449, First Surgical Volume, Cases 217, p. 69, 219, 2C0, p. 70, 224, p. 71, and 303, p. 113, supra, are examples of the rapidly fatal peritonitis following fsecal effusion after shot wounds. Cases 206, p. C2. and 233, p. 76, illustrate the same condition after stab wounds. Case 216, p. 68, is a remarkable illustration of a large circumscribed faecal effusion uj a case in which life was prolonged for four weeks. SHOT. III.] COMPLICATIONS—EXTRAVASATIONS. 195 faeces are poured out into the cavity of the abdomen, and there is a sudden interruption of the stools, and as sudden a tension and swelling of the belly, with vomiting, hiccough, and speedy death. Salzmann, Heister, Poland,1 and a few others have referred to the escape of entozoa from wounds of the bowel. Travers (op. cit., p. 27) considers this a peculiar case, to which no reasoning on the effusion of inanimate matter can apply. Cases 172, 215, 221, and A5, on pages 42, 68, 71, and 206, furnish illustrations of this rare accident.2 After a solution of continuity of the digestive tube, the conditions under which fascal effusion within the peritoneal cavity fails to ensue appear to be: First, that the orifice shall not exceed three lines in extent,3 when reduced by muscular contraction. The eversion and pouting of the mucous membrane may be sufficient to occlude such an aperture, whether its direction is transverse, oblique, or longitudinal. Secondly, if the lesion of the intestine is in parts of the duodenum or colon uninvested by peritoneum, the effusion will be interstitial or external. Thirdly, the edges of the orifice in the intestine may immediately adhere to the peritoneal lining of the parietes, and the extravasation will then take place externally; or adhesions may form with neighboring coils of intestine, or with the surfaces of the solid viscera, or the aperture may be closed by the apposition of the omentum or mesentery. Lastly, the vulnerating instrument may inflict such violence as to annihilate the peristaltic action of the bowels, when the intestine may be lacerated in many places, without effusion taking place. Under all other circumstances, fascal extravasation is the inexorable sequence of a perforation of any magnitude, for the digestive tube is never absolutely empty. The uniform equable pressure with the beneficent tendencies that John Bell and Travers so earnestly and wisely insisted on, favors the accidental formation of adhesions; but it must be steadily held in view that unless occlusion is immediately effected through the agencies adverted to, or by surgery, fsecal effusion must result, unless the muscular coat is paralyzed. Argument to prove that the contents of the bowel must follow the line of least resistance and escape through an orifice in the bowel large enough to permit their escape would appear to be supererogatory. Yet some writers mistake the explicable exceptions to this rule for the rule itself. Physicians do not question that perforation of the bowel following ulceration will almost inevitably be followed by effusion. That extravasation almost infallibly results from ruptures of the intestine without external wounds is not doubted. Travers ably explained why effusion should not take place in many punctured wounds. It has latterly been alleged that faecal extravasation is uncommon in shot wounds of the intestine. Mr. Erichsen's assumptions (op. cit., 1859, 1st Am. ed., p. 328; 6th ed., 1872, Vol. I, p. 509) on this subject, in which Petit's exploded hypothesis on the circumscription of fascal effusions is revived, have been almost literally copied, without acknowledgment, by Surgeon-Major Williamson (Mil. /Surg., 1863, p. 104), whose familiarity with the morbid anatomy of shot wounds of the abdomen might have been expected to have deterred him from endorsing statements so widely at variance with the results of sound theory and of practical experience. The teachings of Ballingall,4 and careless interpretations of the 1 SALZMANN (J.), De chirurgia curtorum, Argent., 1713; Heisteu, Gen. Syst. of Surg., 17(i9; POLAND, Guy's Hosp. Rep., 1858, Vol. IV, p. 149. 2 In Case 207. p. 64, lumbrici escaped through the external wound, and in Case 283, p. 94, a similar escape of another worm, the trichocephalus dispar, was observed. Baudens, De IjISLE, and BRIOT give similar instances. 3 The experiments of Professor GROSS are decisive on this point. They are succinctly detailed in his System (5th ed., A'ol. II, p. 6G3), and are more elaborately stated in his exhaustive Inquiry (op. cit, p. 10). A synopsis of the results appears in note 4, page 60, supra. 4 Ballingall (Outlines of Military Surgery, 5th ed., p. 352): "Extravasation of the contents of the bowel within the peritonaeum is by no means so liable to occur as speculative writers would lead us to imagine. 196 PENETRATING WOUNDS OF THE ABDOMEN. | CHAP. VI. experiments of Travers, and of John Bell's eloquent exposition of the salutary effects of the uniform equable pressure, may have misled Mr. Erichsen, Mr. Teale, and Dr. William- son into the support of this unsafe doctrine, to which it would be sufficient to oppose the authority of John Hunter,1 of Velpeau,2 of Jobert,3 and of Professor Gross,4 if it was impracticable to refute it by appealing to facts. It wTould be easy to multiply examples from the records of the War; but as it might be objected that these were selected cases, the fallacious assumption of the rarity of faecal effusion after shot wounds of the digestive canal may be preferably controverted by adducing instances from other writers.5 That extravasated alimentary or stercoral matters may become encysted, and, pro- ducing circumscribed abscesses, may be discharged externally or into the intestinal canal, is doubtless true; but such facts are among the rarest of exceptions. The instance observed by Archer (p. 43, supra, note) of an incised wound of the stomach, with escape of its con- tents into the peritoneal cavity, and recovery after the discharge in the groin of an abscess containing portions of cabbage, is one of the most remarkable. Such instances of extravasation of lymph, from division of the thoracic duct.or of the reservoir of Pecquet, as Morgagni details in the fifty-fourth epistle, and as Sandifort, Portal, Scherb, and Lieutaud have described, were not observed. As Velpeau observes, such effusions are doubtless possible, but it may fearlessly be asserted that their existence has never been satisfactorily demonstrated. My observations have not confirmed those of Dr. Williamson in regard to the displacement of the wounded gut,6 but are in accord 1 Hunter (Gunshot Wounds, op. cit, p. 545), in the paragraph preceding that in which he relates the exceptional instance of the officer wounded in the Hyde Park duel, lays down the general principle that a ball striking one of the abdominal viscera will produce effects of two kinds, and the first "is common to them all, viz : their contents or extraneous matter escaping into the cavity of the abdomen." 2 Velpeau (Article Epanchements dans l'abdomen, in Diet, de Mid., 1832, T. I, p. 201), after recalling that faecal effusions often result from ruptures of the alimentary tube, adds: "les plaies pen6trantes en sont une cause encore plus fr6quente." 3 Jobf.rt, treating1 of wounded in the revolution in Paris in July, 1830 (Plaies d'armes a feu, 1833, p. 215), gives an instance of faecal effusion, and remarks: "les matieres fecales s'epanchent souvent dans le ventre, et il en r6sulte une peritonite mortelle." 4GKOSS (System, etc., 1872, Vol. II, p. 664): "In gunshot wounds cf the bowels, and in incised wounds attended with severe contusion, the eversion of the mucous coat is generally very slight, and sometimes even absent. Owing to this circumstance, wounds of this description, even when very small, are extremely prone to be followed by faecal extravasation and fatal peritonitis." Mr. POLLOCK (Mr. Holmes's System, 1870, Vol. II, p. 671) justly observes: "All the experiments by Mr. Travers, Dr. GROSS, and others lead to this conclusion, that, upon the infliction of a wound of the intestine, some escape of feculent fluid, though perhaps a very small quantity, takes place, and is the chief cause of the subsequent peritonitis." 6 Only in a small proportion of the observations of fatal shot wounds of the alimentary canal recorded by authors are the post-mortem appearances described, and in these the presence of fascal effusion is seldom specified, probably because, as Travers remarks, "the extravasation of faecal matter seems to have been regarded as a consequence so inevitable of a rupture of the bowel, that the notice of the former circumstance after tho mention of the latter probably approached somewhat in the writer's idea to the nature of an identical proposition." Many writers on military surgery seldom detail fatal cases. Purmanx and LARREV, for example, who are especially full and instructive in treating of wounds of the abdomen, adduce only examples illustrating tbe successful efforts of nature or intervention of art. Notwithstanding, from the comparatively small number of recorded fatal shot perforations of the intestine, it is possible to collect many instances of faecal effusion. Thus, BECK (Die Schusswunden, 1850, S. 216) records five dissections of soldiers who died after the battle of Vicenza from shot wounds of the intestine; large faecal intraperitoneal extravasation was present in all. These patients perished on the second and third, and one on the fourth day. And Schwartz (Beitrdge zur Lehre von den Schusswunden, 1854, S. 125) gives the autopsies of H. S., wounded at Altenhof, April 21, 1848, with faecal effusion and hyperacute peritonitis, ending fatally in twenty-four hours, and of A. P., 31st Prussian regiment, wounded April 23, 1848, at Schleswig, who survived a faecal effusion from shot perforation of the small intestine five days. LOHMEYER (Die Schusswunden, 1859, S. 160) records the autopsy of Lieutenant II., wounded September 12, 1850, who died from faecal extravasation from a shot wound of the colon. Assistant Surgeon Horxer, U. S. A. (Circular No. 3, S. G. O., 1871, p. 48), records a case of faecal extravasation following a shot perforation of the colon, fatal in a few hours. SOCIN (Kriegschir. Erfahrungen, 1872, S. 95) gives the autopsy of Fille, shot through the colon at Gravelotte, August 18, 1870; died with faecal effusion. FISCHER (II.) (Kriegschir. Erfahrungen, 1872, S. 129) records au example of faecal effusion from shot wound of the colon and small intestine in the case of Thodkein, 13th Prussian regiment, wounded August 14, 1870; fatal in four days. Baudexs (Plaies d'armes a feu, p. 335) describes the autopsy of a case of shot wound of the colon with faecal effusion. Serbier (Traiti des plaies d'armes a feu, 1844, p. 268) mentions a single fatal case of shot wound of the small intestines, in which five convolutions presented each two perforations; a large faecal extravasation excited peritonitis, terminating fatally in twenty-four hours. SEDILLOT (Campagne de Constantine, 1828, p. 157) details a fatal case of faecal effusion from a shot wound of the intestine, and adds: " Nous perdimes ainsi pendant le reste de la campagne tous ceux qui presenterent des plaies penitrantes abdominales, et ni les heureuses adhfirences sur lesquelles on compte pour prfevenir l'epanchement, ni la pression mutuelle des visceres ne purent empScher dans aucun cas cette termination funeste." BERTHERAXD (Campagne d'Italic, 1860, p. 97) reports the case of Lieutenant-Colonel V------, who received a shot wound of the small intestines at Solferino, causing fascal effusion and death iu forty-eight hours. G Surgeon-Major GEORGE WILLIAMSON observes (Military Surgery, 1863, p. 112): " It is curious to remark, on post-mortem examination of a case of direct gunshot perforation of the abdomen, that the intestine is wounded in many places considerably removed from the direct course of the ball. Is this removal of wounded portions of intestine from the line of the ball due solely to the natural peristaltic action, or to something more than this, as the result of the injury ? Probably the latter influence is considerable; as it has been remarked, and 1 believe truly, that under perforation of the intestines by ulceration there is not only contraction in calibre, but marked shortening of the intestinal canal. This action beyond the peristaltic may be expected, and really appears to follow equally perforations by injury and disease, thus explaining the withdrawal of the wounded points of intestine from the line of the ball, as indicated by the orifices of entrance and exit." SECT, in.] COMPLICATIONS--EXTRAVASATIONS. 197 with those of Baudens and of Legouest, that in shot wounds of the abdomen the intestinal lesion is usually found just behind the entrance orifice in the parietes. Further inves- tigation of this point is desirable. Theoretically, there appears to be no reason why the contraction of the longitudinal fibres should not produce displacements in addition to those resulting from peristaltic and antiperistaltic movements. Pus.—Effusions of pus into the peritoneal cavity may be primary, depending on the extravasation of the contents of abscesses; or consecutive, as exudations resulting from peritonitis. The following cases, though not very characteristic, have been classified in this category: Case 015.—Private W. H. Sanborn, Co. A, 12th Massachusetts, aged 22 years, received a perforating wound of the chest and abdomen at the Wilderness, May 7, ISC I, by a conoidal ball, lie was treated in the field hospital until the 12th, when he was transferred to Armory Square Hospital, Washington. On May 2(ith, he was sent to the hospital at Chester. Surgeon T. H. Bache, U. S. V., reports that, "when admitted, the wounds were almost healed and his general health was good; on the fourth or fifth day following, he was taken with a chill, followed by hot accelerated pulse, and had these rigors daily for two or three days, with slight diarrhoea, epistaxis, tenderness in right iliac fossa and over the liver, and about this time pseudomena appeared over the abdomen; he was progressing favorably until the evening of June 9th, when his pulse was 110, full and bounding; and on the next day he was still failing; the skin cold and clammy, and pulse barely perceptible; he died at five o'clock P. M. Autopsy : The missile had entered near the eighth rib, on the left side of the chest, and made its exit above the fifth rib, on the right side, about four inches from the sternum. The serous cavities were filled with grumous-looking pus, and the liver much enlarged and displaced; a large cavity was found on the under surface of the right lobe, capable of containing thirty-two ounces of pus; the track of the ball through the liver from entrance to exit was well marked; the glands of Peyer were much enlarged, and there was considerable congestion of the intestines." Case 437 (see p. 132).—Private E. Holbrook, Co. F, 16th New York, aged 24 years, was wounded at Chancellorsville, May 3,1863. He was treated in field hospital until May 8th, when he was admitted into Stanton Hospital, Washington. Acting Assistant Surgeon G. A. Mursick reported, on the Medical Descriptive List, that the patient was paraplegic when admitted, and urine and faeces passed involuntarily; his pulse was small and feeble, and respiration thoracic; he had never spit blood. He was much prostrated, and had a troublesome bed-sore. These symptoms continued until May 10th, when they assumed a typhoid type. On May 12th, there was effusion into the right pleural cavity, and some cough; the tongue was coated and dry. On May 19th, the pulse was 110 and feeble, and was gradually growing weaker; had very little appetite; bed-sore increasing in size. On the 21th he had a chill, and, on the 28th, the abdomen became tympanitic, with pain and constriction. He died on the following day, at 5 o'clock a. m. The treatment had consisted of cold applications to wounds, with tonics, stimulants, and nutritious diet. Post-mortem examination showed that the ball had entered the back, passed through the body of the tenth dorsal vertebra, traversed the cavity of the abdomen, passing between the aorta and ascending cava, perforated the diaphragm and liver, and lodged in the intercostal space between the seventh and eighth ribs." Case 616.—Private George Johnson, Co. H, 116th Ohio, aged 19 years, was wounded at Piedmont, June 5, 1864, and admitted to Confederate hospital at Staunton on June 7th. Assistant Surgeon W. Grumbein, 20th Pennsylvania Cavalry, reported as follows: "Wounded by three balls, one of which struck the crest of the ilium and entered the abdominal cavity; another struck the thigh over the trochanter. The wounds were not considered dangerous at first. The suppuration was profuse and unhealthy. The patient was of a scrofulous diathesis, and was weakened to a great extent by diarrhoea, which could not be checked by medicine. Haemorrhage took place toward the last, which nothing but steady pressure would check. He remained sensible until he died, July 13, 1864. The post-mortem examination showed that the psoas and iliac muscles were entirely dissected and in an advanced state of putrefaction ; so also was the pelvic fascia; the peritoneum was of a mottled appearance, bordering on a scarlet color. The course of the ball was not discovered on account of the disorganized state of the tissue. In the left iliac fossa was found about a pint of coagulated blood and pus." Case 617.—Private William A. Dickey, Co. B, 13th Tennessee Cavalry, aged 27 years, was wounded at the assault on Fort Pillow, April 12, 1864, and on the 14th was admitted into the hospital at Mound City. The following report of the case was made by Surgeon Horace Wardner, U. S. V.: "April 17th, the patient complained much of pain in the left side and back; the abdomen was swollen and tympanitic and very tender. Warm-water fomentations were applied, and also anodynes, under the influence of which he sometimes rested tolerably well. About June 1st fluctuation was detected in the left lumbar region, and, on the 3d, this was relieved by incision, about sixteen ounces of dark-gray and very offensive pus being discharged. He sank rapidly, and, on the 4th, hiccough set in and continued until June 6th, when he died. Autopsy sixteen hours after death: Rigor mortis perfect; body much emaciated, and abdomen swollen. The ball entered four inches to the right of and one inch above the umbilicus, passed obliquely downward and to the left, between the internal oblique and transversalis muscles, near to the pubis; it then passed upward and backward, striking the posterior superior spinous process of the ilium, producing a zigzag fracture two and a half inches in length, and lodged on the left side of the last lumbar vertebra below the transverse process. The ilium was denuded of periosteum in a space two or three inches in diameter. The peritoneum, omentum, descending colon, and rectum were black, and had been much inflamed, and there were appearances of congestion along the whole intestinal canal. The kidneys were normal and the spleen somewhat congested; the liver was not examined; stomach appeared healthy; peritoneal adhesions very extensive; and about three ounces of dark stinking pus was found between the psoas muscle and the ilium." 19S PENETRATKV; WOUNDS OF THE ABDOMEN. [(HAP. VI. Casks 12-), 212, 304, 307, 414, and 449, on pages 24, 67, 101, 135, and 136, supra, furnish hotter examples of this complication, and a great number may be found in the autbors cited in the note.1 In the cases of peritonitis attended by a copious effusion of pus that have come under my observation, there was less pain than in those associated with pseudomembranous exudation, or, still worse, with fsecal effusion. Air or Gases.—Air, in rare instances, may accumulate, to a small extent, in the peritoneal cavity through a long narrow wound in the parietes, and somewhat less rarely through perforations of the lung and diaphragm. The extravasation of intestinal gases is a very common, if not a uniform, result of a division of the walls of the alimentary canal. Dr. F. H. Hamilton2—who has thoughtfully discussed the subject of abdominal effusions, and whose authority might have been added to those invoked in confirmation of the frequency of fsecal escape after shot wounds of the bowels—suggests three explanations of the mechanism of these extravasations: First, that by admission of air through the track of the wound the peritoneal surfaces, normally in absolute contact, may be separated, and an intra-peritoneal air space may be formed, into which the contents of the intestine, impelled by peristaltic action, may be freely found. Secondly, holding that "the intestines contain always a certain amount of gas,"3 Dr. Hamilton conceives that immediately on the reception of a wound the muscular tunics of the intestines vigorously contract and expel this confined gas; the intestine collapsing, and the gas having gained admission to the peritoneal cavity, the fluid and solid contents of the intestine readily follow. Thirdly, the faecal matter may be displaced and carried forward by the missile precisely as any other substance lying in its way. There can be no question that sudden meteorism is the most constant and characteristic symptom of rupture of the intestinal walls. Jobert's4 claim, that it is of pathognomonic value, is, perhaps, exorbitant; for, as Mr. Le Gros Clark5 observes, in his very able and discriminating analysis of the semeiology of traumatic abdominal lesions, severe contusions of the belly with shock are ordinarily accompanied by tympanitis and constipation, referable to the suspension of function of the ganglionic nerves; yet the sudden apparition of this symptom, conjoined with other circumstances, as bloody stools or vomiting, may convert the presumption of a solution of continuity in the intestine very nearly into a certainty. The decomposition of the fluids in deep wounds of the loins sometimes evolved gases that permeated the connective tissues, and constituted a variety of emphysema. Effusion of the gaseous contents of the bowels attended many of the cases that have been narrated; Cases 224 and 226 may be partic- ularly referred to.6 1 FABRICIUS HrLDANUS, Opera omnia, Francofurti ad Mcenum, 1646, Cent. H, Obs. LVII; BLASIUS, Observationes med. rariores, Amstelod., 1677, Pt. I, n. 10; BECKER, Abscessus abdominis effusione curatus, in Eph. Nat. Cur., 1670, ann. I, p. 198, obs. LXXXII; LlEUTAUD, Historia anat. med., Paris, 1767, L. I, Obs. 721; THOM, Erfahrungen und Bemerkungcn aus der Arzney- Wundarzney- und Entbindungswissenschaft, Frankfurt, 1799, p. 174; Salzmann, J. R., Varia observata anatomica, Amst., 1669; Osiander, Denkwurdigkeiten fur die Heilkunde und Geburtshulfe, Gottingen, 1794, B. I. S. 101; CaVALLINI, Collezione istorica di cast chirurgici, etc., Firenze, 1762, I, p. 283; HAUTESIERCK, Recueil a"observations de midecine des hOpitaux militaires, etc., Paris, 1766 and '72, p. 329; FABRICIUS, Curatio juvenis prsegrandi musculorum abdominis infiammatione et periculosa effusione puris laborantis, Helmst., 1749; Begin, Mem. sur Vouverture des collections purulentes et autres developees dans l'abdomen, in Jour. univ. hebd. de mid. et de chir., 1830, T. I, p. 417; CliOWTHER, Case of Abscess in the Abdominal Muscles which terminated fatally, in Edinburgh Med. and Surg. Jour., April 1, 1806, Vol. II, p. 129. 2 HAMILTON (F. H.), Lectures on Gunshot Injuries of the Abdomen, in Am. Med. Times, 1864, Vol. VHI, p. 229. 'Doubtless gases are constantly found in all parts of the intestines, as 51. LONGET (Traiti de Physiologic, 1861, T. I, p. 152) and Dr. FLINT (The Physiology of Man, 18(i7, Part II, p. 379) agree; but, under Dormal conditions, they abound only in the large intestine, the mephitic gases being confined to the colon by the action of the ileo-caecal valve. In vivisections, and in opening the abdomen in animals just killed, far less distension of the small intestines is observed than in dissections made some hours after death. 4 JOBERT (DE Lamballe), Traiti thiortque et pratique des maladies chirurgicales du canal intestinal, 1829, T. I, p. 60. 6 CLARK (F. Le G.), Lectures on the Principles of Surgical Diagnosis, p. 2C8. 'Consult CLEMENT (De I'ipanchement d'un liquide ou d'un gaz comme accid. des plaies de l'abdomen, Paris, 1839); Blaxdin (Diversx inabdomine effusiones, Paris. 1827,1; Guyon (Epanchements dans l'abdomen, en Diet, encyc. des sci. mid., 1864, T. I, p. 167); Rokitaxsky (Lehrbuchder Patholog- ischen Anatomic Wien, 18:6, B. Ill, S. 146). SKCT. HI.] TRAUMATIC PERITONITIS. 199 Traumatic Peritonitis.—A most frequent and .most fatal complication, common to penetrating wounds and ruptures without external lesions, and, in a less degree, to parietal wounds, is inflammation of the peritoneum. "You perceive," said John Bell, in the third of his incomparable Discourses, "you perceive that a lecture on wounds of the abdomen must be a lecture on inflammation of that cavity, and of the various ways in which it is produced." And here it may be remarked that, in awarding the credit due this brilliant man for his account of peritonitis, it must be remembered that this affection was not previously distinctly recognized,1 and that the merit of distinguishing it from visceral inflammations has been claimed for the immortal Bichat, who wrote six years subsequently. It is probable that traumatic peritonitis differs from what is termed the idiopathic form mainly in a less liability to become diffused. While fully recognizing the dangers of spreading inflammation from mechanical violence to the peritoneum, it must be remem- bered that a limitation of the inflammation by salutary adhesions more commonly ensues. It seems to be well established that in more than half of the fatal cases of ovariotomy, no signs of peritoneal inflammation are discovered after death.2 Effusions are the most com- mon cause of general traumatic peritonitis; yet, as has been exemplified, this is not the necessary result of effusions of blood and pus, while, in rare instances, even the more irritating extravasations of faeces, bile, and urine may cause only circumscribed peritonitis. Shot wounds implicating the small intestines almost always cause fascal effusion3 and con- sequent acute peritonitis, while in similar lesions of the colon these complications are often avoided. Baudens and M. Legouest state that the hyperacute generalized peritonitis resulting from this cause is generally fatal within twenty-four hours. The patients of this group observed during the War often lived until the second or third day, and thirty- six and forty-eight hours would be near the average limit.4 The pathogeny of peritonitis is strictly analogous to that of pleuritis and of pericarditis (Niemeyer); there is hypersemia, then a loss of epithelium, and a migration of colorless blood-corpuscles, leading to new formation of young connective tissue in the membrane, which causes a velvety appearance; then the surface is covered with fibrinous exudation containing young cells in variable number; then follow sero-fibrinous'exudations in great variety. Traumatic peritonitis usually begins with severe pain at the seat of injury, rapidly extending over the entire abdomen. This is especially observable if there is effusion. If 11 speak advisedly. Tonnele (Arch. gin. de mid., T. XII, p. 4G3) has adduced some observations of HlTFOCUATES referable to puerperal and chronic peritonitis; Mokoa<":xi, in his thirty-eighth epistle, describes some of the anatomical lesions of peritonitis; and VOGEL, in 1764, and Cullen, in 1782, gave a place in nosology to peritonitis; but it is plain that the disease was not understood at the latter date, for Cullen wjote (First Series of the Practice of Physic, Chap. VI11, § 384): " I have given a place in our Nosology to the Peritonitis. * * * It is not, however, proposed to treat of them here; because it is difficult to say by what symptoms they are always to be known." CllOMEL (Diet, de Med.; 1841, T. XXIII, p. 559) ascribes to BlCHAT the credit of describing peritonitis as a distinct affection from enteritis and other visceral phlegmasia, in the same sense that pleuritis is distinct from pneumonia. But the Anatomie ginerale was not published until 1801, and JOHN Bell's Discourses were printed in 1793-5. JOHN Hunter doubtless appreciated the subject aright; yet, in his treatise, he dwelt principally on the reparative adhesive inflammation, and alluded only once and briefly (op. cit, 1794, p. 545) to diffuse peritonitis as a consequence of effusions: " Universal inflammation of the peritonaeum will take place, attended with great pain, tension, and death." [Since writing the above, I have recalled two other passages in the first part of HUNTERS work (On the Blood, Inflammation, and Gunshot Wounds, 1794, pp. 244-24C), too long for quotation, but affording incontestable proof of Hunter's correct appre- ciation of this subject. It is not improbable that JOHN BELL derived his view from his illustrious cotemporary—his publication dating 1793-5.] 2Of 51 deaths from ovariotomy, reported by Dr. Peaslee (Ovarian Tumors, 1872, p. 348), 12 resulted from peritonitis, or 23 per cent. Of 150 deaths from the same operation, collected by Dr. J. Clay (Appendix to Kiwiscii's Lectures, p. CXXXIII), 64, or 42.6 per cent., were from peritonitis. Of 128 deaths in Mr. Wells's table (Diseases of the Ovaries, 1873, pp. 402-428), 50, or 39 per cent. In 49 deaths recorded by Dr. Atlee (Gen. and Dif. Diag. of Ovarian Tumors, 1873). the cause of death is not uniformly specified; the fatal result is ascribed to peritonitis in only eight instances. 3Socix (Kriegschirurgische Erfahrungen, 1872, p. 94) remarks: "Die meisten Schussverletzungen des Darmes fuhren zum Austritt von Koth- massen in die Bauchhohle und zu rasch todtlicher Peritonitis." 4 I cannot resist the conclusion that our cases survived rather longer, on an average, than those described by the French authors, nor the impression that this postponement of the fatal issue was due to abstention from the blood-letting, deemed essential in such cases by our colleagues in France. On the ordinary duration of traumatic peritonitis, I may quote some well-considered remarks of Dr. PEASLEE: "Acute peritonitis proves fatal in twelve to twenty-four hours, and on to the eighth day; nearly one-fourth of the whole number dying on the third day alone, and nearly two-thirds of the whole within the first seventy-two hours. Asthonic peritonitis proves fatal from the ninth up to the twenty-first day, or even later."—Peaslee, Ooarian, Tumors, 1872, p. 351. 2(H) PENETRATING WOUNDS OF THE ABDOMEN. [CHAP. VI. the inflammation is propagated from a wounded viscus, its progress is more insidious; the pain, heretofore limited to the vicinity of the injured organ, gradually increases and extends. In all cases, there is general depression along with the pain, and subsequently fever; but the commencement is not marked by a severe chill followed by febrile reaction, as in peritonitis from infection or the rheumatic dyscrasia. The pain is the most constant and characteristic symptom; the slightest pressure increases it, so that the patient is intolerant of the weight of the bed-clothes even, and fixes the diaphragm to prevent its descending pressure in respiration, and draws up the lower extremities to relax the abdom- inal muscles, an attitude the artist has well represented in Plate IV (opp. p. 77). For a like reason, the patient speaks in a low tone, and dreads the hiccough and disposition to vomit that commonly attend this condition, or the slightest cough, or any change of posture. Tympanitis comes on early, almost immediately, if there is fsecal effusion. Its cause is not clear, but is ascribed partly to the expansion of the contained gases, through paralysis of the muscular coat, partly to their retention, rather than to the decomposition of the intestinal contents. Constipation and scantiness or retention of urine, feebleness and frequency of pulse, a rapid alteration and contraction of the countenance, are the remaining more prominent symptoms. In the earlier stages, it is asserted that auscul- tation sometimes detects a friction sound,1 and percussion is occasionally an auxiliary in diagnosis in cases of effusion. The temperature has been found generally to rise to 105° or more.a The mental faculties commonly remain unustially clear until near the close, when sometimes the mind becomes cloudy and the patient grows apathetic or delirious. At the same time, the pulse becomes very frequent and thready, the countenance is profoundly altered, the surface is bathed in a clammy sweat, and the patient soon succumbs. A few hours are sufficient for the development and catastrophe in this series of symptoms;3 but the fatal termination usually takes place from the third to the fifth day. In the rare instances in which diffuse traumatic peritonitis terminates in resolution, the disease gradually assumes a chronic form, and progresses through a slow convalescence, leaving visceral adhesions and other anatomical alterations, which cause much subsequent suffering, and admit of a great liability to relapses. Schwartz observes4 that the gravity of the symptoms of traumatic peritonitis is sufficient to mask the minor signs indicative of the lesions of particular viscera, and that a diffuse inflammation of this membrane precludes all differential diagnosis. The distinction between circumscribed peritonitis and the traumatic visceral phlegmasise with which it is commonly associated, is not less impracticable.5 To avoid iteration, the subject of the complications of abdominal injuries may here be concluded, and the treatment of traumatic peritonitis may be considered in connection with the concluding remarks on the treatment of injuries of the abdomen. 1 "Aussi le frottement peritoneal n'est pergu que dans certains cas de peritonite, et surtout de peritonite tuburculeuse."—Barth et ROGER, Traiti prat, d'auscultation, 3e 6d., 1850, p. 556. Consult DE6PRES (Mim. de la Soc. anat, Jane, 1834); CORRIGAN (On the Mechanism of Friction Sounds, in the Dublin Jour, of Med. Sci., November, 1836); BRIGHT (Med. Chir. Trans., 1835, Vol. XIX, p. 176), and DESPRES (These inaug., Paris, 1840). 'It is now a subject of investigation, whether very grave visceral traumatic lesions of the abdomen are not attended by a constant lowering of the animal temperature. Should this prove to be true, it would probably be found that in such cases peritoneal inflammation was not present. 'One or two peculiarities of the symptoms may be noted: The vomiting is commonly a regurgitation without co-operation of the diaphragm. Singultus is sometimes the earliest symptom, and may continue throughout, becoming an excruciating complication a few hours before death. The thirst is sometimes insatiable. The meteorism is so great as to force the diaphragm upward until the liver and heart ascend to the third rib, and great dyspnoea, with cyanosis, is induced. 4 Schwartz (Beitrage zur Lehre von den Schusswunden, 1854, S. 123) remarks: "As regards the progress of penetrating shot wounds of the abdomen, the symptoms of peritonitis always occupy a prominent position; so much so, that a symptomatology, indicating the simultaneous injury of single viscera, such as the liver, spleen, stomach, etc., becomes impossible." s Consult Rdjdfleisch, On the Morbid Anatomy of Serous Membranes, in A Manual of Pathological Histology, Dr. Baxter's translation, New Sydenham Society, 1872. Vol. I, p. 309; Peyre, Diss, sur la piritonite traumatique, Montpellier, 1823, These 58; MOUILL1E, Considirations gtnirales sur la piritonite traumatique, in Mem. de mid. de chir. et dephar. mil., 1860, Juillet; NUSSBAUM, Traumatische Peritonitis, in PlTHA und Billroth. SECT. III.] RELATIVE FREQUENCY. 201 Frequency of Wounds of the Abdomen.—Sender has sought to determine,1 by collecting observations from various authors, the relative liability of different regions of the body to injury from .shot wounds, and concludes that wounds of the belly ordinarily constitute about 6.6 per centum of the whole number of wounds coming under treatment. Serrier does not specify the sources whence his figures are derived, and for the safe employ- ment of the numerical method his data are inadequate. I have, therefore, computed, from the authors mentioned in note 2, the proportion of wounds of the belly to the aggregate in eighty-nine thousand seven hundred and thirty-one cases, and found the ratio to be 3.8 per cent. Table I, on page 6, sets forth the number (4,577) of abdominal injuries in one hundred and six thousand eight hundred and forty-six cases of shot wounds, comprised in the partial .field returns of the last year of the War. The ratio is 4.28 per centum. Naturally, the field returns give a larger percentage than those of fixed hospitals, because of the excessive early mortality of grave shot wounds of the belly. Again, if to the 4,821 cases of wounds of the abdominal parietes recorded in Table II, p. 8, be added the 52 injuries of viscera without external wounds, rendered in Table III, p. 26, and the 3,717 cases of penetrating wounds of the abdomen included in Table IV, further on an aggregate of 8,590 injuries of the abdomen, derived from statistical returns embracing 253,142 cases, is obtained, the ratio of injuries of the abdomen being 3.3 per centum, or about one case in twenty-nine. In considering these averages, the reader will bear in mind the restrictions in the classification of abdominal injuries observed in this Chapter, most wounds of the pelvis and all flesh wounds of the lower dorsal region being excluded. The most extended observations on the seat of injury in those slain in battle are by Generalarzt Lceffler, on the Prussians killed in action in Schleswig in 1864. Similar, though more limited observations, by Inspector General Mouat, Dr. Bertherand, Surgeon Lidell, and the editor of this work, are of importance from the great rarity of authentic comparisons of this sort.3 All the observations amount to six hundred and ninety-seven cases. Excluding seventy-three by Dr. Bertherand, in which the ratio of abdominal wounds is so large as to suggest either error in observation or some special liability to injuries of this class in Algerian warfare, the remaining six hundred and twenty-four cases present, with tolerable uniformity, a percentage of deaths from injuries of the abdomen of about ten or eleven per cent, of the aggregate killed in action. It will be observed that, so far as the fragmentary data at present attainable permit an approximative estimate, about a tenth of those slain in battle perish from injuries of the abdomen, and that from three to four per cent, of the wounded who come under treatment are wounded in the abdomen. 1 Serrier (Traiti des plaies d'armes a feu, ouvrage courronfi (mfidaille dor) par M. le Ministre de la guerre, en 1844, p. 30). From an analysis of 784 cases, subdivided into twenty-one groups, the author finds wounds of the abdomen (52) seventh in the order of frequency, and slightly less common than those of the chest (53). 2 The cases are taken from Dr. MATTHEW'S official report of the British wounded in the Crimea (op. cit, T. II, pp. 257-8-9), 10,279 cases. 368 wounds of abdomen ; from M. CllEXU's Crimean report (Camp, d" Orient, p. 627), total 34,306, abdomen 665 ; M. C'HENU'S report of the Italian War of 1859 (Camp, d'ltalie, T. U, p. 850), aggregate 17,054, abdomen 917; from M. Bertherand (Camp, de Kabylie, p. 314), total 1,422, abdomen 51; from DEMME, Italian Wax (Studien, S. 19, Oestreicher), 8,500, abdomen 515; Idem (op. cit, S. 20, Franzosen), 8,595, abdomen 595; from Inspector General Mouat'S (Army Med. Dept Rept. for 1865, Vol. VII, p. 489) report of New Zealand War, total 415, abdomen 23; from Herr LrjLFFLER, Danish War of 1864 (Generalbericht, u. s. w., S. 54), total 1,968, abdomen 103; from Dr. Stromeyer (Erfahrungen uber Schusswunden im Jahre 1866), total 1,394, abdomen 30; from statistics of the Bohemian War of 1866: Generalarzt BECK (Die Schusswunden), total 238, abdomen 6; Dr. MAAS, Kriegschirurg- ische Beitrage, 1870, total 212, abdomen 11 ; from the Franco-German War of 1870: Herr BECK (Chirurgie der Schussverletzungen, 1872, S. 519), total 4,344, abdomen 106; Professor H. FISCHER (Vor Metz, op. cit), total 875, abdomen 33; Dr. K.LKBS (Beitrage, u. s. w., 1872, S. 4), total 129 autopsies, abdomen 12. ' The figures are: Lceffler (Generalbericht, table quoted in First Surgical Volume, page 603), killed 387, struck in abdomen 44, or 11.4 per cent.; MOUAT (Army Med. Dept Rept, Vol. VII, p. 473), killed 118, abdomen wounds 11, or 9.3 per cent.; LIDELL (Circular No. 6. S. G. O., 1865, p. 39), killed 43 abdomen wounds 5, or 11.6 per cent.; Otis (First Surgical Volume, p. 60:.1), killed 76, abdomen wounds 9, or 11.8 per cent.; BERTHERAND (Camp, de Kabylie, 1854, pp. 92 and 147), killed 73, abdomen wounds 21, or 28.7 per cent. Twenty of M. BERTHERAND's cases, with a large preponder- ance of wonnds of the belly, were collected by his assistant, Dr. Bezixs. 26 202 injuries of the abdomen. [CHAP. VI. Mortality of Wounds and Injuries of the Abdomen.—Before proceeding to comment upon the comparative fatality1 of abdominal injuries, it will be proper to present, in a tabular form, the statistics of the penetrating wounds of the abdomen that have been considered in the foregoing Section : Table IV. Numerical Statement of the Cases of Penetrating Wounds of the Abdomen returned during the War. WOUNDS. Cases. Recovered. Unknown Patio of mor- tality of deter- mined cases. vit-..i. *-i • ■ i f Punctured and Incised. Without known injury to I the Viscera. |gh()t................. 'Punctured and Incised. With injury to theVTscera, ^ of known character. Shot wounds* of the Stomach. Intestines Liver---- Spleen... Pancreas. Kidney .. Blood-vessels, Omentum, and Mesentery. , Supra-renal Capsule..... With visceral injuries, of ^ which the nature and extent were not deter- , mined with exactness. J Shot. 13 19 14 79 653 173 29 5 78 54 2,599 4 7 12 60 484 108 27 4 51 47 2,226 9 12 2 19 118 62 2 1 26 7 51 3 186 187 30.7 36.8 85.7 75.9 80.3 63.5 93.1 80.0 66.2 87.0 100.0 92.2 Aggregates................................................ 3,717 3,031 444 242 87.2 Adding the aggregates in the foregoing table to those in Tables II and III, the total number of cases of injuries of this region, including flesh wounds, visceral injuries without 1 In the Crimean War, in the British army, "where penetration of the abdominal cavity by gunshot injury was considered to be beyond doubt, death was the rule, recovery the rare exception, only nine patients (including both officers and men) having survived out of one hundred and twenty where this was believed to have taken place, and even of this small number some of the cases were not unequivocal." Matthew (op cit, Vol. II, p. 328): The mortality rate then, where an approximation to accuracy obtained in the returns, was 92.5. In the French army, M. CHENU (op. cit, Camp, d' Orient, p. 197) records the results of one hundred and twenty-one penetrating shot wounds of the abdomen, of which one hundred and eleven, 91.7 per cent., resulted fatally. As regards the Italian campaign of 1859, M. Chenu in his official report (Statistique Med. Chir. de la Camp, d'ltalie. 1869, T. II, p. 489) states that "the penetrating wounds of the abdomen, very grave usually, gave a great mortality on the field, and an equally great mortality in the hospitals. Without speaking of the inflammatory complications which these injuries induced, we will say that all degrees of gravity were observed—visceral lesions, visceral protrusions, etc.—but we have found only rare and incomplete abstracts of observations transmitted to the chief medical officer." M. Chenu then presents thirty-two abstracts of cases. These brief but interesting notes record the disabilities resulting from two bayonet wounds, three cases of contusion, and twenty-seven penetrating shot wounds. Among the latter are included one instance of alleged lesion of the stomach, two of the liver, one instance in which a ball was voided at stool, four cases of wounds of the bladder, four cases of faecal fistula, in one of which Dupuytren's operation for abnormal anus was unsuccessfully practised. M. Chenu then tabulates (p. 493) two hundred and fifty-seven cases of penetrating wounds of the abdomen, of which two hundred and forty-six were cases of shot wounds, with one hundred and sixty-three deaths, or a death-rate of 66.2 per cent. Of the twenty-two classes into which M. CHENU distributes the injuries he discusses, the fifth is assigned to injuries of the abdomen. The sixth to the tenth classes include injuries of the sacro-lumbar, iliac and gluteal, inguinal, genital, and anal regions. In these five classes instances of wounds involving the abdominal cavity are evidently included, but to what extent is not apparent. DEMME (Militar-chir. Studien, 1861, B. II, S. 121) professes to give an analysis of two hundred and fifty-nine shot wounds of the abdomen, observed in the North Italian hospitals in 1859. Of these sixty-four were penetrating wounds, and forty terminated fatally, a mortality rate of 62.5 per cent. Of these, thirty-seven, with nineteen deaths, a death-rate of 51.3, were unattended by visceral injury. Of twenty-seven cases complicated by visceral lesions, twenty-one were fatal, or 77.7 per cent. The precision of these summaries would be admirable, if they inspired confidence. * Some of the cases in this category are duplicated, triplicated, or oftener repeated, as involving several viscera. To avoid the error in the aggregate which would otherwise result, I have subtracted equivalent numbers of recoveries and deaths from the undetermined visceral injuries. The 1.072 complications of wounds of the stomach, liver, etc., occurred in 928 individuals; the differences (144 cases, 117 deaths, 23 recoveries, 4 cases unaccounted for) are deducted from the columns opposite visceral injuries not determined with exactness. SECT. III.] MORTALITY. 203 external lesions, and penetrating wounds, was eight thousand five hundred and ninety.1 In sixteen hundred and ninety of these the result was not ascertained. Of the remaining sixty-nine hundred, thirty-three hundred and twenty-seven2 died, or 48.21 per cent.; or, roughly, about half of all the cases reported as shot wounds of the belly, and nine in ten of those reported as penetrating wounds, proved fatal. The published statistical informa- tion regarding the mortality of penetrating shot wounds of the belly in other wars is meagre. The returns having pretension to precision are collated in the following table: Table V. Showing the Number of Penetrating Shot Wounds of the Abdomen on the Occasions named, and from the A uthorities quoted, with the Patio of the Mortality. ACTION, &c. Peninsular War (Alcock).................................................. Revolution in Paris in 1830 (Meniere)....................................... Revolution in Paris in 1848 (Baudens 6, Jobert 11, Huguier 4, Roux 4, Escalier 2) New Zealand War (Mouat)................................................ French iu Algeria (Bertherand, S6dillot)..................................... French in Algeria in 1854 (Bertherand)...................................... British in India (Balfour).................................................. French in Crimea (Chenu)................................................. British in Crimea (Matthew)............................................... French in Italy in 1859 (Chenu)............................................ Austrians and Italians, after Solferino (Demme).............................. Prussians in Danish War of 1854 (Lceffler).................................. Danes in Danish War of 1864 (Lceffler)..................................... Prussians in Six-Weeks War (Maas)........................................ Prussians at Langensalza (Stromeyer)....................................... Prussians at Landeshut (Biefel)............................................. Germans in Franco-Prussian War (Billroth 8, Beck 73)....................... Germans near Metz (Fischer 5)............................................. Germans at siege of Paris (Kirchner 32, Mosetig 4)................ .......... Germans at Massy (Rupprecht 3), at Worth (Christian 16).................... Germans in Reserve Hospital at Carlsruhe (Socin 7), Dusseldorf (Graf 4)....... French at Sedan (Despr&s 6, MacCormac 7), at Strasburg (Tachard 10, Poncet 15) French at siege of Paris (Boinet 12, Berenger-Feraud 6, Mundy 4)............. Aggregates....................................................... 19 21 27 15 32 7 38 121 120 246 64 103 89 10 17 5 81 5 36 19 11 38 22 1,146 18 14 21 14 28 7 32 111 111 163 40 59 57 4 9 1 61 3 34 16 7 36 15 861 Ratio of Mortality. 94.7 66.6 77.7 93.3 87.5 100.0 84.2 91.7 92.5 66.2 62.5 57.2 64.0 40.0 52.9 20.0 75. 3 60.0 94.4 84.2 63.6 94.7 68.1 75.1 1 The figures for the separate categories are: Of thirty-three hundred and seventy-three determined flesh wounds of the abdomen, 266 deaths, or 7.8 per cent.; of fifty-two cases of external wounds without visceral injuries, 30 deaths, or 57.6 per cent.; of thirty-four hundred and seventy-five determined penetrating wounds of the abdomen, 3,031 deaths, or 87.2 per cent. 2 The writings of Alcock, Meniere, Baudens, Mouat, Bertherand, Sedillot, Chenu, Matthew, Demme, Lceffler, Maas, Stromeyer, BlEFEL, BILLROTH, Beck, FISCHER, SOCIN, MacCormac, from which many of the above statistical facts are derived, have been already cited. The later statistics are from the following writers: KIRCHNER (C.) (JErztlicher Bericht uber das Koniglich-Preussische Feldlazareth im Palast zu Versailles wdhrend der Belagerung von Paris vom 19 Septembre, 1870, bis 5 Mdrz, 1871, Erlangen, 1872) ; MOSETIG (V.) (Erinnerungen aus dem Deutsch-Fran- zosischen Kriege, in Der Militdrarzt, 1872, Nos. 1, 5, 7, 10, 12, 17, 20); RUPPRECHT (Militdrdrztl. Erf. wdhrend des Deutsch-Franzosischen Krieges im Jahre 1870-71, Wttrzburg, 1871, S. 59); CHRISTIAN (J.) (Relation sur les plaies de guerre observies d, I'ambulance de Bitschwiller, in Gazette mid. de Strasbourg, 1872, No. 22); GRAF (E.) (Die K'onigl. Reservelazarethe zu Dusseldorf wdhrend des Krieges, 1870-71, Elberfeld, 1872); DESPRES (A.) (Rapport sur les travaux de la 7" ambulance a I'armie du Rhin et I'armie de la Loire, Paris, 1871, pp. 46, 56); TACHARD (E) (Reflexions pour servir a I'histoire de la chirurgie en campagne, in Gaz. des Hopitaux, 1872, Nos. 58, 60, 67); PONCET (F.) (Contribution a la relation mid. de la guerre de 1870-71, In Montpellier Medical, Dec, 1871, p. 537); BOINET (Service chirurgical, Bulletin de la Sociite francaise de secours aux blessis militaires des armies de terre et de mer, No. 14); BERENGER-FERAUD (Des blessures de I'abdomcn observies dans la 2me division des blessis au Val-de-Grdce pendant le siige de Paris, in Montpellier Medical, Novembre, 1871); MUNDY (Service medico-chirurgical de I'ambulance du Corps legislatif. Etat et mouvement des militaires blessis traitis dans cette ambulance du 19 Septembre, 1870, au 31 Janvier, 1871, in Gaz. des Hop., 1871, No. 149). 204 INJURIES OF THE ABDOMEN. [CHAP. VI. It is certain that the aggregates in this table with small mortality rates, as those reported by Drs. Billroth, Biefel, and Maas, represent insulated groups rather than fair averages, and consequently reduce the mortality ratio unduly, and it is probable that the returns from the Italian War are too incomplete to give adequate expression to the deadliness of shot wounds of the belly.1 Moreover, several of the authorities quoted include in their returns wounds of the pelvis, which, as will appear in the next Chapter, are far less fatal than wounds of the abdomen. The comparatively small category of cases of recovery after indubitable shot pene- tration of the abdomen may be arranged in three divisions: The first, and largest group, would include the cases of perforation of the large intestine in parts uncovered by peritoneum, followed by recovery with or without abnormal anus. The second, a group so small that the absolutely authenticated examples can be counted on the fingers, comprises the instances of wounds of the solid or membranous viscera, with extravasation of their contents within the peritoneal cavity. In the third division would be placed the cases of recovery after undoubted penetration or perforation of the peritoneal cavity without visceral injury, or, as it would be safer to say, with very slight visceral injury. On rigorous examination, these also would probably be found few in number. To the instances adduced in an early portion of this Section (pp. 31-40) should be added the following observation by Dr. J. J. B. Wright:2 Case 1*.—"Private Edward Pfau, of the permanent party of the garrison at Carlisle Barracks, was wounded in a skirmish with the rebel pickets, near Hagerstown, Maryland, on the 6th day of July, 1S34. He was transported on a litter to the hospital of the post on the 11th, five days after the infliction of the wound. A minie ball had penetrated the back three inches to the right of the spinal column, three-fourths of an inch above the crest of the ilium, and two inches below the margin of the false ribs; its course was perpendicular to the line of the body, and it was extracted from beneath the integuments in front of the abdomen, distant two and a half inches from the' umbilicus, in a line with the superior posterior spinous process of the ilium. By means of opiates and the use of nutritious food, leaving but small material for the formation of fseces, his bowels were kept in a state of perfect quietude until July 20th, fourteen days after the reception of the wound, when a large, healthy faecal discharge occurred, without any admixture of blood or pus. On July 25th his bowels were again moved, and subsequently, during his convalescence, he had healthy alvine dejections as often as every other day. Purulent matter of offensive smell and ichorous character was discharged from both orifices up to the 18th of August, when both healed kindly. Nothing occurred during the history of the case to interrupt the progress of cure, except the supervention of an abscess in the walls of the abdomen immediately below the site of the wound, caused by the extraction of the bullet. Pfau is now entirely convalescent, and will be returned to duty in a few days. There can be no doubt that in the above case a minie ball of large size passed directty from rear to front through the belly, almost through the centre of the intestines as they lie coiled up in the abdomen. It is inconceivable how the bowels could have escaped rupture in several of their folds, and yet the case presented no evidence of their integrity of structure having been impaired, no fsecal matter being discharged from either orifice, and no pus per anum. It is very certain that the ball passed in a direct line from its place of entrance to its lodgement in front, and was not deflected. Of this fact I fully satisfied myself by a careful examination when the case was first presented to my notice." This instance, with those previously cited, proves that Malgaigne's denial of pene- trating wounds of the abdomen without visceral injury can only be accepted in a restricted sense. The almost marvellous examples of impalement, of which some of the most curious have been recorded by Dr. J. B. S. Jackson,3 demonstrate the slight degree of visceral injury that may sometimes attend penetrating wounds of the abdominal cavity. 'The reader can compare with the remark ascribed by Dr. CHISOLM to Sir Charles Bell, "that, although abdominal wounds bore a fair relative proportion to other wounds immediately after a battle, a few days sufficed to remove them; so that, by the end of the first week, there was scarcely one to be seen," the following observations of Herr LCEFFLER (Generalbericht u. s. w., 1867, S. 49) after the Schleswig-Holstein "War: "On the field of battle the chest wounds were the most fatal; and also iu those patients that reach the hospital, the wounds of the chest are more fatal than the wounds of the head. The wounds of the abdomen and pelvis, as regards the immediate fatality, give way to the above two classes, but surpass them already in the first two days. They are, of all shot injuries, the deadliest; fortunately they are not the most frequent." »This abstract is taken from the monthly report of Carlisle Barracks for August, 1864, from Brevet Brigadier-General J. J. B. WRIGHT, Surgeon V. S. A. It is remarkable that the same graceful pen that long ago indited the report, well known in surgical annals, of a recovery after shot perforation of the chest (the case of General Shields, related in a letter from Dr. Wmght, printed in Hamilton's Practical Treatise on Military Surgery, 1861, p. 157), should also describe one of the very few satisfactory examples of shot perforation of the belly without visceral injury. 3 JACKSOX (J. B. S.), Boston Med. and Surg. Journal, 1857, Vol. LV, p. 387. See also: SARGENT (J.) (Am. Jour. Med. Sci., 1853, Vol. XXV, p. 385); KEMPEK (C. R.) (Stethoscope, 1854, Vol. IV, p. 9); HOME (Z.) (Boston Med. and Surg. Jour., 1840, Vol. XXII, p. 69); Bailey (T. P.) (Charleston Med. Jour, and Review, 1854, Vol. IX, p. 604); DlX (W.) (London Med. Repository. 1826, Vol. Ill, p. 347). Med and SiirgEist of the Wax of tlie Rebellion Parti Vol.1. Opposite page -O.' Ward phot J.Bien. l\th PLATE XI. RUPTURE OF ILEUM BY THE KICK OF A MULE. No. 6269. SURGICAL SECTION * J .■:■■■ ■'.&... .*'* #*:' iu pi ATE XI. RUP1 -):" KICK OF A '* N:. 6269 SECT. m.| CONCLUDING OBSERVATIONS. 205 Without a rigid analysis, of which the outlines have been thus indicated, the statistics of injuries of the abdomen are liable to be very misleading; and, as deductions from these statistics directly influence practice,1 it is of the utmost importance to discriminate the different forms of injury in estimating the mortality of wounds of the belly. Concluding Observations—In treating, in the Second Section, of ruptures of tin- intestine, allusion was inadvertently omitted to an interesting observation by Dr. Chisolm,2 of secondary perforation of the descending colon following a contusion by a spent shell. In rupture of the small intestine, intra-peritoneal extravasation appears to be inevitable. An account of another interesting example of an injury of this description, with the pathological specimen, has been contributed to the Museum by Dr. Hartigan:3 Case A\—Dr. J. F. Hartigan, assistant coroner, presented to the Army Medical Museum the specimen of ruptured ileum, represented in Plate XI opposite, with the following notes of the case and autopsy: "William S------, a coal-barge hand, aged 16 years, was kicked in the abdomen by a mule on June 2'U\, at eight in the morning, and died twenty hours afterwards, at four o'clock a. m. of June -J 1. 1S73. The attendants stated that the lad suffered extreme pain, with nausea and vomiting immediately after the injury, and that Dr. Wise, from the Navy Yard, came and prescribed for him. At the autopsy, ten hours after death, there was found general redness of the peritoneum, the omentum and mesentery being deeply injected, and the coils of the small intestines and of the colon being hyperaemic. There was copious fsecal extravasation, but no effusion of blood. There were many lumbrieoid worms lying free in the abdominal cavity. There was tympanitis, with extensive distention; before the cadaver could be sewn up it was necessary to puncture the intestines. The seat of external injury was in the right iliac region, and was indicated by a slight contusion, with slight ecchymosis in the abdominal muscles. Two preparations were obtained, one of contusion and partial rupture of the transverse colon [6270, Sect, I, A. M. M.], and one of laceration of the ileum [G2(39. Sect. I. A. M. M.]." Dr. John C. Wise, of the Government steamer Tallapoosa, politely furnished the following clinical notes of the case: "I was requested this afternoon (June 23,1873) to visit a lad about 14 years of age, frail constitution, but in previous good health—an employe on a canal barge—who had been kicked, about eight o'clock a. m., by a mule in the right groin. I saw him about 6 o'clock P. M. Inspection revealed the ecchymosis made by the toe and points of the iron shoe; diffused redness and pain extending over the entire abdomen; the pulse was quick and wiry, (?) that on face of inflammation below the diaphragm; the skin very dry; the respiration costal, short, and frequent, deeper inspiration being exceedingly painful; there was nausea and slight vomiting; the lips were very dry and everted, showing the teeth; the eye was brilliant and the countenance anxious; the intellect was clear, questions being intelligently answered. Suffering was so intense as to cause the little sufferer to cry aloud, complaining of tightness of the abdomen and great thirst; the patient lay upon his back with the thighs in strong flexion. I ordered stupes to cover the abdomen, soaked in camphorated soap liniment, tincture of arnica, and laudanum, an ounce of each, and to take a pill every hour containing a grain each of calomel and opium; bits of ice were given to allay thirst. This treatment was continued till eight o'clock with no signs of improvement, and, a little later, symptoms of collapse were manifest. The pulse was almost imperceptible at the wrist, and had lost its wiry character. The hands, feet, and surface generally was cold; the respiration frequent, the countenance pinched, and the mind wandering; tympanitic sounds over the abdomen, but no distention of the bladder. Carbonate of ammonia and brandy were now resorted to, but in vain; the symptoms advanced, and the patient died twenty hours after the occurrence." In view of the invariable and, it would appear, necessary fatality of such cases, the question arises of the propriety of abdominal incision for the removal of the extravasated 1 The advocates of the do-nothing system base their arguments mainly on the number of recoveries from penetrating wounds of the abdomen that take place under what they term "the general plan of treatment," and as illustrations they commonly adduce instances belonging to the first or third of the divisions indicated on the preceding page, instances that, for the most part, are to be regarded as examples of wounds of the abdominal viscera in parts without tbe peritoneal cavity, or else as penetrations without visceral injury. But it is to the last degree illogical to adduce such instances as indicating the course of treatment appropriate to wounds of the viscera within the peritoneal cavity. In the preceding pages the editor has sought to analyze the different varieties of this last group and to estimate the comparative mortality of wounds of the liver, spleen, and kidneys, and of the alimentary canal, and it is believed that those who will take the trouble to examine the evidence will be unable to resist the conclusions that, while recoveries from wounds of the liver are more frequent than was formerly believed, and wounds of the spleen and kidney occasionally, and those of the colon frequently, terminate favorably, the rarity of recoveries from wounds of the stomach and small intestine treated without operative interference is extreme. 2Chisolm (J. J.) (A Manual of Military Surgery. 1864, p. 354): "Sergeant E. L. Davis, Co. C, 7th battalion S. C. V., was injured on the 10th of July, during the bombardment of Battery Wagner, by the explosion of a shell. Two days afterward, when he entered the general hospital, he complained of pain in tbe left lumbar region, where he had been struck. There was no ecchymosis present, although there existed some tumefaction— not, however, sufficient to excite any apprehension. There was slight abrasion about his face and right side. Six days after the injury, he having suffered much with pain, fluctuation was detected in the lumbar region. A puncture wais made, which discharged a large quantity of pus, and, with it, faecal matter. Some of this escaping into the cellular tissue of the loin and buttock induced a phlegmonous condition, with rapid sloughing of cellular tissue. Although free incisions were made, the sloughing could not be checked. It-extended in every direction, until one vast sloughing cavity occupied half the trunk, from the ribs to the trochanter, and from the vertebral column to the pubis. An autopsy revealed a double rupture in the descending ColCn, with opening parallel to the circular fibres, which had permitted the free escape of fascal matter into the cellular tissue, between the bowel and quadrat us lumborum muscle. Collecting in quantity, it had separated and disorganized the tissues as low as Poupart s ligament, forming a large sac distinct from the peritoneal cavity, and separated from it only by the peritoneum. In this the iliac artery was lying bare. Had the faeces not escaped in the loin it would have dissected to the groin, as the faecal cavity was bounded below by Poupart's ligament." 3 Since Case 119, illustrated by Plate I, was printed on page 23, Dr. Hartigan has published it in abstract, with comments, in the Medical and Surgical Reporter, 167:1, Vol. XXVIII, p. ill. 206 INJUEIES OF THE ABDOMEN. [CHAP. vi. matter, and the practice of enteroraphy. The tendency of progressive surgery, as indicated bv the undertakings for the removal of abdominal tumors and of intestinal obstructions,1 as well as for the extraction of foreign bodies and for the treatment of wounded intestines, is in this direction, and it appears probable that laparotomy, if that may be the correct general term for abdominal sections, will henceforward be employed with increasing frequency, not only in the treatment of morbid growths, but in obstructions and wounds of the abdominal organs. Diagnosis.—The mass of evidence that has been reviewed contains little regarding the symptomatology of injuries of the abdomen, and contributes only indirect aid in the problems of differential diagnosis.2 The numerous examples of unsuspected lesions revealed after death testify indirectly to the truth of the maxim that there is no absolute distinctive sign of wounds of either of the abdominal viscera, save the escape externally of its secretion or its contents. The observations indicate the uncertainty of haematemesis and bloody stools as signs of wounds of the alimentary canal, and bring prominently in view the importance of sudden meteorism as a symptom of perforation of the bowels.3 Abundant evidence is produced to refute the doctrine, still taught in most text-books, that general peritonitis is an almost uniform result of penetrating wounds of the abdomen; the absence of this complication having been verified by numerous autopsies. On the other hand, no information is furnished on the important question of the state of the animal temperature in grave abdominal injuries,4 and there is a remarkable absence of any comments on the obscure subject of shock. As a general rule, shock is more profound and persistent in grave wounds of the abdomen than in wounds of any other region; yet the diagnostic value of this symptom is diminished by the fact that it often supervenes after simple contusions without organic lesion, and its intensity or continuance even is not a standard by which the nature of the injury can be determined. It is of the utmost importance to discriminate the collapse due to syncope from internal bleeding from true shock. Vomiting and retention of urine are common but not constant accompaniments of injuries of the abdomen, and by themselves have little significance. Persistent localized pain is very suggestive; but grave visceral injury is sometimes attended by comparatively 1 Consult on this interesting subject an able article by Dr. Samuel Whitall (Gastrotomy for Intestinal Occlusion, in the New York Medical Journal, 1873, Vol. XVIII. p. 113) ; also Dr. Stephen Roger's elaborate paper on Intussusception (Trans. New York State Med. Soc, 1872). The erudite Hevix, in his Recherches historiques sur la gastrotomie, ou Vouverture du bas-ventre, dans le cas de Volvulus, ou de I'intussusception d'un intestin, in Mim de I'Acad. Roy. de Cliir., 1768, T. IV, p. 201, adduces many instances and arguments from the older writers in favor of laying open the abdominal cavity for the relief of strangulation, intussusception, and obstruction of the bowels from various causes. The Academy, it is understood. compelled Hevix to modify, in his published essay, the favorable conclusions which he deduced from the facts and arguments he collected; so that while his memoir commences with the observation that the ancients had proposed many very useful operations that the moderns had neglected or abandoned altogether, at the end he is reserved in his advocacy of abdominal sections. One of the earliest distinct propositions to lay open the abdomen was made by Baubette, in his Chirurgia sive Heelkonst na de hedendaagze practyk beschreeven, Amsterdam, 1657. The Latin version, in the edition of 1693, is as follows: "Annon etiam praestaret, facta dissection'e musculorum et peritonaei digitis susceptum intestinum extrahere, quam certae morti aegrotantem committere?" Compare BOXETUS (Polyalthes sive Thesaurus medico-pradieus, Genevae, 1692, Lib. IV, Cap. 26, § 58, p. 510, and also in the Sepulchretum, Genevas, 1700, Lib. Ill, Sec. XIV, T. II, p. 228), a dissertation by VELSE (De mutuo intestinorum ingressu, Lugd. Bat., 1742), and PLATER (F.) (Praxeos mediae, Basil, 1736, T. II, Cap. XIII). 2Socix (Kriegschir. Erf., 1872, S. 89) observes that "the injuries of the abdomen and its contents are of a peculiar diagnostic interest, and severely test the surgeon's sagacity. But, with the keenest diagnosis, the treatment does not gain correspondingly in precision. Frequently we must be satL-fied with very general therapeutic indications, and much must be left to kind nature, who sometimes proves herself truly amiable, an indulgent helpmate to the surgeon." 3 Tympanitis may also arise without aDy physical lesions as a consequence of simple contusion, the concussion of the ganglionic nerve-centres leading to temporary paralysis of the muscular coat of the bowel. 4Clakk (F. LeO.) (Lectures on the Principles of Surgical Diagnosis, London, 1870, p 288) observes: "As regards temperature. I cannot say I have been fortunate enough to obtain any results which satisfy me of its value in determining the presence of visceral lesion, and still less the locality of that lesion. Of the fact that the temperature is depressed in these injuries, as well as in contusion, there can be no doubt; but I have not succeeded in verifying, from my own observation, the remarks of the writer of an article on 'Animal Heat in Surgical Diseases,' in the Nouveau Dictionnaire de Medecine et de Chirurgie pratique, viz : that the depression of temperature is in proportion to the proximity of the lesion, be it from internal strangulation or other cause, to the stomach. Certainly the intensity of the shock seems to bear a direct ratio to this relation, and, inasmuch as depressed vitality is accompanied by a proportionate degradation of temperature, in this way the observation referred to may be explained." SECT. III.] CONCLUDING 0BSEKVATIOJNS. 207 little pain. In reviewing the injuries of the several viscera, the chief diagnostic signs of injury in each, so far as they are known, have been alluded to; but it is obvious that this is a field in which there is still much to be learned. Treatment.—In the general management of wounds of the abdomen, venesection was abandoned, as far as can be learned, in the armies on either side, even more completely than in the treatment of wounds of the chest.1 There were those who still placed con- fidence in the controlling power of mercurial preparations over inflammation, and the administration of calomel formed part of the treatment in many cases. Surgeon E. Swift observed several apparently desperate cases of traumatic peritonitis, which terminated favorably under the method commended by the elder Larrey, of inunction with gray ointment after vesication of the entire surface. But, in all cases, opium was the main resource. The facility with which its salts could be exhibited hypodermically was grate- fully appreciated in the numerous cases of this class in which the stomach rejected all medicine. Suppositories also afforded an excellent means of administering opium in < injuries of the abdomen.2 Apart from the general advantages of this invaluable remedy, in cases of wounds of the abdominal viscera, by arresting peristaltic action, it aided in securing the rest of the wounded part, the first condition in the reparation of all traumatic lesions. Diffuse inflammation once established, however, neither this nor any other remedy was of avail,3 an experience repeated in the recent Franco-German War.4aDd5- But traumatic peritonitis is often circumscribed, and when localized in immediate proximity with the wound or ball-track, it is unattended by general reaction, and the local reaction may be protective only, not transgressing the plastic stage, and serving simply to establish adhesions which may guard against effusions into the peritoneal cavity. Even when less strictly circumscribed, when effusion has taken place, local traumatic peritonitis may still exert a beneficent protective influence, by encysting the foreign matters extravasated into the peritoneal cavity by plastic exudations. To restrain inflammation within these salutary limits, absolute rest is the most important indication, the patient being suffered neither to be moved nor to move himself; and hence the best contemporaneous surgeons strongly insist that men with penetrating wounds of the abdomen shall be permanently treated as near as practicable to the spot where they fall. Every rod they are transported 'Only four instances of blood-letting were observed in the returns, viz: Two cases iu which venesection was practised: Case 234, p. 76, and CA6E 41)7, p. 155; and two cases of cupping: Case 'XW, p. 138, and Case 367, p. 131. The old views on this subject are well known; they are expressed by Thompson (J.) (Report of Qbs., etc., after Waterloo, 1816, p. 106): "It cannot be too frequently repeated that copious blood-letting and the use of the antiphlogistic regimen, in all its parts, are the best auxiliaries which the surgeon can employ in the care of all injuries of the viscera contained within the cavity of the abdomen." But forty years later, in the Crimean War, it was discerned by the British surgeons, at least, that the am iphlogistic treatment formerly in vogue was no longer applicable. Thus, JIattiiew (Med. and Surg. Hist, etc., p. 329) observed: "In none of these eases does general blood-letting appear to have been indicated, and it was employed in very few instances." After the Austro-Prussian War of 1866, Is'kudOrfeh wrote (Handbuch der Kriegschirurgie, 1867, S. 731): "As regards blood-letting, the majority of the later French surgeons, as well as some of the Germans, who cannot shake off the fetters of the older French tradition, still cling to venesection; but the majority of German and American and English surgeons, formerly staunch supporters of venesection, have now abandoned it." 2 There is hazard in exorbitant doses of opium, and an instance was noted, in the reports, in which the patient apparently perished immediately from narcosis, rather than from the direct effects of the wound; but practitioners of ordinary experience and discretion will seldom err in this direction. 'Fischer (H.) (Kriegschir. Erf., Vor Metz, 1872, S. 131) remarks: "Gegen die diffuse Peritonitis kampften wir mit Opium und Mercur vergeblicb." (Against diffuse peritonitis we vainly battled with opium and mercury.) 4 In the Franco-German War of 1870, according to Professor SOCIN (Kriegschirurgische Erfahrungen, Leipzig, 1872, S. 92), "the treatment con- sisted of topical applications of ice, injections of morphia, with opium internally; with no solid food whatever." Professer H. Fischer, of Breslau (Kriegschirurgische Erfahrungen, Erlangen, 1872, S. 131), states that: "The treatment of shot wounds of the abdomen was solely symptomatic. Absolute rest, with sparing liquid diet, and opium internally, until the inflammation subsided." 5GORDON (C A.) (Lessons in Hygiene and Surgery from the Franco-Prussian War, London, 1873, p. 140) reports that "the statistics of tho Franco-Prussian War support the generally fatal character of gunshot wounds penetrating the cavity of the abdomen." But his acquaintance with such statistics appears to be limited, extending to only twenty-nine cases, gleaned from SI. Despres and Mr. MacCormac. The interpretations of the Crimean and American statistics by this writer being in several instances obviously erroneous, his conclusions respecting the Franco-German experience maybe received with distrust. The most important lesson conveyed by his work is the danger of generalizing from insufficient data. LOSSKN (H.) (Kriegschir. Erf. aus den Baraclcen-Lazarethen zu Mannheim, Heidelberg und Carlsruhe, 1870-71, in Deutsche Zeitschrift fur Chirurgie, B. I) contends that, "as long as the entire material of shot wounds, including killed and wounded, is not taken in consideration, apparently inexplicable differences of percentages will bo the result of statistics." 208 INJURIES OF THE ABDOMEN. [CHAP. VI. adds to the formidable peril they have already to encounter.1 Food and drink, save a little ice or cold water, are to be absolutely interdicted at first, and then the blandest nutriment, such as milk, may be sparingly allowed. The reports indicate that this rigid regimen was not always enforced, and that the absolute rule forbidding the early employ- ment of purgatives was sometimes neglected, and that these errors had disastrous conse- quences. The position of the patient is of importance. If there is a single wound, the patient should lie in that posture that will place the orifice downward and favor the approximation and adhesion of the viscera to its edges. - If the abdomen is perforated, it will usually be best to make the exit orifice dependent. When there is evidence that a viscus is wounded, the parietal wound must always be left open, except in cases in which enteroraphy is practised. No advantageous effects were obtained by local depletion2 or by emollient fomentations at an early period; but extended and protracted applications of ice over the entire abdomen were believed, in several instances, to have exerted a decided influence in moderating inflammation. The majority of surgeons esteem moderate com- pression by a circular bandage useful. Dr. Neudorfer regards the gypsum bandage as peculiarly adapted to this class of injuries. If the stomach or small intestines are divided, there is no reasonable presumption that faecal extravasation and consequent hyperacute generalized peritonitis can be averted unless by operative interference. Under these circumstances, therefore, the surgeon should enlarge the wound, carefully cleanse the cavity, and unite the solutions of continuity in the wounded viscus by sutures.3 1 Stabsarzt Baiir (Deutsche Klinik, 1871, B. XXIII, S. 406) remarks: "Days at least are required to cause death from peritonitis alone; faecal matter passed into the peritoneum docs its work quicker. Were the wound in the wall of the abdomen sufficiently large to allow the contents of the peritoneal sac to escape freely, it would be comparatively easy to cleanse the cavity and to keep it clean. The patient might assume the knee-elbow position to empty the peritoneal sac, while the viscera are to be kept back by a gauze bandage and the wound of the gut is to be closed by suture. In future those wounds must be cared for on the battle-field, and the surgeon must come prepared to lay open and enlarge the wound of the abdominal wall." 2 At the beginning of this Chapter (p. 2) it was observed that the experience of the War induced surgeons to modify, in some essential particulars, the rules laid down by Guthrie and endorsed by Tripler, in relation to the management of injuries of the abdomen. There are twenty-one of these well-known aphorisms (GUTHRIE'S Commentaries, I. c, p. 612; Tripler's Handbook, I. c, p. 86). The validity of the fifth, sixth, and seventh, restricting the employment of sutures in incised wounds of the abdomen, is no longer recognized by practical surgeons. The ninth, on the management of protruding omentum, is too absolute. The aphorisms from the tenth to the seventeenth inclusive are excellent, and their value has only been confirmed by more extended observation. The three following conclusions relate to wounds of the pelvis rather than of the abdomen proper. The twenty-first aphorism, enjoining a rigorous antiphlogistic regimen, with the general and local abstraction of blood, and the exhibition of mercury, is utterly at variance with the therapeutical doctrines now commonly accepted. 3 Besides the works of albucasis, Alberti, Ashhurst, Boerhaave, Bilguer, Boiin, Beaumont, Ballingall, Baudexs, Boyeu, Berard, Bell, Bresciiet, Broca, BertrandI, Beck (B.), Bryant, Billroth, Celsus, Cooper, Callisex, Chisolm, Diemerisroeck, Dupuytren, Denaxs, Desault, dorsey, Doxau, Demme, Durham, Ettmuller, Erichsen, Emmert, Fabricius, Fallopius, Flajaxi, Fischer, Fayrer, Galex, Garengeot, Goffres, Guthrik, Gunther, Gely, Gross, Haly Abbas, Hollerius, Heister, Hallfr, Hevin, Hennen, Hermann, Henrici, Hunter, Hamilton, Jobeet, Juncker, Klebs, LeDran, Langenbeck, Littre, La Motte, lieutaud, Lohmeyer, Longmore, Lembert, Legouest, Le Gros Clark, Morgagni, Marjolin, Macleod, Matthew, Marcus, Is'euuoefer, Nelaton, Pare, Pukmann, Percy, Ploucquet, Poland, Pollock, Pirogoff, Rhazes, Richter, Reybard, Ravaton, Stahlpart van der Wiel, Schlichting, Scultetus, Seidelius, Schenckius, Scarpa, Sabatier, Stromeyer, Socin, Tulpius, Tieffenbacii, Teichmeyer, Ten Haaff, Thomson, Travers Vidis Vidius, Van Swietex, Vogel, Vigla, Velpeau, Vidal, Volkmann, Warren, and Weber, and others, referred to in the preceding pages, the following may be consulted: BECK, Zur Behandlung der penetrirenden Bauchwunden, in Deutsche Klinik, 1857, S. 3; Baty, Plaies de l'abdomen, 1838, these de Paris; BODELIO, Plaies pinitrantes de l'abdomen, 1831, thdse de Paris; Pexasse, Sur les contusions de l'abdomen, 1831, these de Paris ; Girardin, Essai sur les indications et le traitement des plaies pinetrantes de l'abdomen, 1829, thfise de Strasbourg: TOMBEUR, Plaies du bas-ventre, 1806, these de Paris; Gaultier, Playes pinitrantes de l'abdomen, 1810, these de Paris; Aubriet, Plaies de l'abdomen, 1815, these de Paris; CANDY, Plaies pinitrantes de l'abdomen, 1824, these de Paris; LlTTEE (A.), Observations sur des plaies du ventre, in Mim. de I'Acad. des Sci. de Paris, 1705, p. 32; CANDY, Plaies pinetrantes de l'abdomen avec issue de viscere, TMse, Paris, 1824; THORP, Cases Illustrative of the Ben- eficial Effects of the Opium Treatment in Injuries and Operations interesting the Intestines and Peritoneum, in Dublin Hosp. Gaz., 1857, Vol. IV, p. 161; JOUET, Plaies pinetrantes de l'abdomen. Sutures. Guirison, in Gaz. des Hopitaux, 1855, p. 158; Ellis, On Injuries of the Abdomen, in the Lancet, 1834-5, Vol. II, p. 753; ROUBARD, Utilitide Vapplication du froid dans le traitement des plaies pinitrantes du bas-ventre, These, Paris, 1808; RlCH- EHAXD, Obs. sur Vobscuriti du diagnostic dans les plaies pinetrantes de l'abdomen, in Jour, de med., chir. et pharm., par CORVISART, etc., 1803, T. II, p. 352; Chamaisox, Considerations sur les plaies du bas-ventre, suivies de quelques observations particulieres a Vauteur, These, Montpellier, 1815; ElCHHOFF, De vulnerum abdomen penetrantium lethalitate, Berolini, 1829; FABRICIUS, Medicinisch-gerichtlicher Fall der Tbdlichkeit einer penetri- renden Bauchwunde, mit Vorfall und Verletzung, nebst Erinneruvgen aus der chirurgischen Lehre von der Darm- und Bauchnath, Mainz, 1824; CaRPENTIER, Quelques considirations sur les plaies pinetrantes de l'abdomen avec issue de ipiploon, Thdse, Paris, 1870: BRUN (R. A.), Des dangers des plaies par instruments tranchants non-penetrantes du bas-ventre, Paris, Thdse, 1838; FOCKE, Diss, de abdominis vulneribus, Gottingae, 1798; MAR- KIGUES, Dissertation sur les plaies du bas-ventre, Paris, 1778 ; Veegez, Plaie d'arme a feu pinitrante dans It bas-ventre, in DESAULT, Jour, de Chir., Paris, 171)1, T. II, p. 66; GOYAXD, Plaies pinetrantes de l'abdomen et procide de suture nouvelle, pour la guerison des anus contre-nature, These, Paris, 1870; PlTnA und BILLROTH, Handbuch der allgem. und spec. Chir., B. Ill, Absch. V, S. 169; WALTER (J. GOTTLIEB), De morbis peritmxi, Berlin, 1785; BICHAT. Anat gin., Nouv. cd., 1812; Laexxec. Histoire d inflammation du piritoine, in Corvisart'S Jour, de mid., chir. et phar., Fructidor, an X. and Vcndemiaire, an XI (August and September. 1802); Pixel, Nosographie philosophique, 6e ed., 1818, T. II, p. 428; PlCARD (A. L.), Diss, sur la piritonite, Parr>. It'll. CHAPTER VII. INJURIES OF THE PELVIS. The injuries of the pelvis1 that will be considered in this Chapter are shot fractures of the innominate bones, sacrum, and coccyx, wounds of the contained parts, principally of the bladder and rectum, and wounds of the genital organs. Of other wounds of the external soft parts, those of the inguinal and iliac regions have been included with flesh wounds of the abdomen, and those of the gluteal and sacral regions will be more conveniently considered in connection with lFlesh Wounds of the Pack," a category that might appropriately have been included in the Fourth Chapter, and, because found encum- bered with many instances of penetrations of the chest and abdomen, reserved until these should be eliminated, to form, with the observations on wounds of the hips and buttocks, a supplementary Eighth Chapter. Nine or ten examples of fractures of the pelvis by crushing or by falls are reserved in like manner for a separate Chapter, which it is proposed to devote to the simple and compound fractures not caused by shot. These reservations made, there remains for examination a large and important class of cases, which, with the exception of a few operations for non-traumatic affections, and a single instance of bayonet injury, are examples of shot wounds exclusively. Some instances will appear in which the abdominal as well as the pelvic organs were implicated; for, though it was designed that all cases in which the peritoneal cavity was primarily involved should be considered in the last Chapter, such was the multitude and variety of the instances to be analyzed, that strict conformity with the arbitrary boundaries established was probably sometimes unattained. And here, as elsewhere throughout this work, while the advantages of a rational systematic classification are conceded, adherence to nosological forms and the requirements of the nomenclatures in vogue are held subordinate to the main purpose of putting in evidence the principal facts. These will not always occupy the places where their relations would most advantageously appear, defects due not so much to the extent of the materials as to their variety, and to the diversity of the sources from which they have been collected, disadvantages which copious indices may in some measure relieve, an atonement the patient reader will surely find at the close of the work. In the First Surgical Volume, in the Fourth Chapter, six cases are related among the injuries of the spine that were, at 1 The older anatomists described the innominata, sacrum, and coccyx as appendages of the vertebral column or of the lower extremities. Realuus Columbus (De re anatomica, 1559) appears to have been the first to compare the assemblage of these bones to a basin or pelvis (pelvis, L., iru'eAos, G.): Pelvis imaginem elegantissime conformant, quie utero, vesicae, ac intestinis tutiits continendis a naturd parata est After him, anatomists uniformly described the hypogastric cavity containing the bladder and rectum, and the uterus in woman, as the pelvis. Thus, Verheven (De anaiome corporis humani, Louvain, 1693) : Pelvis insignis cavitas in qud continentur vesica et intestinum rectum, atque uterus in mulieribus. Galen described as anonyma the great pair of bones forming the anterior and lateral walls of this cavity; whence the ordinary designation of innominate bones, ossa innominata. It was CELSUS (L. VIII, cap. 1, et cap. 10; item L. II, c. 7) who denominated them coxte, or haunch bones (ossa coxarum), from kox^vti, the part near the pudenda and anus. 27 210 INJURIES OF THE PELVIS. [CHAP VII, the same time, instances of shot fracture of the pelvis. In the preceding Chapter of this volume, thirty-four examples of shot fracture of the pelvis are included with wounds of the abdominal viscera. In the distribution of the cases to be considered in this Chapter into three sections, it appears inadvisable to adopt any unvarying principle of classification. Many of them present a variety of lesions. A case of wound of the bladder or rectum, for instance, may be simultaneously an example of fracture of the pelvis, and of wound of tho genitals; and while its position should generally be determined by the gravity or rarity of the principal lesion, other considerations may render a different grouping desirable. It may be advantageous to colligate dissimilar cases with a single important feature in common—all of the examples of foreign bodies in the bladder, for instance, or all the cases of traumatic stricture of the urethra, though they may be associated with a variety of complications. Besides these intentional departures from a systematic classi- fication, abstracts of cases misplaced through editorial oversight, or from typographical exigencies, will violate the requirements of a rigorous method. A general view of the injuries of the pelvis, within the restricted limits assigned, discloses noteworthy contrasts to the injuries of the abdomen lately under consideration. In the pelvic injuries there is a far less formidable fatality than in penetrating wounds of the belly. It may be roughly stated that while the mortality of shot penetrations of the abdomen greatly exceeds 75 per cent., that of shot wounds of the pelvis is in inverse proportion, more than three-fourths of the cases exempt from grave visceral lesions term- inating in recovery. Of about eight hundred shot fractures of the ilium, complicated and uncomplicated, reported during the War, over six hundred resulted favorably. In wounds of the belly, traumatic peritonitis is the chief cause of danger; in wounds of the pelvis, purulent infiltration, cellulitis with gangrene, urinary infiltration, necrosis with exfoliations and protracted suppurations, paralysis, and pyaemia are the more common causes of death. Though it is often impracticable to establish an exact diagnosis in deep wounds of the pelvis, the degree of obscurity is less than in analogous lesions of the abdomen; the contained parts are more accessible to exploration; their functions are known, and their disorders cognizable. In wounds of the belly, the limits within which the reparative efforts of nature can be assisted by art are extremely restricted. In wounds of the pelvis, interference for the removal of dead bone, the extraction of foreign bodies, the liberation of confined fluids, the ligation of wounded vessels, or the restoration of obliterated canals is not infrequently required. Larrey, Hennen, Guthrie, Ballingall, Tripler, and most of the writers on military surgery of the last generation, treat of injuries of the pelvis in connection with wounds of the abdomen, and Dr. Neudorfer, Dr. F. H. Hamilton, and others, persevere in this classification;1 but Dr. Stromeyer, Generalarzt Beck, Professor Socin, Professor H. Fischer, M. Legouest, Mr. Blenkins, Mr. Birkett, and the majority of contemporaneous writers on war surgery, prefer to describe the injuries of the pelvis separately. Porter tells us2 that, in the war with Mexico, injuries of the pelvis were esteemed "exceedingly dangerous;" and Dr. Stromeyer observes3 that, in the war in Schleswig- 1 The form of Inspector General Taylors classification, presented by Deputy Inspector General Longmore as that employed in the British army (Medico-chir. Trans., Second Series, 1871, Vol. LIV, p. 20), makes no provision for shot fractures of the pelvic bones unless complicated with injury to the abdomen. In the Surgical History of the Crimean War, Dr. Matthew (op. cit, Vol. II, p. 327) adds to the class of "gunshot wounds of the abdomen '* two orders or subdivisions, one for ' rupture of viscera without external wound," and one for " fracture of the pelvis, not being at the same time wounds opening the cavity of the abdomen." * PORTER (J. B), Surgical Notes of the Mexican War, in Am. Jour. Med. Sci., 1852, Vol. XXIII, p. 30: " Wounds of the pelvis and parts adjacent art; exceedingly dangerous." 3 Stromeyer (L.), Gunshot Fractures (StaTHAM's translation, Am. ed., 1862, p. 41). SECT.I] SHOT FRACTURES OF THE PELVIC BONES. 211 Holstein, "such injuries were always very dangerous." This attribute may be predicated, with proper qualifications, of mechanical lesions of any portion of the body; but I think that the reader, in analyzing the material to be set before him, will be impressed by the severity of the injuries compatible with recovery, that the parts in this region will sustain, rather than by their extreme danger. In the first section it is proposed to select from the large category of reported shot fractures of the pelvis a sufficient number to fully illustrate the varieties of this group of lesions, and the operations they occasionally require. In the second section, mainly devoted to wounds of the bladder and rectum, some notice will be taken of the surgical diseases of those parts, and penetrations without visceral injury will also be considered, and lesions of the blood-vessels, and ligations. As the discussion of injuries of the bladder will occupy much space, injuries of the urethra, with the subject of traumatic stricture, will be relegated to the third section, on injuries of the genital organs. Section I. SHOT FRACTURES OF THE PELVIC BONES. There is great diversity in the direction, extent, and gravity1 of the lesions produced by the impact of projectiles upon the bones of the pelvis. Contusions, grooving of a single lamina, cleanly cut perforations, sinuous canals through the cancellated structure, comminutions with widely radiating fissures, or detachment of fragments, are varieties to be again subdivided, according to the injuries of the soft parts with which they may be associated. Balls are sometimes deflected by the oblique planes of the ossa innominata; sometimes they split or flatten on the laminae; often they are impacted in the spongy tissue, and often completely traverse the osseous girdle in all directions. Missiles may impinge either on the exterior of the bony basin, or, penetrating the soft parts in the inguinal, iliac, or lumbar regions, through the notches, or foramina, or the perineum, they strike the inner surfaces of the pelvis. Hence an important distinction, according as the splinters detached by the ball, the primary sequestra of Dupuytren, are driven within the pelvic cavity or outwardly. The difference in gravity in shot perforations of the chest, according as the ball fractured a rib on entering, or traversed an intercostal space and either avoided the bony case altogether or fractured the rib only in emerging, was pointed out in the Fifth Chapter; and Dr. Pirogoff informs us2 that in the late Franco-German war the significance of these conditions made much impression. I have mentioned3 that Surgeon J. H. Brinton drew my attention to this important distinction in 1861, and finding no earlier reference to it, I think the great merit of exposing it should be conceded to him. The cases to be adduced will show that an analogous rule obtains in shot penetrations of the pelvis: 1 The compilers of the Confederate Manual (A Manual of Military Surgery, prepared for the use of the Confederate States Army, Richmond, 1863, p. 61) regarded the prognosis of shot fractures of the pelvis very gloomily: "When portions of the pelvic parietes are fractured by heavy projec- tiles, very protracted abscesses generally arise, connected with necrosed bone, and the vital powers of the patient are greatly tried by the necessary restraint and confinement. The great force by which these wounds must be produced, and the general contusion of the surrounding structures, cause a large proportion, sooner or later, to prove fatal, notwithstanding the peritoneal cavity may have escaped. Even apparently slight cases, as where a portion of the crest of the ilium is carried away by a shell, or ball lodged in one of the pelvic bones, often prove very tedious from the long-continued exfoliations and abscesses which result." sPlROCOFE, Bericht ueber die Besichtigung der Militair-Sanitiitsanstalten in Deutschland, Lothringen und Elsass im Jahre 1870, Leipzig, 1871. 3 First Surgical Volume, p. 488. 212 • INJURIES OF THE PELVIS. [CHAP. vn. Iii striking the pelvis, large solid shot, unless impinging very obliquely, occasion such frightful disorders that death ensues before inflammation has time to set in; the soft parts are lacerated or pulpified and the bones comminuted. The condition is that described in treating of injuries of the cranial bones, as ecrasement, or smash. Grapeshot or shell fragmrnts may occasion similar lesions; but instances will be adduced where life has been prolonged for a considerable time after formidable mutilations by these missiles. Musket balls cause a very great variety of comminutions. Even slight shot fractures of the pelvis are long in healing'—the necrosed parts maintain obstinate fistulae; the form of the sequestra is unfavorable to their elimination; operative interference is often advantageous in expediting or consummating this process. Laugier1 lays much stress upon the remark- able accidents that result from detachment of the spines of the ilium or pubis or of the tuberosity of the ischium. The muscles attached to these tuberosities losing their fixed points of insertion, their contraction displaces the movable fragment, and a separation takes place analogous to those observed in fractures of the olecranon or patella. By position, something may be effected favoring ligamentous union. In fractures of the anterior iliac spine, for example, the sartorius should be relaxed by flexing the lower extremities; in fractures of the tuberosity of the ischium, the thigh should be extended. Shot Fractures of the Ilium.—From its greater size and more exposed position, the ilium2 is more subject to fracture than the other portions of the innominate bone. Its injuries are also generally more accessible to exploration.3 The variety in form of these lesions has already been noted. The crest or spines may be notched or detached,4 and injuries analogous to the detachment of epiphyses in long bones may be caused; or the wing of the bone may be cleanly perforated, as represented in the print opposite (Plate XXXVI); or the ball may penetrate one lamina and remain impacted, as in a specimen in the Dupuytren Museum; or may split and rest astride the bone, as in a preparation in the Museum of Val-de-Grace, figured on page 419 of M. Legouest's work; or may entirely detach the iliac portion of the innominate from the ischium and pelvis, as in another. preparation at Val-de-Grace, represented in M. Legouest's Figure 52; or shatter the bone in various directions,5 as shown in many of the succeeding wood-cuts; or the ball may bury itself in the thick, spongy portions of the ilium, or tear away the coccyx, as in Andouill^'s observation.6 The eminent Dr. Stromeyer insists upon two facts in relation to these injuries, that were corroborated by the experience of our War, and should be remembered in framing a prognosis, viz: the liability to pyaemia, and the greater danger where the missiles entered posteriorly and traversed the thick gluteal muscles before fracturing the bone, the long shot-tracks favoring purulent infiltration and sloughing, when dilatation by deep incisions was of little avail. 1 Laugier (S.), Article Plaies du bassin, in Diet, de Mid., 1833, T. V, p. 70. 2 Hium, from its supporting the ilia, or flanks; or, according to DUNGLISON (Diet Med. Sci., 1860, p. 490), from its seeming to support the ileum (ciAc'w, I twist); or possibly from the curved or twisted form of its crest. 3 Duverxey (Traiti des Maladies des Os, Paris, 1751, T. II, p. 279) is said by the erudite Malgaigne to have been the first to describe fractures of this bone. He gives a good account of them, and one has no inclination to question his claim to priority. 4 Stromeyer refers to this group of cases as exceptions to the ordinary gravity of shot wounds of the pelvis: "These injuries were always very dangerous, excepting those where the crest of the ilium was struck and shattered. These cases almost always ended favorably, the inflammation being moderate, so also the subsequent suppuration ; the sequestra were removed gradually after suppuration had fully commenced, and only the discharge of tertiary sequestra in some degree hindered the cure. As a rule, in these cases, the bullet had not penetrated deeply, or it was easily removed. Indeed, one case proved favorable where the bullet had comminuted the anterior superior and inferior spines of the os ilium, and had lost itself in the neighborhood of the horizontal ramus of the pubes, where it yet remains."—Gunshot Fractures, Statham's Translation, Am. cd., p. 42. 6Dr. F. H. HAMILTON, though lavish in censure of M. LEGOUEST for proposing to enlarge abdominal wounds in order to stitch the wounded intestine or to remove balls, makes a discrimination in favor of the removal of bone splinters in fractures of the pelvis (A Practical Treatise on Fractures and Dislocations, 3d ed., 1866", p. 339): "If the frac:ure is compound, and the fragments have penetrated the belly, the wound should be enlarged, and, as far as possible, every piece of bone should be removed." 6 Andouille> Mem. de I'Acad. de Chir., 1753, T. II, p. 488. ■»m .<■■.....-^ '•'V Wli •.e ma.-.' raction [a] e 0bR.'f<\ ; ;■; l:.; ■;{ V '•■;' •.. !•• or;-... I i.r.ii •anon. ( . ■nee. i ' •• : pivseuivo ':>\ '■■ ' " ',n r>v •■' ■ '' ' "■ : '- ■' ,; ,p! Med and Surg Hist of the War of tlie Rebellion. Parti. Vol I. Chap W Opposite page 212 Ward pliot J.BieiL I it'll. PLATE XXXVI. SHOT PERFORATION OF THE RIGHT ILIUM. No. 2869. SURGICAL SECTION. SECT. 1.1 SHOT FRACTUEES OF THE PELVIC BONES. 213 Among fourteen hundred and ninety-four cases of shot fractures of the pelvic bones reported during the War, the ilium was implicated in eight hundred and twenty-nine. There were also three hundred and ninety-five cases, recorded as shot fractures of the pelvis or of the os innominatum, of which a considerable, but indeterminable, proportion undoubtedly interested the ilium." In seven hundred and ninety-nine of the eight hundred and twenty-nine cases, the ilium was alone involved; while, in thirty instances, the pubis, ischium, and more frequently the sacrum, and sometimes the pelvic viscera, were simul- taneously injured. There is a group of cases which are often mistaken for, and proclaimed as recoveries from, shot perforations of the abdomen, in which the position of the orifices of entrance and exit favors such an hypothesis, though the ball-track is, in reality, entirely without the peritoneal cavity, and passes through the muscles and the broad wing of the ilium. An example is figured in Plate V, opposite page 81, and the facts of that and similar cases may introduce us to the series of particular instances of shot fractures of the pelvic bones: Cask C18.—Commissary Sergeant George E. Corson, 1st Battalion, 17th U. S. Infantry, was wounded at the battle of Spottsylvania, May 1'2, 18114, by a conoidal musket ball, which entered six inches to the left of the umbilicus, and passed directly backward, fracturing the crest of the ilium. He was taken to the Fifth Corps Hospital, and four days subsequently was sent in an ambulance to Belle Plain, and thence to Washington, where he was admitted to Judiciary Square Hospital. There was no symptom of peritonitis at any time, and the wound gave little trouble, except from the rather copious suppuration attending it. In the latter part of July, 1834, Sergeant Corson was ordered to the headquarters of his regiment, at Fort Preble, Maine. On August 29th, he was discharged from service. On October 10, 1364, he was appointed a hospital steward, and was assigned to clerical duty in the Office of the Surgeon General. In December, 1865, the entrance and exit wounds were still open. From time to time fragments of necrosed bone escaped. It was possible to pass a probe through the track of the wound without causing pain. There was but slight suppuration. This steward remains on duty in the Surgeon General's Office at this date, August 2, 1373. He now enjoys comparatively good health, and suffers but slight inconvenience from his injury. The appearance of the cicatrices is shown in the right-hand drawing of Plate V, opposite page 81, ante. Case G19.—Major II. A. Barnum, 12th New York, was wounded at Malvern Hill, July 1, 1862, by a conical musket ball, which entered midway between the umbilicus and the anterior superior spinous process of the left ilium, passed through the middle of the ilium, and emerged posteriorly. The wound was regarded as fatal, and the patient was left in a field hospital. On July 2d, he was captured and taken to Libby Prison, a distance of eighteen miles, in an express wagon. On July 17th, he was taken to Aikin's Landing in an ambulance, a distance of seventeen miles, and exchanged. He was conveyed by water to Albany, and thence, by rail, to Syracuse, New York. At no time were any symptoms of peri- tonitis manifested. On October 1st, Major Barnum went to Albany, where Dr. March dilated the anterior wound by an incision and extracted several fragments of the ilium, and directed that a tent should be worn. Promoted to the command of the 149th New York, Colonel Barnum took the field in January, 1863. He wore the tent about a month, when the anterior wound healed. About the middle of March, a large abscess formed and evacuated itself at the site of the anterior wound. In April, Dr. March again cut down to the ilium and intro- duced a tent. No loose fragments of bone were found. The colonel resumed his duties, and commanded his regiment at Gettysburg. In January, 18G4, another large abscess formed and discharged posteriorly. The orifice was enlarged by Dr. L. D. Sayre, of New York, and a seton of oakum was passed from before backward through the entire track of the ball. This was worn for several weeks, when Surgeon M. K. Hogan, U. S. V., substituted a seton of candle-wick, which was gradually reduced in size, and finally replaced by a single linen thread. The photograph, of which a reduced copy is presented in the wood-cut (Fig. 141), was taken at the Army Medical Museum in August, lH:>r>. The wound still discharged slightly, and the thread seton was still worn. Promoted to be a brigade commander, General Barnum was almost continually in the field for the next two years. He participated in the c;u;i]>;ihu- of Atlanta, Georgia, and Carolina, was shot through the right forearm at Kenesaw Mountain, and received a shell wound of the side at Peach Tree ('reek. Since the close of the War General Barnum has enjoyed comparatively good health, and has actively participated in political affairs. Fir.. 141.—Fistula following a shot perforation of the fliink and left ilium. [From a photograph.] 214 INJUEIES OF THE PELVIS. [CHAP. VII. Case 620.—Private W. A. Harkness, Co. K, 7th Ehode Island, aged 35 years, was wounded at Cold Harbor, June 3, I'vVl. At the regimental hospital the injury was recorded as a "wound of the bowels." On the 7th, he was transferred to Carver Hospital, Washington, whence Surgeon O. A. Judson reported the case as a "flesh wound of the abdomen." On September 26th, he was admitted into Lovell Hospital, Portsmouth Grove, and discharged the service January 26, 18,'ir>. Surgeon Charles O'Leary, U. S. V., notes upon the monthly report as follows: "Gunshot wound of the abdomen; the ball passed beneath the umbilicus, injuring the bone by escaping through the ilium. A painful tumor marks the track of the ball." He was pensioned, and Examining Surgeon Eobert Millar, of Providence, reported, January 21, 1870, that the "ball entered the abdomen at the median line, about two inches above the pubes, passed outward toward the left side, fracturing the left ilium at the anterior superior spinous process, and emerged about two inches beyond. The irritation seems to have extended to the bladder, and if he stands he has a constant desire to urinate; any heavy lifting produces pain and fulness in this region. He also has pain at the seat of the fracture, which has recently increased, probably owing to some necrosed spiculae of bone. He says that he can perform no hard labor which requires standing or lifting." He was last paid on December 4, 1872. Cask 621.—Lieutenant Colonel John M. Hedrick, 15th Iowa, was wounded near Atlanta on July 22, 1834, and after Surgeon William H. Gibbon, of his regiment, had applied a primary dressing, he was transferred to the hospital of the Seventeenth Army Corps, thence was admitted into hospital at Chattanooga, where Surgeon J. H. Phillips, U. S. V., records the injury as a fiesh wound of the back. Thence this officer wTas sent to hospital at Louisville on August 10th, where Surgeon A. T. Watson, U. S. V., records "gunshot wound of left forearm and of left hip." He was mustered out of service on August 11, 1866, and was pensioned. On September 4, 1867, Pension Examiner W. L. Orr reports : "A musket ball carried away the left transverse process of the fifth lumbar vertebra, penetrated the os ilium of the same side near its connection with the sacrum, and emerged through the ilium near its anterior superior spinous process. The wound has been followed by extensive exfoliation of the ilium, which has not yet entirely ceased. Disability total." Promoted to a colonelcy, and brevetted a brigadier for gallantry, this officer subsequently regained his strength, and, in 1872, visited Washington, in tolerably robust health. Case 622.—Musician J. Dalley, Co. H, 53d Pennsylvania, aged 28 years, was wounded at Fredericksburg, December 13, 1862. He was treated in the field, and at Armory Square Hospital, Washington, and was discharged from service March 6, 1863. The certificate of disability, signed by Surgeon D. W. Bliss, U. S. V., states that there was a "gunshot wound of the left side; the ball entered through the skin over the liver, passed obliquely downward and backward through the ilium, two inches below the crest. Necrosis of ilium." Dalley was pensioned, and was paid to March 4, 1869, when his pension was discontinued. Case 623.—Private W. H. Davis, Co. F, 15th Ohio, aged 22 years, was wounded at Kenesaw Mountain, June 23, 1864, by a conoidal ball. On June 27th, he was admitted to No. 1 hospital, Chattanooga, from the field, with "gunshot wound of the abdomen," and, on July 1st, he was transferred to Nashville, to hospital No. 2, in charge of Surgeon J. E. Herbst, U. S. V., the injury being recorded as "gunshot wound in umbilical and sacral region." On the 27th he was furloughed, and on November 25th was admitted to Brown Hospital, at Louisville, where Assistant Surgeon B. E. Fryer, U. S. A., recorded the case as a "gunshot fracture of the crest of the left ilium." On the 30th he was transferred to Madison, and on January 6, 1865, to Columbus, Ohio, and Surgeon S. S. Schultz, U. S. V., described the injury as "gunshot wound of the abdomen, injuring the crest of the left ilium." This soldier was discharged the service on February 14, 1885, his disability rated at three- fourths. Pension Examiner A. H. Hewetson, of St. Clairsville, reported, March 31, 1865: "Ball passed from a point about two inches above and a'little to the right of the superior spinous process of the ilium to the left sacro-iliac symphysis; several pieces of bone were discharged. The hip is painful and the spine weak, so that when the weight of the body is thrown upon the left limb it is violently agitated. He suffers considerable pain of a nervous character before changes in the weather; disability three-fourths, to some extent temporary." This pensioner was last paid to June, 1873. Case 624.—Private J. J. Smith, Co. E, 22d Georgia, aged 30 years, was wounded at Gettysburg, July 3, 1863. He was cared for at the Third Corps Hospital until the 28th, and then transferred to Camp Letterman. Acting Assistant Surgeon Eowand reported that " a mini6 ball entered a half inch below the umbilicus, passed on under the integuments, aud escaped at the upper edge of the right os innominatum, fracturing the crest of the ilium, a portion of which it carried away. The missile then passed through the middle third of the right arm, fracturing the humerus. The arm was amputated on July 4th, by circular operation. The after-treatment consisted of cold-water dressings, with stimulants and tonics." The patient convalesced rapidly, and on October 1st was transferred to West's Buildings Hospital, Baltimore, and on November 12th to City Point, for exchange. Case 625.—Private J. N. Kaufman, Co. G, 151st Pennsylvania, aged 21 years, was wounded at Gettysburg, July 1,1863. He was removed to the field hospital of the 3d division, First Corps, and, on the 11th, was transferred to Camden Street Hospital, Baltimore. Surgeon Z. E. Bliss, U. S. V., states that "the ball entered the left side above the crest of the ilium, passed superficially across, and emerged below the margin of the ribs, about four inches from the umbilicus. When admitted, there was free discharge from the upper orifice." On July 24th, the patient was transferred to Harewood Hospital. Acting Assistant Sm-geon L. Dorsey noted on the medical descriptive list that "the ball entered the abdomen about one inch below the last rib of the left side, and passed out above the posterior superior spinous process of the ilium. The patient was discharged from bo.-pital August 12,1863, at which time the wound was nearly healed." Kaufman was pensioned, and Examining Surgeon D. L. Beaver, of lieading, reported, September 28, 1863, as follows: "The ball struck opposite, three inches off [from the median line?], passed directly backward, and made its exit through the upper portion of the left ilium. The wounds are both discharging, and there is great induration at the ilium. Swelling and irritation exist, showing that the bone is affected. Disability three-fourths; may change." This pensioner was last paid in March, 1873. Case 626.—Corporal I. N. Porter, Co. E, 154th New York, aged 25 years, Avas wounded at Pine Knob, June 15, 1864. In the field hospital at Chattanooga, at Cumberland Hospital, Nashville, and at Clay Hospital, Louisville, the injury is noted as a "s.hot wound of the abdomen." On August'.», 1^64. he was admitted into hospital at Cleveland, and discharged from service SECT. I.] SHOT FRACTURES OF THE PELVIC BONES. 215 March 6, 1865. Assistant Surgeon George M. Sternberg, U. S. A., states upon the certificate of disability that there was a " gunshot wound of the light colon, with fracture of the ilium." Pension Examiner IT. C. Taylor, of Brocton, N. Y., reported, November 10, 1866: " Gui shot wound in the abdomen, the ball passing entirely through from a point a little to the right of the umbilicus to a point in the back a little below tho kidney. The disability has of late increased. He is unable to peiform manual labor and, in my opt lion, the disability is complete." Pension paid to March, 1873. In this group—often confounded with shot perforations of the abdomen—of pene- trations in the iliac region with fracture of the crest or wing of the ilium, it would be possible to adduce many instances of recovery; but these may here suffice, as others will appear in further subdivisions of the subject. Though very uncommon, there were examples of recovery after shot lesions involving both iliac bones : Case 627.—Private C. C. Condra, 3d Tennessee, was admitted into the general hospital at Paducah, Kentucky, for a gunshot wound through both ilia, received on February 5, 1863. Pyaemia was developed on March 8th. It was successfully treated with quinia and iron, anodynes and stimulants. Case 628.—Major Jacob Selieu,* 7th New York, aged 34 years, was admitted from City Point to Armory Square Hospital on May 7, 186."), for a shot perforation of the pelvis, received at South Side Railroad on May 2d. A conoidal musket ball had entered three inches below the centre of the crest of the right ilium, passed through the pelvis anterior to the sacrum, and emerged at a corresponding point on the opposite side. On admission, he suffered intense pain; there was incontinence of urine and paralysis, but increased sensitiveness of the lower extremities, with slight contraction of the extensor muscles of the foot. The wound had nearly closed, but suppuration had taken place along nearly its whole length. After enlarging each wound slightly, several loose pieces of bone were removed from both, and an abscess beneath the gluteal muscles was evacuated. Perfect rest was enjoined; poultices were applied; stimulants and anodynes administered. The patient was transferred to De Camp Hospital on August 18th. By September 15th, he was improved; there was a slight discharge from both wounds, and the atrophied limbs could easily be moved about in bed. This officer was discharged the service on April 18, 1866. He was subsequently a patient of Dr. Charles A. Leale, who states, November 14, 1867: "The patient has good use of his limbs and can walk easily; he has slight paralysis of one leg." Lateral perforations in front of the vertebral column, implicating both innominata, must commonly be attended with fatal visceral injuries; but a ball passing parallel to the sacrum may readily notch both of the iliac crests posteriorly, where they project beyond the sacral spine, and such injuries are not necessarily very grave. Two instances approx- imating to this description, the cases of Russell and Woodbury, will be found with the histories of the fractures of the sacrum. In the early dressing of shot fractures of the ilium it is sometimes necessary to remove very large detached fragments, as in the following instance : Case 629.—Private W. J. Gibson, Co. G, 102d Pennsylvania, aged 20 years, was wounded at the Wilderness, May 5, 1864, by a six-ounce grapeshot, which entered the front of the abdomen a little below a line drawn from the umbilicus to the anterior superior spinous process, and about three inches from the border of the right ilium, and passed through the middle of the ilium, carrying before it a portion of the bone more than two inches square ; both the ball and the fragment of bone lodged in the gluteal muscles. He was removed to the field hospital of the 2d division, Sixth Corps, where Surgeon George T. Stevens, 77th New York, administered chloroform, and removed, through an extensive incision along the nates, the missile and the fragment of bone which lay in proximity. The borders of the large opening in the ilium were smoothed by means of the bone forceps somewhat enlarging the orifice. The wound was then brought together, and water-dressings applied. He passed through the hard experience of the wounded of the Wilderness, being drawn in an army wagon two nights and a day over rough roads, and for several days received little or no care. [The above notes of the case appear on a special report furnished by the operator.] On May 25th, the patient was removed to Lincoln Hospital, Washington, and on July 28th, to the hospital at Pittsburg, where he was transferred to the Veteran Reserve Corps, January 30, 1865. He was dis- charged June 19, 1865, and pensioned. Examining Surgeon D. N. Rankin, of Allegheny City, reported, July 5, 1865, that " the missile entered the right iliac region and fractured the right ilium. Great deformity of the parts and a partial loss of the use of the right leg resulted. He has had poor health since the reception of the injury." This pensioner died October 7, 1886. Dr. Stevens had prepared and sent to the Museum a ferrotype of the specimens removed, which are represented, of the size of nature, in the adjacent drawings (Figs. 142 and 143). Fig. 142—Fragment of right ilium carried away by a grapeshot. [From a photograph] Fig. 143.—Grapeshot that produced the foregoing frac- ture, and then lodged in the buttock. ' See Remarks on this case in the Medical Record, 1874, Vol. IX, No. 3 (No. 195), p. 73. 21<> INJURIES OF THE PELVIS. [CHAP. VII. Fig. 144.—Shotfrac ture of the inner lam ina of the left ilium Spec. 1743. Fig. 145.—Call taken from the pelvic cavity. On examining the shot fractures of the ilium1 somewhat in the order of the extent of the osseous lesions, the collection of the Army Medical Museum will afford a variety of illustrations. Partial fractures, involving one lamina, notchings of the crest or epiphyseal fractures, and embedded balls, may first be selected for notice : Case 630.—Sergeant William L------, Co. D, 10th New York Cavalry, aged 25 years, was admitted to hospital at Alex- andria on October 15, 1863, having received a gunshot wound at Bristoe's Station on the previous day. The ball entered the left groin one-half inch to the outside of the femoral artery and half an inch below Poupart's ligament, extending backward; the probe could be passed toward the pelvic cavity for a distance of five inches, but the ball could not be found. At the time of admission there were no symptoms of injury of the abdominal viscera; his general health was good, and there was no derange- ment of the functions. On October 16th, he was attacked with a violent diarrhoea and had passages of a light-green color; the pain in the groin was slightly relieved and the diarrhoea was partly controlled on the next day, and, on the 19th, he had a slight chill, and there was a yellow discoloration of the skin around the wound; pulse 100 and feeble; patient weak; diarrhoea more severe. The yellow discoloration of the skin increased, and, by the 21st, was decided and general over the whole body and whites of the eyes. On the 22d, the bowels were regular as to the number of passages, but of a loose character and light-green color; pulse 100 and feeble; he had a severe chill, and died five minutes after- ward, death being caused by pyaemia. The post-mortem examination showed that the ball had struck the os innominatum and caused a compound impacted fracture of a portion of the bone, two inches square, above the acetabulum. The ball had passed into the pelvic cavity, and was found lying directly under the bladder. The whole course of the intestinal canal as well as the stomach was found highly congested. An abscess was found in the right lobe of the liver con- taining two and a half ounces of pus, and the whole organ was softened. All the abdominal viscera were congested. The specimen (FlG. 144) consists of the iliac portion of the left acetabulum and adjacent bone, with a conoidal ball (FlG. 145), which has contused the internal surface of the ilium just below and behind the anterior inferior spinous process, and was contributed, together with the history, by Acting Assistant Surgeon T. Hunt Stillwell. Case 631.—Private D. G:------, Co. F, 56th Pennsylvania, aged 38 years, was wounded at Southside Railroad, October 27 1864, by a conoidal ball, which entered over the crest of the left ilium and emerged two inches to the right of the spinal column. He was sent to City Point, thence to Alexandria, Virginia, where he was admitted to hospital on November 2d. " He complained of severe pain; there was no paralysis either of sensation or of motion in the lower extremities, and he micturated freely. Water dressings were applied, opiates administered, and a half diet with extras was allowed. A few days before the 13th, the patient had a chill, which was followed by fever, low muttering delirium, quick and feeble pulse, icteric hue of the skin, and breath of a saccharine odor. Supporting treatment was of no avail; he gradually grew worse, and died November 13 1864. Noticeable at the post-mortem examination, thirty-four hours subsequently, were the great degree of rigidity, slight emaciation, suo-rds eight cases, with one death. In the Bohemian War of 1816, however, Dr. BECK (Kriegschir. Erf., Freiburg, 18G7, S. 251) had five cases of shot fractures of the ilium, of which two were fatal. In the Italian War of 1859, Dr. Deiime (Studien, 1861, B. II, S. lt>8) records six cases of shot fractures of the ilium, with two deaths. RavatOX (Chirurgie d'Armee, 17C8, p. 140) relates a case of recovery from a shot perforation of the ilium; Baudexs (Clinique des plaies d'armes a feu, 1836, p. 399) gives two such cases. CllIl'AULT (Fract par armes a feu, 187:1, p. 75, Obs. LXXX and LXXXI) records two cases of shot fracture of the left ilium: Pivot-Taffut, trumpeter, 27th marching regiment, Artenay, December 2, 1870, perforation near anterior superior spine, convalescence : SimonJPetir, 59th regiment, Beaugeney, December 7, 1870, shot fracture, extraction of necrosed fragments, amelioration. BEKTUKK.\NI> (Camp, de Kab., 18'i2, p. 29) gives one fatal c;ise of shot fracture of the ilium, and two others in which he does not report the result, a total of fifty-five cases, with twelve deaths, a mortality of 21.8 per cent. FlG. 146.—Upper portion of the left ilium with a shot fracture of its crest. Spec. 3408. SECT. I.] SIIOT FRACTURES OF THE ILIUM. 217 FlG. 147.—Section of the left ilium, frac- tured by a conoidal musket ball which is embedded near the crest. Spec. 3212. FlG. 148.—Exterior view of the specimen. and the patient so far recovered as to re-enlist as a private in the 11th Infantry, December 4, 18G2. He served with his regiment in Georgia, and made the march from Atlanta to Washington. The wound having reopened in April, 1866, he was admitted into hospital at Fredericksburg. Surgeon Charles Page, U. S. A., made an exploratory incision, and discovered the ball almost completely embedded in a new osseous tissue, but the propriety of removing it was considered doubtful. The patient was sent with his regiment to Camp Grant, Richmond, and was returned to duty October 4, 1H60. He was discharged from service November 2, 1866. Rarely, however, are balls impacted in the ilium the sources of so little irritation.1 Ordinarily, osteitis may be anticipated, and, eventually, caries and necrosis, unless the patient should perish from pysemic infection, as occurred in the first of the following cases: Case 633.—Private M. S------, Co. H, 116th Pennsylvania, aged 30 years, having sustained a gunshot fracture of the left ilium at Cold Harbor on June 3, 1864, was sent to Alexandria, and admitted to Sickel Hospital on June 12, 1864, in a weak and exhausted condition. Simple dressings were applied to the wound; tonics, stimulants, and anodynes were administered, and a full diet was allowed. A spicula of bone was removed on June 2Cth, after which improvement took place. On July 14th, bed-sores appeared over the sacrum; on the 18th, a large spicula of bone was removed from the left anterior superior spinous process of the ilium. On August 2d there was dysuria, with high-colored urine, which disappeared under appropriate treatment. On August 17th, the patient went to Philadelphia on seven days' leave of absence. His subsequent history is as follows: August 26th, sinking with exhaustion; wound has opened and discharges unhealthy pus; bed-sores increased in size and exceedingly foul. September 1st, pyaemia rapidly setting in; abscess appears before the anterior superior spinous process of the ilium. Death occurred September 8, 1864. At the autopsy, pus was found in the peritoneum, and a conoidal musket ball rested on the internal iliac muscle. Acting Assistant Surgeon E. Xeal forwarded to the Museum the pathological preparation, represented by the wood-cut (FlGS. 147, 148). "The fragments are irregularly attached by callus, but the track of the ball is carious. The inner face of the ilium shows slight osseous deposits beyond the line of fracture."—(Cat, p. 227.) Case 634.—Surgeon W. L. Baylor, P. A. C. S., in a special report, states that "Captain P. Poindexter, Co. T, 14th Virginia, aged 36 years, having been wounded in a skirmish before Suffolk in May, 1863, was sent to Petersburg, and admitted into the Washington Street Hospital in June. He had been struck by shrapnel in eight places. Six of these wounds were flesh wounds of the extremities; the other two were fractures of the ilii. The balls were embedded in the bone. The wounds of the ex'tremities were not long in healing. After two weeks' attention, he was sent into the country and passed into the hands of another physician, who removed a ball from the right ilium. The patient died of exhaustion on October 28, 1863." Case 635.—Private A. W------, Co. F, 27th Indiana, aged 21 years, was admitted to hospital at Aquia Creek, May 15, 1863, for a wound received at Chanceliorsville on May 3d. A conoidal musket ball had passed through the centre of the ilium, burying itself in the sacrum within a line of the vertebral canal. The patient having been made a prisoner, his wound was neglected for eleven days, his fare during that time consisting of crackers and bread, and he suffered from protracted dorsal decubitus. On June 14th, he was sent to Washington and admitted to Douglas Hospital. Here he rallied after the administration of tonics, stimulants, and a nourishing diet; but in a few weeks failed again, and died July 8, 1863. An autopsy was made by Acting Assistant Surgeon Carlos Carvallo, who contributed to the Museum the interesting pathological preparation (Fig. 149) and notes of the case: "The ala of the ilium, for a space of nearly three inches square, is missing; externally, the perforation is fringed with foliaceous callus; internally and posteriorly, a border nearly an inch wide is necrosed and nearly separated; inferiorly, a longitudinal fissure extends parallel with the anterior wall of the ischiatic notch; and the sacrum near the iliac junction is carious and has lost much tissue by absorption." The frequency with which balls are embedded in the ilium is considerable. In fifty- two of the recoveries from shot fractures of the ilium balls were extracted, and in many of these cases the missiles were firmly wedged in the bone. In seventeen of the autopsies, balls were found impacted in the ilium. 1 Experience fully confirms the justice of Guthrie's precept on this subject: " Balls which lodge in these flat bones may often be removed, and the comfort of the patient assured, by a timely operation, instead of proving the source of much torment and misery for many years by their being allowed to remain."—Commentaries, 6th ed., 1855, p. 597. 28 FIG. 149.—Section of left os innominatum and longitudinal half of sacrum, with an impacted conoidal ball. Spec. 1(341. 218 INJURIES OF THE PELVIS. |CHAP. vii. Fig. 150.—Upper half of the right ilium, Hull impacted in the iliac crest. (Musie Du- puytren.) [After LiKGOUEST.] FIG. 151.—Shot perforation of the left iliac fossa. (Musie Dupuytren.) [After Lkgouest.] Elsewhere examples will be given of the extraction of projectiles impacted in the ilium. Balls lodge most readily, of course, in the spongy parts of the bone, and, in very rare instances, may become innocuously encysted. There is a specimen in the Dupuytren Museum, represented in the wood- cut (Fig. 150), where a ball im- pacted in the iliac crest has led to very little local mischief. A yet more remarkable example is illustrated by Figure 151. The preparation was taken from a soldier wounded at the battle of Leipzig, October 18-19, 1813, who died in Paris, in 1843, from an affection unconnected with his injury. A fistulous opening on the left hip had never cicatrized. The ilium is much thickened, the roughness of the crest and other points of muscular attach- ment is much exaggerated. There are many osteophytes, and. in short, all the indications of chronic osteitis. In extensive comminutions, though death from shock commonly takes place soon after the infliction of the fracture, patients occasionally withstand an astonishing amount of injury, as in the following case, which appeared to be progressing favorably until recurring intermediary haemorrhage from one of the lumbar arteries supervened : Case 636.—Corporal H. M------, Co. C, 22d Pennsylvania Cavalry, aged 21 years, having been wounded in a skirmish near Martinsburg, June 30, 1864, was sent to Frederick, and admitted to hospital on July 5th. "Acting Assistant Surgeon J. C. Shinier reports that a " fragment of shell had entered behind the left ilium, fracturing and severely comminuting its crest, forcing and firmly embedding the fragments in the lumbar muscles and against the left side of the lumbar vertebra; there was incom- plete paraplegia; the pulse was some- what excited, but the appetite tolerably good and the bowels regular. The frag- ment of shell had been removed on the field. Anodynes, friction of the lower extremities with alcohol, the removal of a spicula of bone from the wound, and antiseptic dressings were employed. On the 10th, the pain at the seat of injury had subsided, but at times there were excruciating pains along the course of the left sciatic nerve. July 15th, general condition had deteriorated. There was, however, an absence of pain; healthy granulations had appeared at the bottom of the wound covering the broken bone, and the bowels were apparently normal. On the 20th, the patient was sinking; his countenance anxious, pulse accelerated and feeble, tongue pale, respiration quickened. July 21st, haemorrhage occurred from one of the lumbar arteries amounting to twenty ounces, and causing great enfeeblement. It was checked by compression, but recurred on the 22d to the amount of eight ounces. An effort was made to remove the fragments of bone and to secure the ruptured vessel. Some spiculse were removed; but the larger fragments could not be separated. A clot was allowed to form, and the bleeding ceased. The patient died July 23, 1" il. On post-mortem examination nothing abnormal was found in the viscera. The pelvis was terribly shattered." (Figs. 152, 153.) "There is a fracture of the posterior superior third of the ilium, one line of which extends from the posterior inferior spinous prm-ess of the crest two inches behind the anterior superior spinous process. The fragment thus broken off is bisected bv a fracture running at right angles, and of the posterior fragment the inferior half is missing."—(Cat., p. 227.) Fio. 152.—Lieft os innomiuatum and section of sacrum fractured by a shell fragment. Spec. 3813. FlG. 153.—Exterior view of the same specimen. SECT. 1.1 SHOT FRACTURES OF THE ILIUM. 219 Fig. 154.—Sacrum and left os innominatum frac- tured by a musket ball. Spec. 3826. FIG. 155.—Exterior view of the specimen. Case 637.—Private A. W. P------, Co. F, 3d Vermont, aged 21 years, was wounded at Boonesboro', July 10th, and entered hospital at Frederick on July 12, 1863. Acting Assistant Surgeon W. S. Adams reports that "a conoidal musket ball, which entered just above the anterior superior spinous process of the left ilium, passed downward, backward, and inward, struck the superior border of the great ischiatic notch and fractured the ilium, and passed out through the left side of the fourth and fifth bones of the sacrum. Delirium ensued on the lGth ; wet cups were applied to the temples and behind the ears; warm fomentations and sinapisms to the lower extremities. The delirium con- tinued, with complete anorexia and urinary trouble, and, on the 17th, a quart of bloody urine was drawn by a catheter. Tlie abdomen subse- quently became tympanitic. On the 19th, there were well-marked symp- toms of pyaemia. In treating this case diuretics, stimulants, tonics, and anodynes were administered. The patient died July 22, 1863. The post-mortem examination revealed an abscess in the right lung; the left lung and kidney much congested; there were evidences of peritonitis; the coats of the bladder were thick- ened, and its internal surface was covered with lymph; the external coat of the rectum was in a state of ulceration." The pathological preparation (FiGS. 154, 155), consisting of the sacruwi and left os innominatum, showing an absence of nearly two square inches of the inner surface of the ilium just anterior to the sacral articulation, a longitudinal fracture extending three inches toward the crest of the ilium, and a fissure two inches toward the anterior superior spine, was contributed to the Museum by Dr. Adams, with the foregoing notes. Case 638.—Private H. Rice, Co. G, 25th Illinois, aged 38 years, wounded in the right ilium by a rifle ball, at Merrys- ville, in December, 18G3, was admitted into hospital at Knoxville on December 16th. He was transferred to Nashville on April 24, 1834, and admitted to Cumberland Hospital. Assistant Surgeon W. B. Trull, U. S. V., reports that the wound was treated by simple dressings, and that a general stimulating treatment was pursued; but the case progressed unfavorably and terminated fatally on July 4, 1864, from "nostalgia." This singular cause of death is assigned in two separate reports without explanation. Case 639.—Private B. M. P------, Co. 1,126th Ohio, aged 21 years, was wounded at the Wilderness, May 6, 1864, and admitted to Douglas Hospital, Washington, on May 26th, where he {lied of pyaemia on the 28th. The following notes of the case, with the specimen, were contributed by Assistant Surgeon W. Thomson, U.S.A.: "The ball entered just within the left posterior superior spinous process of the ilium and escaped over the dorsum of the bone. When ad- mitted, the patient was delirious and had a rapid, feeble pulse, a dry tongue, and an icteroid hue of the whole body. No examination was made of the lungs, but the symptoms clearly indi- cated bis death to be due to pyaemia." The specimen is represented in the adjacent wood-cuts (FiGS. 156,157), the long shot canal from the sacro-iliac junction internally to near the middle of the dorsum externally being im- perfectly indicated. Case 640.—Sergeant G. W. Feiestel, Co. K, 200th Pennsylvania, aged 22 years, was wounded at Fort Steadman, on March 25, 1865, by a conoidal ball, which entered above ,and one inch to the left of the pubic symphysis, grazing the upper side of the os pubis, passed outward and backward, and emerged on the outer side of the left buttock. He was admitted into field hospital, and transferred, on April 7, 1855, to Alexandria. Surgeon E. Bentley, U. S. V., reports that, "on the 12th, he had chills, which became severe and frequent, and there was a profuse discharge of fetid pus from the wound. On the 14th, the patient was delirious; involuntary evacuations of the bowels and bladder occurred; he passed into a state of stupor, and died on April 17, 1835. During the treatment the patient was stimulated and nourished. At the autopsy, the skin was very yellow; a considerable quantity of very offensive pus was found between the os pubis and the peritoneumt also in a cavity outside the pubic bone. The left lung was healthy; the lower lobe of the right hepatized, its middle and upper lobes crepitant. There was very yellow lymph on the lower lobe of the right lung, but no adhesion. The heart was large; the pericardium distended with serum. Tlie liver was large and pale; the spleen large; the ileum injected, and there was a tubercle (?) in the right kidney the size of a pea." Fig. 155.—Section of the left ilium obliquely perforated by a musket ball. Spec. 3531. Fis. 157.—Reverse of the same specimen. 220 INJURIES OF THE PELVIS. [CHAP. VII. Flo. 158.—Ventral view of appearances after a shot perforation of tho right ilium. Spec. 2015. FIG. 159.—The exterior view of tho same specimen, showing the shot canal fringed with osteophytes, and the cavity of an abscess of bone. Case 641.—Private J. W. C------, Co. G, 2d North Carolina, was wounded in a skirmish at Kelly's Ford, November 7, 1*63, and was admitted to Cavalry Corps field hospital on the same day; on the 23d, was received into Lincoln Hospital, Wash- ington, and died December 28, 1863. Assistant Surgeon Harrison Allen, U. S. A., contributed to the Museum the diseased portion of the innominate, with the following notes: "The autopsy, four and a half hours after death, showed that the ball had entered two and a half inches above the anterior superior process of the ilium and passed directly from before backward and slightly downward, making its exit at the posterior inferior portion of the ilium two inches below the crest. The ilium was fractured at the point of entrance and exit of the ball, and Avas entire between these points. In the iliac fossa an irregularly shaped abscess was observed extending beneath the iliac fascia and downward toward the crural opening, internally over the psoas muscle, undermining it and separating it from its attachments, the muscle appearing to traverse the abscess. The cavity extended the entire length of the crest of the ilium, and con- tained about two ounces of pus of a dark mahogany color, and very offensive. The anterior wound of the ilium connect- ed with the iliac fossa by a fissure in the fracture, and the pus had discharged freely through this opening during life." Assistant Surgeon A. A. Woodhull, U. S. A., remarks (Cat., p. 228): "The specimen (Figs. 158 and 150) consists of tho greater portion of the right ilium. The bone is perforated near its crest, two inches posteriorly to the anterior superior spinous process, as if by a buckshot. The track of the ball is carious, but on the lower external surface is a large fringe of spongy callus. Surrounding the internal orifice is a small quantity of new bone. Just above the posterior superior spinous process is a contused wound three-fourths by one and one-fourth inches, over which the outer surface is wanting, and which retains a corresponding involucrum." Case 642.—Private Isaac N------, Co. A, 155th Pennsylvania, aged 23 years, was wounded at Fredericksburg, December 12, 1832, by a ball and three buckshot, one of which passed through the ilium, and another entered the crest, He was admitted to Harewood Hospital on the 13th. Acting Assistant Surgeon W. A. Harvey reports that a buckshot was removed, and the patient was treated with nitric acid, iron, brandy, etc., and that the wound was kept open with tents. The patient died January 31, 18G3. Dr. Harvey sent to the Museum the specimen represented in the wood-cuts (Figs. ICO, 131). A buck- shot had perforated the dorsum about its centre, and another lodged in the outer border of the crest near the superior extremity of the insertion of the latissi- mus dorsi; the borders of the perforating fracture are necrosed, and the bony tissue in which the ball lodged is carious. , Co. H, 24th New Jersey, was wounded at Fredericksburg, December 13, 1852, and on the 17th was transferred to Harewood Hospital. Acting Assistant Surgeon W. A. Harvey reports that "the ball was removed on December 20th, when the diagnosis was made of fracture through the left ilium. The patient died December 28, 1832. Post-mortem examination revealed a fracture of the ilium, and a large mass of coagulutn between the bone and iliacus muscle, and two fragments of bone driven in. Pus and coagulated blood had bur- rowed into the cavity of the pelvis." The specimen (FiGS. 162, 163) was contrib- uted to the Museum by Dr. Harvey. Assistant Surgeon Woodhull remarks (Cat., p. 228): "The external fracture embraces nearly two square inches of surface, and the internal fracture nearly four square inches. One square inch of bone is missing, and the fractured portion of the inner table is bent inward; the border of the fracture is necrosed." Co. E, 31st Georgia, aged 18 years, was wounded at Monocacy Junction, July 9,1864, by a conoidal ball, which penetrated the right hip and passed through the upper border of the ilium without penetrating the abdomi- nal cavity. He was sent to Frederick, and admitted into hospital on the 10th. Acting Assistant Surgeon T. E. Mitchell reported that "the wound continued to suppurate freely, and tonics and stimulants were administered. On, the 25th, the patient was attacked with diarrhoea, which lasted about ten days, but yielded finally to astringents. After this, his appetite became good FIG. 1G0.—Upper two-thirds of the right ilium, showing a shot perforation and a ca- rious cavity, from which a small ball was extracted. Spec. 988. Case 643.—Private R. H. R--- FIG. 161.—External view of the same specimen. Fig. 162.—Superior half of left ilium perfo- rated by a conoidal ball above the sacral articu- lation. Spec. ;!£.">. Case 644.—Private T. J. I- FlG. 163.—Dorsal aspect of the same specimen. Me■. • i-xtr;icix'i( ■ .i t> . 2:v . M Mr. ■..' • .'•jte'.vr'^:\'-i'' :;^.<:*v. rM.ATE XXXIV CARIOUS SHT FRA' -fo j ." i.RC.ICA HE RIGHT ILIUM J Btrnv l-.*< SECT. I.] SHOT FRACTURES OF THE ILIUM. 221 and his strength increased. The part of the ilium through which the ball passed became necrosed, and several small sequestra were discharged. On August -20th, a fragment, three inches in length by one-half inch in width, was removed. The parts around the wound of exit sloughed, and pus burrowed downward along the venter of the ilium till September 8th, when it penetrated the abdominal cavity. Hyperacute peritonitis ensued, and the patient died on September 10, 1864. At the post- mortem examhiation the abdominal cavity was found filled with pus, an abscess having burst into the cavity. The bone in the vicinity of the wound was much necrosed. The pathological specimen, represented in the photo-relief print opposite (Plate XXXIV). was contributed to the Museum by Dr. Mitchell. It consists of "the anterior half of the right innominatum, commi- nuted at the anterior superior process of the ilium, where a wedge-shaped fracture, two inches in depth by the same base, with loss of substance, has been caused by a couoidal ball. The fractured edges are torn and carious. On both surfaces is a layer of periosteal deposit nearly separated. The bone immediately adjacent to the fracture is necrosed and partly detached." (Catalogue, 18G0, p. 226; description of specimen 3900, XI, A. B. b, 11.) Case 015.—Private Joseph S- -, Co. C, 1st Wisconsin Cavalry, aged 29 years, was wounded at Dandridge, January £3l 17, 1804, by a conoidal ball, which entered the right hip anteriorly at the superior portion of the ilium, ranging inward and downward. On the next day he was admitted to Asylum Hospital at Knoxville, where simple dressings were applied, opiates, astringents, and tonics administered, and the ball was extracted some time in April. On August l"2th, the patient was trans- ferred to the Clay Hospital, Louisville, and thence, on the 23d, to Harvey Hospital, Madison, where the following report of the case was made by Surgeon H. Culbertson, U. S. V.: "A sinus had opened over the right pubis, which discharged unhealthy pus; the right foot was turned out, and the leg and foot were swollen from effusion of serum. Chronic diarrhoea and dysuria supervened, followed by extreme emaciation, and he died on August IU, 18(5"). At the examination, twenty- four hours after death, the pubic sinus was found leading to the bladder, and along the inner face of the right ilium; the bladder was ulcerated at points in its outer coats and through the three coats at one point, and its mucous coat was generally discolored, softened, and in a state of chronic inflammation. At the seat of the fracture of the ilium fragments of the inner table of the bone had been driven in by the missile, and were feebly attached by new bone; the track of the ball was carious and the orifice raised by new osseous deposits. The head of the femur was partially dislocated and anchy- losed against the iliac margin of the acetabulum. The articular surfaces were softened and par- tially absorbed, and the inner surface of the femur was eroded. The specimen consists of the sacrum, right os innominatum, and upper portion of the femur, and is represented by the wood-cuts (FiGS. 164 and 165). FlG. 165.—Interior view of this specimen. FlG. 164.—Caries and subluxation of the head of the right femur, in a case of shot perforation of the ilium. Spec. 3232. In a large proportion of the cases the side on which the injury was inflicted was specified, and the results, as set forth in the following tabular statement (Table VI), indicate that, notwithstanding the partial protection afforded by the canteen, haversack, and side-arms, there was a predominance of injuries of the left hip of about 10 per cent., the ratio in which the right ilium was struck being 44, and that of the left 56, per cent. of the determined cases. • Table VI. Indicating the relative Liability of the Right and Left Ilia to Shot Injury. Rrsult of Shot Fkactukes of the Ilium. Cases. Right Ilium. Left Ilium. Both Ilia. Side not specified. Recovery........................................ 594 192 10 224 64 2 269 95 5 3 2 1 98 31 2 Death........................................... Undetermined.................................... 796 290 369 6 131 222 INJURIES OF THE PELVIS. [CHAIV VII. The three following cases illustrate the greater danger of shot fractures of the posterior spinous processes of the ilium than of lesions of the same magnitude of tlie anterior processes. The three patients apparently perished from pyaemia, two a fortnight after being wounded, one at the expiration of four weeks: Case 646.—Private J. C. M- -, Co. G, 116th Pennsylvania, aged 18 Fig. 166.—Superior portion of sacrum, posterior portion of right ilium, fifth lumbar vertebra, and battered conoidal ball which fractured the three bones. Spec. 1C56. r^^^ -''-—- years, was wounded at Reams's Station, August 25. 1864, by a mini6 ball, which shattered the crest of the right ilium just above the posterior superior spinous process, fractured the spinous process of the fifth lumbar vertebra, passed across to the opposite side, and lodged below the crest of the left ilium. He was sent from a field hospital, on the 26th, to Emory Hospital. He suffered intense pain from the time of admission, and on September 1st gangrene set in. The treat- ment consisted of detergent topical applications, and the administration of anodynes and stimulants, with nourishing diet. He died September 7, 1864. The autopsy, made the next day, disclosed the course of the ball as above stated. The specimen (FlG. 166) was contributed, with the foregoing history, by Acting Assistant Surgeon H. G. Bates. Case 647.—Private A. B------, Co. M, 63d North Carolina, aged 35 years, was wounded at Madison Court-House, September 22, 1863, by the explosion of a shell, and was admitted to Stanton Hospital, Washington, on the 25th. Assistant Surgeon G. A. Mursick, U. S. V., reported that "a piece of shell entered his left side, fracturing the crest of the ilium, and passed backward to the lumbar vertebrae; the wound presents a ragged appearance, and is about one and a half inches in diameter; there is complete loss of motion and partial loss of sensibility in the left lower extremity; there is paralysis of the bladder, and relaxation of the sphincter ani, the urine being retained, and two stools passed involuntarily. He complained of pain in the abdomen and left foot; pulse 80, full and quick. The treatment consisted of applications of simple dressings to the wound, the administration of opiates, and drawing off of the urine by the catheter. October 1st: He passed his urine this morning without the aid of a catheter, and retains his fasces; the wound is suppurating; he is very restless find is suffering great pain; some pieces of bone were removed from the wound this morning; opiates were given, and a flaxseed poultice was applied to the abdomen. October 6tb: The pain in the abdomen is slight, but is more severe in the foot, and he is very restless. October 12th: There has been but little change in his condition; he has some irritative fever, and has but little appetite; he is emaciated, and his pulse is frequent and feeble. October 16th : He is gradually failing in strength; the tongue is dry and furred; bowels constipated; the pain in the foot continues. An enema was given to move the bowels. October 18th: He has had a severe chill during the night, and has fever this morning; the tongue is dry and brown; the pain in the abdomen still remains, with slight tympanitis. Opiates, tonics, and stimulants were given. On the 19th, he had rigors, and on the 20th, he had a slight haemorrhage from the wound; the rigors continued, and the skin was of a yellow hue; there was nausea and vomiting, respiration was embarrassed, aud there were" sibilant sounds in the posterior part of the lungs. On the 21st, he had rigors and slight delirium. He died October 22, 1863. Autopsy, eighteen hours after death, showed well-marked rigidity, body emaciated, and skin of a yellow hue. A piece of shell had struck the posterior part of the crest of the ilium, breaking off some pieces, and, passing backward behind the colon, it struck the upper part of the sacrum, fracturing it, and also the body, laminae, and transverse processes of the fourth and fifth lumbar vertebrae, and partially divided the spinal cord, lodging with some pieces of bone in the muscles of the back. The lungs were congested, and contain a number of small abscesses; none were found in the liver. The other abdominal viscera were healthy. The heart preseuted evidences of an old pericarditis, and the mitral valves were Sickened." The specimen (FlG. 167) consists of the sacrum and posterior part of the left ilium. A portion of the ilium in the region of the posterior spines has been carried away by a fragment of shell, and the neighboring bone is necrosed. It was contributed to the Museum by Surgeon John A. Lidell, U. S. V. Cash 648.—Sergeant Walter S- Fig. 167.—Sacrum aud portion of the left ilium, the dorsal portion of the spine of the latter shattered by a shell fragment. Spec. 1519. FIG. 16t*.—Shot fracture of the posterior inferior spinous process of the right ilium. Spec. 3532. -, Co. I, 109th New York, aged 24 years, was wounded at the Wilderness, May 12, 1854, and admitted to the field hospital of the 3d division, Ninth Corps, on the same day, and, on the 26th, transferred to Douglas Hospital, Washington, where he died on May 27,1864. The surgeon in charge reported: "Death was caused by pyaemia. This man must have been treated at Fredericksburg after his injury; he had well-marked pyaemia on admission, and died from that cause a few hours after. There was no examination of the lungs, but his external hue, sweet- smelling breath, delirium, and nervous prostration, left no doubt as to the nature of his disease." The specimen (FlG. 16S) consists of the sacrum and right ilium; the spongy portion of the ilium near the sacral junction is fractured over a space one and a half inches square, and the sacrum is fractured at the second intervertebral notch as though by the impact of a ball, and was contributed, with the foregoing report, by Assistant Surgeon William Thomson, U. S. A. Mea and Sure Hist of the War of t_ho Rebellion Parti Vol I. Chap W 'ppositf pat»e ??3 Ward phot J.TJit-n Iifh. PLATE XXXV FRACTURE OF THE LEFT OS INNOMINATUM BY A SHELL FRAGMENT, No 4130 SURGICAL SECTION. ■•, ■If' •'•/■ ■■■*r^r ■ ■ .rV- •'■•'■'V-'Vf. •'• ■':.■*.•«•'' XXXV SECT. 1.1 SHOT FRACTURES OF THE ILIUM. « 223 Cask 649.—Private J. L. E- -, Co. A, Cobb's Georgia Legion, aged 35 years, was wounded at Sailors' Creek, Prince Edward's, Virginia, April 6, 1865. He was admitted to the field hospital of the Fifth Corps on April 14th, and was transferred to Washington, on the steamer State of Maine, on the 18th, and received into Lincoln Hospital on the 19th. Acting Assistant Surgeon I. P. Arthur reported: "Gunshot fracture of the left ilium, missile entering two inches from the sacro-iliac synchon- drosis, passing through into the pelvis, where it remained. The patient died from haemorrhage April 28, 1835. The specimen consists of the sacrum and left os innominatum. A fragment of shell, one inch and a half by two inches, has perforated the ilium near its centre and caused a complete fracture of the bone from the level of the base of the sacrum." The specimen was contributed by Surgeon J. C. McKee, U. S. A. In the photo-relief print opposite (Plate XXXV) the sacrum has been dis- mounted to give a better view of the venter of the ilium. Cash 650.—Private O. W. Goodale, Co. G, 10th Vermont, aged 20 years, was wounded at Petersburg, April 2, 1863, and taken to a hospital of the Sixth Corps. On the 11th, he was transferred, by City Point, to Harewood Hospital. Surgeon W. A. Child, 10th Vermont, Assistant Surgeon J. Sykes Ely, U. S. V., and Surgeon R. B. Bontecou, U. S. V., in charge of the several hospitals, reported a shell wound of the right hip, with fracture of the ilium, without particulars of the treatment. The patient being transferred to Sloan Hospital, Montpelier, on May 12th, Surgeon Henry Janes, U. S. V., reported as follows: "Shell wound of the right side of the pelvis, involving the ilium. Compound comminuted fracture of the crista near the anterior superior spinous process. Pieces of bone were removed at the time of the injury. The patient says the wound opened into the pelvic cavity. When admitted, the wound was healthy and discharging a little. It was three inches lon.9h ot the canal arc, in some places, fringed with osteophytes, and in necrosed. The pathological preparation is figured in the photo-relief -iiiehusetts, aged ly years, was wounded at Cedar Creole, October ]!), :s, and on November 12th was transferred to a hospital at I'Yederiek; nmshot wound joint. The borders others are carious 01 print opposite (Plate XXXVTT). Cask CC.:?.— Private Henry Keens, Co 1, SOtli Ma 1S;IJ. He was treated at the field hospital for several \ve< thence, on the 18th, to Filbert Street Hospital, Philadelphia, where Surgeon T. 15. Peed, U. S. V., noted through the crest of the ilium;" thence to Turner's Lane Hospital, whence Surgeon I?, A. Christian reported attacks of epilepsy. The patient was discharged from McClellan Hospital .June 4, ISii.j, and pen- sioned. This pensioner visited the Army Medical Museum April '■>, lSo7, when the following notes of the case were obtained by Assistant Surgeon E. Curtis, U. S. A.: "The ball entered just to the outside of the anterior superior spinous process of the ilium of the right side, passed outward and backward, and emerged about six inches from the point of entrance. The man stated that the wounds became gangrenous at the field hospital at Winchester, that be was unable to walk for five months, and that numerous pieces of bone were removed from both orifices, one being two inches long. The wound did not heal for five months, and the orifice of exit reopened two or three times, but no more bone was discharged. At present, the anterior cicatrix is adherent to the bone; the posterior cicatrix is movable. Motion of the hip joint causes pain, and the muscles resist powerfully any attempt to move the thigh; there is, however, limited motion. The knee, also, is somewhat stiff, and can be flexed but very slightly. He walks by swinging the pelvis, keeping the knee joint immovable, and moving the hip joint very slightly. The ankle joint is stiff, and the toes drawn up by the extension. He never had any abscesses in the hip, and prob- ably no disease of the joint except the false anchylosis from long confinement." A photograph of the patient was made, which is No. 177 of the Surgical Photo- graph Series, and is drawn on a reduced scale in the adjacent wood-cut (FlG. 173). The Pension Examining Board at New York reported, February 14, 1872, that "the ball struck the right side of the abdomen, and, passing through the crest of the ilium, emerged posteriorly six inches from the wound of entrance. The anterior cicatrix is adherent to the bone. He is now suffering from epileptiform convulsions. From the history and circumstances of the case we believe that the convulsions are due to disease of the nerve centres, tho result of an ascending neuritis, having its origin in a nerve within the wound. Disability total, third grade. Weight, 12*: age, 2.1; respiration and pulse normal." Caries and Necrosis.—The frequency of these terminations of the osteitis induced shot fractures is so great that Dr. Stromeyer concludes that the preservation of life after these grave injuries of the pelvis is not always to be reckoned good fortune, the patients leading ailing and painful lives,1 exposed to the recurrence of suppuration, and liable to fatal complications from slight accidents, as in the following case : Case G34.—Private John D------; Co. C, 51st New York, aged 41 years, was wounded at Antietam, September 17, 1332, by a conoidal ball, which entered between the anterior spinous processes of the left ilium and escaped just exteriorly to the lowest third of the sacrum. He remained in a field hospital until October 2d, when he was removed to Camp A Hospital, Frederick. " He was greatly exhausted, and the wound discharged unhealthy pus profusely, and the countenance was hectic. Stimulants and nutritious diet were freely given for a fortnight without materially altering his condition, when be began slowly to regain strength. The wound, however. continued to suppurate freely." He convalesced sufficiently to be .able to walk about, but received a severe fall on December 14th, after which he gradually grew worse, and died December 24, 1862. All along he had suffered pain in discourse of the sciatic nerve, but had referred none to the articulation. The neuralgia was excru- ciating after the fall. The specimen (Fig. 174) was contributed to the Museum by Assistant Surgeon W. M. Notson, U. S. A. The exterior surface of the ilium one inch above the acetabulum is grooved by the bullet; ihe walls of its track are thick- ened by new bone, and interiorly a sinus has perforated the bone nearly three inches, and has opened by ulceration the fundus of the acetabulum.2 1 Angeic (Traiti iconographique des maladies chirurgicales, lre monographie, Luxations et fractures, p. 17) figures the right ilium notched and perforated by a conical ball, which has largely splintered the bone. The specimen is taken from n soldier wounded at Solferino, June 24, 1859, who died in Paris in 1864, in N'61aton's ward, from protracted suppuration. 2 Compare Cask 187, Circular No. 2, S. G. O., 1869, p. 92. 29 FIG. 173.—Cicatrix of a shot perforation of tin ilium. [From a photograph.] Ar FIG. 174.—Carious shot canal in the left ilium. Spec. 9:54. INJURIES OF TUP: PELVIS. [CHAP. VII. Cask 655.—Private Alison Simpson, Co. F, 40th North Carolina, aged IS years, was wounded at Antietam, September 17, 18(52, and appears to have been treated at hospital No. 5, Frederick. On October 25th, he was transferred to Camden Street Hospital, F.altiinore. Acting Assistant Surgeon E. G. Waters reported that "a musket ball entered the right iliac fossa one and a half inches internally to the crest of the ilium, passed directly backward and outward, perforating the bone and fracturing it extensively, and escaped posteriorly. October 27th, a number of denuded, detached, and entirely dead fragments of bone were removed through the anterior opening, to the great comfort and benefit of the patient. The discharge continued abundant and offensivo for some weeks; but, as the strength and vigor of the patient returned, it improved rapidly in character and diminished in quantity, liy February 14, 18G3, the wound had healed and the patient was sent to the South. Some contraction of the tissues in the neighborhood of the wound existed tit this time, preventing him from resting the entire sole of his foot on the ground." The Pension Roll affords many illustrations of the protracted suppurations following chronic caries and necrosis induced by shot injuries of the bones of the pelvis. The following are some examples : Case 050.—Private M. G. Jones, Co. I, 5th New York, was wounded at Manassas, August 30, 1862, and taken prisoner; and was subsequently paroled and sent to Annapolis, and, on November 15th, was admitted to the General Hospital under charge of Surgeon T. A. MeParlin, U. S. A., where the following report was made: "The ball entered the abdominal walls three inches above the symphysis pubis, passing over to the right side, making a wound five inches in length. The anterior superior spinous process of the ilium was impinged upon, and pieces of bone had been removed. The wound has healed, but the patient is lame, and complains of great pain in the lumbar region, and can bear no pressure on the abdomen." On January 26, 18G3, he was discharged the service. Pension Examiner S. D. Willard. of Albany, New York, reported, October 24, 1863: "Ball struck the crest of the ilium and tore across the abdomen. There is lameness and disability on movement involving the action of the sartorius muscle." This pensioner was paid to June 4, 1872. Cask 057.—Private C. Daly, Co. A, G2d New York, received a shot fracture of the pelvis at Gettysburg, July 3, 1853. He Avas admitted to a field hospital of the Sixth Corps on the 4th, and on the 26th was transferred to Baltimore, to Patterson Park Hospital. A musket ball had entered posteriorly two inches below the crest of the left ilium, shattering this bone considerably, and passed in the opposite direction, and was found buried in the muscles of the right side, immediately below the bone. It was removed by Surgeon S. D. Freeman, U. S. V., with several pieces of bone, the largest of which were taken from the left ilium near its vertebral and sacral articulation. The patient convalesced, and was discharged from service March l'J, 1864. The specimen (FlG. 175), consisting of a conoidal ball and thirteen fragments of necrosed bone, was contributed by the operator, with the foregoing narrative. Examining Board of Surgeons J. T. Ferguson, M. K. Hogan, T. F. Smith, W. F. Deming, and Charles Phelps, of New York, reported, November 8. 1871: "There is a long, deep, adherent cicatrix in the gluteal region; the movements of the back are interfered with; disability three-fourths. Also gunshot wound of the left hand, between the metacarpal bones of the middle and ring fingers, near the metacarpal phalangeal joint, weakening the middle and ring fingers; disability one-fourth. Disability for both wounds total and permanent." This pensioner was last paid to June 4, 1873. Case 658.—Private C. Dunbar, Co. D, 10th Massachusetts, aged 24 years, was Avounded at Fredericksburg, May 3, 18ii3, by a conoidal musket ball, Avhich entered the upper part of the left natis, passed anteriorly, and lodged. He Avas sent to New York, and admitted into the Central Park Hospital on May 17th. Soon after the reception of the Avound, both testicles became painful and inflamed and remained so for three or four days. On June 29th, an incision, similar to that recommended for ligation of the external iliac artery, Avas made upon a hard substance lying half way betAveen the anterior superior spinous process and the symphysis pubis, and half an inch above Poupart's ligament; it proved to be the ball, Avhich Avas removed, Avith three small pieces of bone. The after-treatment consisted of simple dressings, with quinine and Avhiskey. The patient rapidly convalesced, and returned to duty on September 23d; discharged from service November 24, 1863, on surgeon's certificate of. disability, and pensioned. On April 28, 1870, Pension Examiner P. II. Humphrey reported: "There is necrosed bone, and many pieces have been extracted. He complains of lancinating pains in his groin and hip joint. It almost entirely incapacitates him for labor. Disability total." Case 65[>.—Lieutenant J. Swallow, 51st Pennsylvania, Avas Avounded at Fredericksburg, December 13, 1862, by a conoidal musket ball, which passed through the right ilium near the crest, and emerged posteriorly through the sacrum. On March 21. 1863, he was admitted to the Officers' Hospital, Annapolis. Surgeon B. A. Yanderkieft, U. S. V., reported that there were indications of extensively diseased bone; the general health was good, and the discharge from the wound free. The wound Avas poulticed; the patient exercised moderately in the open air, and took quinia and iron. Several pieces of bone were removed with forceps on May 23d; two large pieces were taken aAvay on June22d; large fragments Avere extracted on July Gth ; and, on September 9th, some came aAvay. The wound continued open and discharged, with very little inflammation, and the patient walked with the aid of a crutch. He was improving rapidly at the date of his discharge from the service, March 15. 18 14. He Avas pensioned, and on April 7. 1855, the pension Avas increased. Pension Examiner W. Corson reports, November 4.1-72. that "the wounds are healed. The pensioner is, and has been since the receipt of the injury, uniformly lame. Ileavv lifting, or prolonged exercise on foot, is followed by soreness and increased disability. The general health is good, and there is no appreciable atrophy of the limb. The disability is rated as total." Pig. 175.—Ball and necrosed fragments from the left ilium. Spec ATM. SHOT. I.J SHOT FRACTURKS OF THE ILIUM. 227 Casio 0(50.—Captain Thomas C. Spademan, Co. 15 198th Pennsylvania, aged 38 years, was wounded at Gravelly Run, March 29, 1855. and sent to a field hospital of the Fifth Corps, where he remained until May 1st, Avhen he was transferred to Armory Square Hospital, Washington. Assistant Surgeon C. A. Leale, 15 S. \ ., reported a "gunshot Avound of the left hip; a conoidal ball entered one inch above tin; trochanter major and made its exit one inch to the left side of the anterior superior spinous process of the ilium. The ball passed through the ilium an inch below the anterior superior spinous process. When admitted, he was suffering considerable pain from a large abscess that had formed on the crest of the ilium, which had been punctured at City Point. A free incision into it evacuated the pus aud permitted the removal of several small splinters of bone; a poultice was then applied. Stimulants, anodynes, and beef extract were given. June 20th: The wound still discharges. By the use of the probe I discovered several small pieces of bone on the inner side of the ilium; I passed a seton of oakum through the Avound, and, in forty hours, drew it through Avith small pieces of hone entangled; applied a poultice and treated tbe case as before. On June 20th, he left the hospital to go to Philadelphia, having been mustered out May 29th. At this time the wounds looked healthy and discharged but a very small quantity of pure pus. He had a flesh Avound of the left leg, which sloughed a little after he Avas admitted. It was so slight then that he did not mention it tome; Avhen he left, this was also healthy. It Avas on the left leg. two inches below the knee, on the lateral aspect." This soldier was discharged the service June 26, 1865. Surgeons 15 A. Smith, T. S. Harper, and J. Collins reported, November 6, 1872, that "the ball shattered the pelvic bones, resulting in five openings, which discharge pus freely at this date, Avith pieces of bone continually coming aAvay. The necrosis of the pelvis is very extensive, and the condition of the applicant is 'such as to incapacitate him for performing any manual labor, but not such as to require constant personal aid and assistance.' He Ls able to dress his Avound, but he is very offensive both to himself and to others. Disability total." This pensioner Avas last paid up to March 4, 1873. Cask 661.—Private John D. Wolff, Co. A, 14th Connecticut, aged 37 years, was Avounded at Morton's Ford, February 6. 1854. He Avas admitted to a hospital of the Second Corps, and Avas subsequently treated in Alexandria, New York, and New Haven, and was discharged from service June 11, 1805. The records of the above hospitals furnish no details of the progress of the case. He received a pension until March, R-67, Avhen he enlisted in Co. E, 42d Infantry (V. R. C), at which date the pension Avas discontinued, though reneAved at the date of discharge, April 2, 1859. Examining Surgeon Thomas B. Reed, of Philadelphia, reported, April 23, 1869, that "the ball entered on the inner side of the erest^of the ilium and passed through and out near tbe sacro-iliac symphysis The wound is still open and occasionally discharges dead bone; the limb is weakened and much impaired. He has slight double inguinal hernia, but does not Avear any truss. He is much debilitated, and unable to earn a living by manual labor." Examining Surgeon Philip Leidy, of Philadelphia, reported, in July, 1809, as follows: '"The ball entered the upper angle of the left iliac region at the anterior superior spinous process, passed imvard, and emerged near the sacro-iliac junction of the same side, fracturing the ilium. The Avound at the point of entrance is still open and discharging freely, due to the presence of necrosed bone. The applicant is under treatment at the Episcopal Hospital in this city. His general health is good and does not seem to be influenced by the existing condition of the Avound, though he is disabled directly from performing mauual labor for any length of time. The diseased bone is not extensive (though it Avill not permit of surgical interference), and may be discharged by the natural process at any time, Avhen the pensioner will be relieved altogether. There is no constitutional cause acting in his case." In February, 1871, the Pension Examining Board at Philadelphia reports that there is "necrosis of the ilium. The wound of entrance is fistulous and discharges profusely. When the discharge ceases for a few days he becomes sick." In September, 1872, they reported that the wound of entrance Avas still discharging freely because of the presence of carious bone. This pensioner Avas last paid to June 4, 1873. Case 662.—Sergeant J. H. Whitney, Co. B, 9th New York, Avas Avounded at Antietam, September 17, 1862. and Avas treated at Locust Spring by Surgeon T. H. Squire, 89th New York, Avho reported that "a musket ball entered the left gluteal region at a point three inches behnv the crest of the left ilium and three and a half inches from the median line of the sacrum, and remains in some unknown part of the body. There is no paralysis, or trouble of the bowels or bladder." On January 23d, the patient Avas sent to Smoketown, and, on May 10th, to hospital No. 1, Frederick, where the report of Assistant Surgeon R. F. \Yeir, U. S. A., is substantially the same. This soldier was discharged June 11, 185)5. and pensioned. Examiner Charles Rowland, of Brooklyn, reported, on March 24, 1854, that "a rifle ball entered the left hip, fracturing the left os ilium, the ball traversing doAvmvard, and was supposed to have lodged near the os sacrum, where it still remains. At times it is exceedingly painful, rendering the soldier's health precarious." On June 18,1859, Pension Examiner W. W. Potter, of Washington, reported that "a large cicatrix exists upon the left buttock, near its centre, Avith an opening through which pus is constantly discharging. The opening indicates the point of entrance of a minie ball, which has perforated the ilium obliquely from left, to right. There are no indications of its exit, and the missile has undoubtedly lodged Avithin tlie cavity of the pelvis; patient states that portions of the bone have been exfoliated, and that the discharge of pus has been constant since"tbe injury Avas received, which indicates necrosis of some of the pelvic bones. Some fibres of the sciatic nerATe appear to have sustained injury affecting the sensation and motion of the left lower extremity. He presents an anaemic appearance, and there is liability to a fatal termination at any time. Disability total, and probably permanent." This pensioner Avas last paid to March 4, 1873. Cask 663.—Sergeant P. Ryan, Co. H, 15th U. S. Infantry, aged 21 years, Avas Avounded at Atlanta, August 7, 1864, and was treated in a field hospital of the Fourteenth Corps until September 3d, Avhen he Avas sent to Chattanooga, registered as a case of "gunshot Avound of left side," and thence, on October 20th, to hospital No. 3, at Nashville, where Surgeon J. R. Ludlow, U. S. V., recorded the case as a "gunshot fracture of the left ilium." This soldier was subsequently in hospital at Jefl'ersonville aud Camp Dennison, and discharged the service April 7, 18,i", and pensioned. Examiner W. M. Evans, of Ashtabula, Ohio, reported, July 31, 1867, that "the wound through the ilium is discharging considerably, and frequently a small piece of spongy bone comes away; some nineteen pieces have been thus discharged, according to the statement of the applicant. He is Aveak, pale, and emaciated. This Avound is probably not a permanent affair, as it will heal when the carious bone is removed. Disability total." This pensioner was last paid March 4, 187.). 2l^ INJURIES OF THE PELVIS. [CHAP. VII. In view of the persistence of Sergeant Ryan's fistula for nine years already, and the experience of the Leipzig pensioner mentioned on page 218, whose fistula remained open for thirty years, it appears unsafe to predict that such lesions will not prove "permanent." landless, intarissable, are the epithets by which Begin and M. Legouest find that such fistulae may commonly be characterized. Tlie following are analogous examples: Case 664.—Lieutenant James Peacock, Co. D, 57th Massachusetts, aged 33 years, Avas wounded at Fort Steadman, March 25, 1865, and Avas sent to a Ninth Corps hospital, Avhere Surgeon M. K. Hogan, U. S. V., noted "Gunshot wounds of both thighs." Transferred to the depot field corps hospital, Assistant Surgeon Samuel Adams, U. S. A., remarked, March 31st, that the "ball entered two inches to the right of the umbilicus and came out at the middle of the crest of the ilium. No hmmorrhage from the boAvels; no abdominal tenderness; no fever; clean tongue; appetite good; no sleep;" and, on April 1st, "pulse good; no fever; countenance bright." This officer appears subsequently to have been treated in quarters. He was honorably discharged June 12, 1865, and pensioned. Examiner Oramel Martin, of Worcester, reported that his disability Avas "total aud permanent. A ball hit about tAvo inches to the right of the umbilicus, passed through the abdomen and out through the centre of the right ilium. The bone is diseased and the wound discharges pus. Exercise Avhich brings the muscles of the abdomen into action creates great lameness, from the adhesions." Case 665.—Private E. H. Jones, Co. H, 14th NeAV York Heavy Artillery, aged 17 years, Avas wounded at Petersburg, July 3, 1804. His injury was recorded at a hospital of the Ninth Corps, by Surgeon M. K. Hogan, U. S. V., as a "gunshot wound of the left hip." Sent to City Point, and thence, on July 6th, to David's Island, Ncav York; this soldier remained at De Camp Hospital until October 18th, and Avas then sent to the general hospital at Rochester. He Avas registered as convalescent from a "gunshot fracture of the crest of the left ilium," and Avas discharged from service April 3, 1865, and pensioned. Examiner Thomas M. Flandrau, of Rome, reported, September 16, 1870: "A rifle ball entered the hip three inches to the left of the spinal column, fracturing the crest of the ilium. The position of the ball Avas not ascertained until December, 1869, Avhen it Avas extracted from the buttock by enlarging a fistula near the tuberosity of the left ischium. Bone was removed shortly after the wounding; none since. The wound of entrance did not heal until after the ball was extracted. There is iioav an ugly fistulous opening over the tuberosity of the ischium, situated in a deep ulcerated cleft, the remains of the incision, Avhich discharges constantly. From the sensitiveness of the part, a probe could not be passed to any great depth. The main trouble is from the inflamed state of the fistula. The man cannot sit on that buttock, walk nor stoop, Avithout occasioning pain and some inflammation. Time and proper surgical treatment Avill probably benefit him." This pensioner was paid March 4, 1873. Examples might be multiplied; but the foregoing, conjoined with instances adduced in other subdivisions, sufficiently illustrate the difficulty in healing of shot fractures of the ilium,1 the complications arising from denudation and caries, and from irritation of branches of the sacral and sciatic nerves and consequent neuralgia, paralysis, or muscular atrophy. Many patients sink under these exhausting influences; purulent infiltration, pysemic or septicasmic infection being ordinarily the proximate causes of dissolution. In the recorded. fatal cases there is, unfortunately, a paucity of detailed necroscopical memoranda. Case 666.—Private Joseph D. Hammer, Co. D, 142d Pennsylvania, aged 24 years, was Avounded at Gettysburg, July 1, 1863. He Avas removed to the field hospital, Avhere he remained until the 14th, Avhen he Avas sent to Baltimore and admitted into Camden Street Hospital. Acting Assistant Surgeon E. G. Waters reported that "when admitted his general condition Avas good. A mini6 ball had entered the right hip just above and behind the great trochanter, passed imvard, and lodged in the ilium posterior to and above ihe acetabulum. He was urged at this time to submit to an operation for the removal of the bullet, but he declined, and nothing further was done at the time. August 27th, the patient Avas seized Avith a severe rigor, great constitutional disturbance, and intense pain in the vicinage of the ball. On visiting him the next morning, he implored me to extract the missile, which Avas done accordingly- I apprehended that he was already suffering from pyaemia, Avhich proved to be true. The bullet av.is found impacted in the ilium, and had to be loosened Avith the elevator before it could be detached. A large fragment of that bone Avas likewise Avithdrawn. The joint Avas not involved, its movements continuing free. August 29th: Slept indifferently, notwithstanding a full dose of morphia. August 30th: Pulse irritable; no appetite; had a severe rigor. He took quinine and carbonate of ammonia, with morphia. September 2d: No improvement; no appetite; but takes beef essence with milk-punch, as ordered; gets his tonic, Avith eight ounces of Avhiskey, daily. September 6th : Treatment the same; another severe rigor; morphia at night, under Avhich he sleeps tolerably well; skin constantly bathed in sweat; pulse very frequent, soft, and irritable. September 8th: Observed at my visit to-day that he had become suddenly and universally jaundiced; much inclined to sleep; complained of no pain, but expressed himself as feeling comfortable; pulse very small, and too rapid to count; body bathed in sweat, as it has been for several days, necessitating frequent changes of clothing; remedies persevered in to no purpose, and he sank at 11 p. ai. Necropsy, twelve hours after death, revealed the ilium badly crushed and the superincumbent tissues in a gangrenous condition. The liver and kidneys were the only organs examined. The former had a yellow patch of considerable extent on its anterior aspect, penetrating several lines into its parenchyma; the latter were healthy, I attributed this man's death to his obstinate refusal to have the bullet extracted soon after his admission; certainlv its removal at that time, with the comminuted fragments of bone, would have diminished risks of ulterior accidents." 'Professor ('. V. LoiIMKVEi: (Die Schusswunden, Gottingen, 18.j9, S. 141) remarks: "A speedy cure, after shot injur}' of the pelvic bones. I have seen but once.'' SECT. J.| SHOT FRACTURES OF THE ILIUM. 229 Cask 607.—Sergeant, James F. Barnes, Co. E, 24th Wisconsin, aged 51 years, was wounded at Mission Ridge, November 2">. 1803. lie was admitted on the same day to hospital Xo. 2, Chattanooga, under the charge of Surgeon Franklin Irish, 77th Pennsylvania, Avho noted the injury as a " shot wound of the groin." On January 29. 1864, he was transferred to hospital No. 3, Nishville, whence Assistant Surgeon Frederick W. Byers, 96th Illinois, reported that "on admission the patient Avas much emaciated and anaemic, and bad suffered with diarrhoea for two Aveeks. The ball had entered near the anterior inferior spinous process and had passed backward upon the dorsum of the ilium and lodged. The wound of entrance had closed. There were bed-sores upon the back and hip, and an incision three inches long had been made behind the trochanter, from which unhealthy pus flowed. Stimulants and tonics were administered, and by February 10th the general condition Avas improved. On February 29th, the diarrhoea was mitigated but not arrested. On March 4th, the ball was extracted through an incision in front of the acetabulum. There was a free discharge of unhealthy pus from tho wound, Avhich gave no evidence of healing. The bed-sores were washed with a solution of permanganate of potash. March l"th, there Avas no improvement in the Avounds, and the discharges from the bowels were more frequent. March 20th: Patient becoming gradually Aveaker, and the discharge from the wounds and bed-sores less copious but more fetid; no healthy granulations, lie died March 27, 1864. Autopsy eighteen hours after death: No rigor mortis; there was a large bed-sore over the left hip, and the surrounding skin and subjacent tissues Avere ecchymosed; the wound of the hip was nearly closed externally; an incision laid open a cavity extending beneath the gluteal muscles; the ball had slightly fractured the anterior margin of the ilium; no pus Avas found in the cavity, but a dark, very fetid, pultaceous matter, Avhich also covered the bed-sores. The right lung Avas healthy, but a portion of the substance of the apex of the left lung, about the size of a hen's vgtx, Avas broken doAvn into a putrilage resembling in appearance and smell the contents of the cavity in the hip; a clot of blood could be traced from the pulmonary artery to the cavity; there was no surrounding hepatization or other evidence of inflammation. Heart healthy, containing fluid blood; small clots; mucous membrane of the ileum abraded." Case 668.—Private F. Panmour, Co. F, 1st Sharpshooters, aged 23 years, wounded at Cold Harbor, June 3d, Avas sent to Washington, and admitted into the Carver Hospital on June 11, 1861. Surgeon 0. A. Judson, 15 S. Y., reports that " a rifle ball had entered the right side about an inch and a half above the groin, had passed transversely backward, producing incom- plete fracture of the neck of the right femur, passed through tbe ilium, and had emerged about one inch above the right natis. On June 26th, a very large quantity of pus, which had collected in the pelvis and burroAved in beneath the superficial fascia in the gluteal region, Avas evacuated. Free incisions were made and tents of lint drawn through. At the time of operation the patient Avas much exhausted. Stimulants and a nutritions diet Avere prescribed." These measures were unavailing, and death from exhaustion ensued June 29, 1864. Case 669.—Private H. Petzerick, Co. P>, lOCth Pennsylvania, aged 5,0 years, Avas Avounded at Petersburg, March 26, 1865. and sent to the Ninth Corps hospital, and thence transferred to Slough Hospital, Alexandria. Surgeon E. Bentley, U. S. V., records, April 6th, that "a conoidal ball had passed through the posterior portion of the crest of the left ilium, through the body of the last lumbar vertebra, and through the right ilium just above its .articulation Avith the sacrum. There Avas paralysis of the bladder and of the lower extremities. Cold-Avater dressings Avere applied to the wound, and the urine Avas draAvn off with a catheter. The case terminated fatally on April 8, 1865. On autopsy the membrane of the spinal cord Avas found to be exposed, but not torn; the abdominal viscera were but slightly inflamed." Cask 670.—Private A. Ecker, Co. A, 74th Pennsylvania, aged 37 years, wounded at Gettysburg July 1st, was admitted to Camp Letterman Hospital on July 25, 1863. A conoidal musket ball had entered at the upper part of the right sacro-iliac junction, splintering portions of the sacrum and ilium. The patient's general condition was improving, but he Avas troubled at times Avith sciatica. On August 24th, the ball, Avith fragments of clothing, Avas removed. From this time till September 1st the wounds improved. From September 10th till October 1st the patient was not doing soAvell; no loose sequestra could be found. SIoav improvement took place from October 1st to the 9th. On November 15th, the patient was transferred to York. He died of exhaustion on December 22, 1863. Pyozmia or septicemia, the prominent causes of death in nine of the cases already recorded in different parts of this Section, were also the immediate causes of fatality in the three following cases; and in thirty-three, altogether, of the two hundred and eleven fatal cases: Case 671.—Private Levi Carter, Co. K, 13th Ohio Cavalry, aged 24 years, Avas Avounded at Petersburg, April 9, 185.". He was sent from Cit}- Point to Baltimore on April 22d, and entered Jarvis Hospital. Assistant Surgeon DeWitt C. Peters, U. S. A., reported that "a gunshot Avound of the left side was complicated by a fracture of the ilium. Symptoms of pyaemia developed on April 28th. Ueef-tea, stimulants, and other restoratives Avere perseveringly, but unavailingly, administered, and the case terminated fatally April 30, 1865. At the autopsy metastatic abscesses were found in.the lungs." Case 672.—Private D. I>. Doxtater, Co. E, 115th Ncav York, aged 20 years, was Avounded, February 20, 1864, at Olustee, Florida, and Avas admitted, on February 26th, to hospital No. 1, Beaufort, South Carolina. Assistant Surgeon C. E. Goddard reported that " a ball struck the highest point of the crest of the left ilium and passed out at the external border of the left psoas magnus muscle. The patient did Avell, under simple dressings with extra diet and stimulants, until March 13th, when the wound discharge diminished, and there Avas a slight chill, followed by febrile reaction. The stimulants Avere increased in quantity, and an opiate at bedtime Avas ordered. On March 14th, the patient was much worse, and had a severe chill; the pulse was small and rapid, and the discharge scanty and sanguinolent. On March 15th, the respiration Avas labored, the pulse smaller and quicker, the skin of a bright yellow hue, and there Avas a tendency to colliquative diarrhoea. Death took place March 16, 1864. The mesenteric glands Avere filled with pus." Case 673.—Corporal A. A. Rich, Co. G. 122d NeAV York, aged 24 years, was Avounded before Petersburg, March 25, 1865. He Avas transferred from a field hospital of the Sixth Corps to Mount Pleasant, Washington, April 2, 1865. Assistant 2:>0 INJURIES OF THE PELVIS. . (CHAP. vu. Sur(>4, Acting Assistant Surgeon M. C. Mulford exsected two and a half inches of the ilium, extending from tbe superior spinous process down into the body of the ilium, following the course of the fracture, and smoothing off the ragged edges of the bone. At the time of the operation his general condition Avas good. The inflammation of the Avound and putrid discharge, Avith slight rigors, decidedly indicated the extension of inflammation to the peritoneum. The operation Avas folloAved by a copious, thin, dark-colored discharge from the deep and extensive wound. Light and nutritious food, with tonics, were given. The patient died on June 17, 1834. from peritoneal inflammation and gangrene." 1 Lideli., On Gunshot Fractures of the Pelvis, in Am. Med. Times, 1864, Vol. VIII, I>- 135. >w INJURIES OF THE PELVIS. ichaiv VII. Cask 67-.—Colonel A.J. Warner, 10th Pennsylvania Reserves, was Avounded at Antietam, September 17, 1832. lie was struck by a conoidal musket ball an inch obliquely beloAV and behind the anterior superior spinous process of the right ilium. There was not much bleeding or faintness. and the colonel Avas able to dismount Avithout assistance. The ball was found to have perforated the ilium very obliquely from before backward and inward, and Avas out of reach of the linger or probe. After his wound Avas dressed he was sent to Hagerstown, and thence, early in October, to Washington, when Surgeon Meredith Clymer, U. S. V., found that a series of chills had attended the separation of the eschars and the formation of pus, and that the inflammatory reaction had in a measure subsided, the shot orifice discharging freely. There Avas nothing to indicate an abdominal complication. A careful search having failed to detect the missile, the treatment Avas limited to general measures until December, Avhen, on account of the persistent lumbar neuralgia, and of symptoms indicative of confined matter, Surgeon Clymer, in consultation with Surgeon J. H. Brinton, U. S. V., determined on a more extended exploration. Except in removing some bits of necrosed bone, this search Avas unavailing, though carried as far as prudence Avould permit, and no further operative interference was undertaken until February 6, 1863. In the meantime, Colonel Warner suffered from recurring abscess-forma- tion, aud acute pain at intervals; but, endowed Avith an iron constitution, his general health deteriorated less than is common under such circumstances, and there Avas no threatening of pysDinic infection. On February 6, 1883, this officer Avas placed under the influence of chloroform, and Surgeon Brinton made an incision upon the dorsum of the ilium and freely exposed the orifice of entrance in the bone. The Avails of the shot canal Avere then chiseled and gouged away, and, after a protracted search, the ball Avas detected near the sacro-iliac synchondrosis, very firmly embedded in the spongy substance of the ilium. After many unsuccessful attempts Avith various forceps, it Avas at last extracted Avith a strong pair of pincers, and Avith it bits of clothing and of bone. The ball, Avhich Colonel Warner retains in his possession, was split at the apex, and a piece of bone was wedged in the fissure. The operation occupied nearly three hours. Considerable, but not excessive, inflammatory action ensued after the operation; but the local pain Avas diminished, and in a few weeks the Avounds shoAved a disposition to cicatrize. In a few months they healed up, but reopened at intervals for the discharge of phlegmonous abscesses, provoked by small exfolia- tions. The colonel was able to resume his command at Gettysburg, and Avas subsequently transferred to the command of the 17th regiment of the Veteran Reserve Corps and brevetted a brigadier general. He continued to suffer from occasional pus-formations at the seat of injury until the end of 1838, Avhen the cicatrices became firmly adherent to the dorsum of the ilium, and free from sensitiveness, except in damp Aveather. His ordinary Aveight of one hundred and eighty pounds gradually augmented to tAvo hundred pounds. He was pensioned. Examiner G. O. Hildreth, of Marietta, reported, November 2, 1837, the shot perforation of the ilium, and subsequent extraction of tlie ball, and stated that: "He suffers from neuralgic pain around the Avound, and on the outside of the leg in the course of the sciatic nerve, especially in cold and damp Aveather." In October, 1873, the editor met this officer and learned the foregoing facts, many of which had not been placed on record. Case 079.—Private George R. Brooking, Co. D, 18th Michigan, aged 22 years, was Avounded at Gaines's Mill, June 27, 1862. He remained at the field hospital until July 20th, Avhen he Avas conveyed, on the hospital steamer Louisiana, to Baltimore, and admitted into the Camden Street Hospital. Here Acting Assistant Surgeon E. G. Waters reported as follows: "A conical bullet, about one ounce and a quarter in Aveight, entered the right buttock, passed horizontally forward through the dorsum of the ilium about three inches below its crest and the same distance from the sacrum, and lodged Avithin the cavity of tho pelvis. The external wound healed sufficiently "in a few Aveeks to admit of his going out into the city daily. The external Avound opened again from time to time, and, on one of these occasions, Acting Assistant Surgeon A. W. Colburn, whose patient he then was, desired me to see him. I discovered satisfactorily, with an ordinary probe (the Nelaton instrument had not then been introduced), a foreign body lying within the cavity. A few days afterward, through the transfer of Dr. Colburn to West's Buildings Hospital, the patient came under my care. lie readily consented to an attempt at removal of the foreign body. Accordingly, on April 9, 1833, he was put under chloroform, and, after an hour's effort, during Avhich it Avas necessary to chisel away much bone in order to reach its locality, the bullet Avas successfully seized and removed. It seemed to have pushed before it the long wall of the pelvis, and lay at the bottom of a tubular cavity of bone, fully four inches from the external surface. No accident followed the operation, and, on July 1, 1833. he left the hospital, cured, for his home, having been discharged from service." This man Avas pensioned. Drs. A. Farnsworth and A. B. Spinney, of East SaginaAV, Michigan, reported, July 30, 1883, that the "ball struck upon the right posterior iliac region about tAVO or three inches to the right of the junction of the last lumbar vertebra with the sacrum, fractured the bone, and, passing through, lodged upon the internal surface of the right ilium. There is much lameness of the spine aud right hip; coldness and numbness of the limb, caused by injury of the nerves." He was last paid December 4, 1872. • Case 680.— Private J. Stichler, Co. G, 184th. Pennsylvania, aged 18 years, Avas wounded at Deep Bottom, Virginia, on August 14, 1864, by a conoidal ball, Avhich entered to the right of the last dorsal vertebra, passed inward and doAvmvard through the dorsum ilii, and lodged in the right iliac fossa. Being sent to Washington, he Avas admitted into the Emory Hospital on the 17th. On the 19th, Surgeon N. R. Moseley, U. S. V., removed the hall (FlG. 176) through an incision of two inches, with small fig. 176.—Conoldalball 15. Surgeon A. 15. Ilasson, U.' S. A., sent to the Museum, with the foregoing particulars, a specimen of the exfoliation removed (Fig. 178)! It consists of a fragment, three-fourths of an inch square, from the iliitm, the laminated surface of Avhich appears to have been partially fractured as if by a nearly spent ball. Pension Examiner L. II. Kobbins, of Lincoln, Nebraska, reported. August 31, 1871: "Pali entered at the upper edge of the superior spinous process of the ilium, fracturing it, and passing into the cavity. There has been a constant discharge through a fistulous opening in the wound, causing great debility, and rendering him unable to perform manual labor; the disability will probably be permanent." He was last paid to June 4, 1873. ' Cask fii-v.-Sergeant H. Oswald, Co. M, 24th New York Cavalry, aged 23 years, was wounded at Cold Harbor, June 3, IS,,}, and sent to Alexandria on the 8th, and thence to Philadelphia, entering Mower Hospital on the 29th. Here Actii." Assistant Surgeon B. Barr reported: "The ball entered the left groin, passing through the left ilium, and lodged near the trochanter major, whence, on July 9th, it was removed, with several pieces of bone, by Acting Assistant Surgeon W. P. Moon The patient did well after the operation. Simple dressings only were used. Wine, brandy, milk-punch, and beef-tea were administered as freely as the patient could take them." Surgeon J. Hopkinson, U. S. V., contributed the pathological specimen, i\o. 3619, consisting of sixty-three small osseous fragments, some necrosed, others constituted by iicav osteophytes, weighing in the aggregate eighty grains. The ball remained in the soldier's possession. He is not a pensioner, being recorded a deserter. Case GS3.—Private B. Cook, Co. I, 63d Pennsylvania, aged 18 years, was Avounded at White Oak Swamp. June 30, 1832, by a musket ball, which grazed the.outer surface of the right arm midway between the shoulder and elbow, and by a fragment of shell, which fractured the crest of the right ilium. He Avas admitted on the hospital steamer Louisiana, on July 20th, as a paroled prisoner of war, and transferred to Baltimore, Avhere he was admitted to Camden Street Hospital on the 21st. At this time he was feeble, and was treated with water dressings locally, and tonics and stimulants. On August 21th, the necrosed surfaces of the ilium were removed Avith the gouge, and small fragments that continued to separate were frequently removed subsequently. On November 21, 1832, he Avas discharged the service cured, there being at this time some contraction of the upper muscles of the thigh, and the foot could not be kept long on the ground Avithout inconvenience. The specimen (Fig. 179) consists of six small fragments of dead bone from the ilium, and was contributed, with the history, by Dr. E. G. Waters, and "transmitted by Surgeon L. Quick, U. 8. V. Pension Examiner G. McCook, of Pittsburg, reported, February 16, 1833: "Locomotion is considerably impaired; the case will be probably improved by time; disability one-half." The pensioner was last paid in November, 1833. No subsequent report to the third auditor. When a missile perforates the ilium and lodges under or in the iliacus or psoas muscles, Baudens teaches1 that it is safer to seek the ball through an incision similar to that made for ligation of the common iliac artery, rather than to enlarge the shot canal in the ilium or to trephine the bone. Fig. 17t).—Necrosed frag- ments removed after a shut fracture of the ilium. Spec. 432. DAUDKNS (Clin, des plaies d'armes H feu, 163G, p. 398) teaches: 'Tl faudrait alors faire agir le tire-fond obliqnement a leur surface et peut-etre meme le rejeter, pour reeourir au trepan. Ce moyen est Sgalement conseille pour retirer les balles profondement engages, et dont la presence ferait redouter la format.on d'abees et de fus6es purulentes funestes. Cette perte de substance csseuse aurait le double avantage d'ouvrir une facile issue A la suppnration et de preparer ainsi les voies d la guerison. Dans une circonstance <;ii a laide dune s, nde javais pu suivrc, a travers une perforation de l'os i laque du cote" droit, le trajet dune balle jusque dans la substance du muscle psoas ou elle s'etait arretee, j'ai rejete le trgpan, et j'ai prefere arrivcr irectement et bien plus surement au projectile en ouvrant l'abdomen par une incision courbe, faite dans le pli de l'aine, comme pour la ligature de 1 artere hypogastrique." 2:U INJURIES OF THE PELVIS. jciiap. vii. There is reason to believe that in some cases of limited caries, after shot fracture, in subjects of sound constitution, palliative measures may be followed by radical cures. Tbe orifice or orifices of the shot canal being kept open, and the fistulous track gently stimu- lated and kept free from minute exfoliations by detergent injections, cicatrization may ensue, without the risk of removing the osseous wall. When, as in the following case, a formal excision would involve breaking down the inner lamina of the ilium, the operation becomes very hazardous: Case 087.—Colonel Joseph B. Kiddoo, 22d Colored Troops, aged 30 years, Avas Avounded in an engagement before Richmond, October 27, 1834. Surgeon Charles G. G. Merrill, 22d Colored Troops, recorded the injury as a "lacerated Avound of the back by a mini6 ball." On October 29th, this officer was sent to Chesapeake Hospital, near Fort Monroe. Assistant Surgeon E. McClellan reported the injury as a "shot wound in the lumbar region, involving the spine." The particulars of the case are not found on the hospital registers or case-books. On January 11, 183."), Colonel Kiddoo was transferred from the hospital and Avas treated in quarters at Washington. On September 4th, he avus brevetted a major-general of volunteers; on July 28, 1833, he was commissioned lieutenant-colonel of the 43d Infantry; on December 15, 1870, he was retired from active service with the full rank of brigadier-general, U. S. A. In Washington, this officer Avas attended by Assistant Surgeon Notson, II. S. A., and it is believed that a memorandum of the facts of the case Avas furnished by him for the files of the Surgeon General's Office, but no record of this paper has been found. In the autumn of 1833, Assistant Surgeons Thomson and Billings saw the case in consultation with Dr. Notson, and an operation Avas determined on for the removal of dead bone or other sources of irritation. Dr. Billings has kindly furnished the following minute of his recollection of the circumstances: "When seen by Drs. Thomson, Notson, and myself," Dr. Billings writes, "there Avas a fistulous opening near the anterior superior spine of the left ilium, from which from half an ounce to an ounce of pus discharged daily. Exercise produced pain in the sacro-iliac junction, Avith tendency to cramp in the posterior muscles of the left thigh. A canal with bony Avails, about the size of a goose- quill, Avas found to lead from the opening doAvmvard," backward, and imvard, the probe passing freely for about eight inches. The outer opening Avas enlarged by incision, and the edge of the bony canal Avas cut aAvay with the bone-gouge forceps. Several scales of dead bone Avere removed from the canal and its walls were scraped out with a raspatory. It Avas then thoroughly syringed out, and the patient Avas directed to lie on his abdomen as much as possible for a few days, to keep the opening at the lowest point. Subsequent treatment consisted in syringing the canal Avith a very dilute solution of carbolic acid. The wound entirely closed, and gave him no trouble for two or three years. I believe it has since opened once or twice." NotAvithstanding the occasional inconvenience arising from his Avound, it is gratifying to knoAV that General Kiddoo, in 1873, nearly ten years after the reception of his injury, enjoys tolerable health, and is enabled to engage in laborious professional avocations. Cask 68-\—Private II. G. Bigelow, 15th Massachusetts, was Avounded at Antietam, September 17, 1832. A musket hall, Avhich struck just beltnv the anterior superior spinous process of the left ilium, channelled the crest of the hone, and escaped near the sacro-iliac junction an inch beloAV the posterior superior process, carrying some splinters out of the orifice. On September 22d, his surgeon (the lamented Haven, killed a few months afterward at Fredericksburg) made an incision three inches long midway betAveen the entrance and exit orifices, and removed several fragments of shattered bone, of Avhich three were seen each at least an inch long, three-quarters of an inch in width, and of the entire thickness of the ilium. In December, the patient was removed to his home in Berkshire County, and Avas attended by Dr. Frank A. Cady, Avho has published an interesting history of the case at this stage.1 In January, 1833, there avas pus suppuration from the orifices of entrance, incision, and emergence, Avith occasional escape of necrosed bone. On January 27, 1863, Mr. Bigelow was promoted to a lieutenancy. The shot canal was daily syringed Avith a dilute solution of nitrate of silver. On March 15th, the wounds had cicatrized, and the lieutenant reported for duty, and was transferred to the Veteran Reserves, and resigned August 28, 1863, aud was pensioned. On May 2, 1871. Examiner J. B. McNett, of Grand Haven, Michigan, reported that "numerous pieces of bone had been discharged through a fistulous opening, and a constant drain of pus had seriously affected his health. He is a book- keeper by profession, but will have to resign his position on account of ill health." Case (580.—Private J. A. Cole, Co. H, 25th IoAva, aged 23 years, Avas wounded at Arkansas Post, January 11, 1863, and was conveyed on the hospital transport Louisville to the Adams Plospital at Memphis. A musket ball had struck the posterior superior process of the left ilium and buried itself in the bone, whence it was extracted soon after the reception of the injury. On April 10, 1833, Acting Assistant Surgeon T. T. Smiley cut down through the indurated tissues near the wound entrance and removed a number of loose pieces of necrosed bone, and then, with the gouge and rugine, scraped cleanly the neighboring carious bone, leaving a cavity of the size and shape of half an egg divided longitudinally. Dr. Smiley has printed an account of the operation, Avith a prognosis that was unhappily not verified.2 The patient Avas transferred to Lawson Hospital. St. Louis. April 17, 1863, and, on June 9th, was sent t.o Keokuk, when he was discharged from service September 6, 1864, Surgeon M. K. Taylor, U. S. V., certifying that there avus "atrophy of the gluteal muscles and loss of sensation throughout the entire left leg." The pension records show that this pensioner died January 30, 1865. Aii analysis of the one hundred and fifty-one operations on the ilium shows eighty- two instances of removal of bone, thirteen of removal of ball with bone-splinters, fifty- five of extraction of balls, and one of extraction of a piece of cloth. In four of the eases 1 Cady (V. A.}, Gunshot wound, in Extracts from the Records of the Berkshire District Medical Society, Boston Med. and Surg. Jour., 18G3 Vol LXVIII, p. -Sfi. 2 Kami.ey. Gunshot Wounds from Arkansas Post, in Boston Mi d. and Surg. Jour., 1803. Vol. LX1X. p. 154. sect, l.] SHOT FRACTURES OF THE ILIUM. 235 of removal of bone and in two of the ball-extractions, portions of clothing also were removed. Of tlie eighty-two operations for the removal of bone, eight consisted in the primary extraction of splinters, and of these cases three resulted fatally; two were instances of formal trephining, one proving fatal and the other failing to effect a perma- nent cure; fifty-seven, with six deaths, were secondary operations, consisting of the removal of exfoliations or of large pieces of necrosed bone, or of the application of the gouge or chisel to carious parts; and fifteen were extractions of sequestra at unspecified dates. Of the thirteen examples of removal of balls1 with bone splinters, two were primary, one resulting fatally; ten, with one fatal instance, were secondary; and one case, with a favorable termination, was of uncertain date. Of the fifty-five ball extractions, fourteen, with five fatal terminations, were primary; thirty-two, with six deaths, were secondary; and nine operations, with three deaths, were of undetermined date. In a single case, a piece of cloth only was removed at a long interval after the injury. In the aggregate, there were twenty-nine fatal cases, or the small percentage of 19.2; twenty-four primary operations, with nine deaths; one hundred and two secondary, with fourteen deaths; twenty-five of undetermined date, with six deaths. In other words, the mortality of the cases in which operative interference2 was undertaken was less than the mean mortality of shot fractures of the ilium, computed from the eight hundred and nineteen known cases with two hundred and eleven deaths, or 25.7 per cent. Sufficient evidence has been adduced to prove that authors have erred in representing shot fractures of the ilium as being dangerous, and to iudicate that the prognosis of Percy should be re-established.3 Professor Hannover, from researches among the Danish invalids, appears first to have noticed this er,ror of the moderns. 1 PlKOGOFF (Grundzuge, a. s. w., I8fi4, S. 835) remarks : " If the bone be at all accessible. I advise, during' the period of suppuration, instead of a tedious, uncertain, and dangerous extraction, the resection of the bone which holds the missile." - Lisfranc (Precis de med. opirat, Paris, 1846", T. II, p. 548) remarks: '• Chez le malade qui tout rficemment a regu un coup de fusil pres du bois du Jleudon, M. VICTOR Baid a enlcve un fragment osseux assez considerable provenant de cette crete." Heyfelder (J. P.) (Gunther, Lehre. von den Blutigen Operationen, I860, I!. IV, S. 2) successfully removed, at Lrlangen, in 1847, a necrosed portion of bone, three inches long, from the ilium at Ihe antero-intemal margin of the ischiatic notch. In a case in which a ball penetrated the ilium an inch below the middle of the crest, and many bone splinters could be felt deep in the wound, and the ball was supposed to have lodged, Dr. LABEK (Preuss. Med. Vereinszeitung, XVIII, 1849) enlarged, two months after the reception of the injury, the shot channel with a trephine, introduced a finger, and removed splinters of bone; the ball could not be found ; the patient recovered in seven months. Heyfelder (J. V.) removed (Beitrage zur Operat Chir., in Deutsche Klinik, 1858, B. X, S. 204), December 23, 1857, the necrosed anterior superior spine of the ilium with a chain saw, in a patient whose pelvis had been fractured in a railway accident; death occurred two days after the operation. Dr. Xeudorfer (Handbuch der Kriegschir., 18C7, S. 804), in the case of Josef Ilacha, a Tyrolean sharp- shooter, shot in the ilium at Solferino, June 24, 185:1. on December 13,1859, enlarged the shot channel with a chisel; the ball was not found, but on cutting away several osteophytes and a point of bone which obstructed the entrance of the shot canal, necrosed fragments were removed ; recovery in two months. Dr. Roux (J.), in Chenu (Statistique med. chir. de la campagne d'Italic en 1859 et 18G0, Paris, 1869, T. II, p. 505), records the case of A. Duprez, wounded at Magenta, June 4, 1859, in the left flank. In October an incision was made, the trephine applied, and Ihe ball with difficulty removed with pincers. Inflammation, oedema, etc.. supervened, and the patient died January 3, 18Gb". DEMME (Studien, WUrzburg, 18G1, B. II,* S. 171) gives the case of G. B., wounded at Solferino, June 24, 1859; the ball entered the ilium and was said to have been extracted at the ambulance station ; several pieces of bone had been removed ; the patient was failing from consecutive caries and suppuration. On October 5th, Dr. Keudokfeu removed the carious portion of the anterior crest of the ilium and extracted a piece of ball that had remained; the patient made a good recovery. Dr. NeudoRFER makes no mention of this incident. Sieuert (Statistilc der Resectionen ausgefiihrt von Professor F. ElEn, Jena, 18(i8, S. 38) states that a triangular piece cf necrosed bone was removed from the right ilium with the osteotome by Dr. ItlED ; recovery. Vaslin (Etude sur les plaies par armes a feu, Paris, 1872, p. 100) relates the case of E. Dumard, wounded near Orleans, December 2, 187.'. in the right ilium. On March 26, 1871, M. LEON Labbe made a free incision and enlarged the shot canal with a gouge and mallet and removed the ball; the patient left the hospital on July 8, 1871. Professor SOCIN' (Kriegschirurgische Erfahrungen, 1670, (3. 17) remarks that in the case of Desire Blot, wounded at Gravelotte, August 18, 1870, Professor Heine made a partial resection of the crest of the ilium ; several necrosed fragments of bone were afterward removed, and the wound did not completely close until the 142d day. 3 Baron Percy (Man. du Chir. d'Armee, 1792, p. 242) taught that " Les fractures des os des iles ne sont par dangereuses." In departing from this precept Hexnen has been followed by most modern surgeons: Thus, Dr. STUOMEYEU (Maximen, u. s. w., 1855, S. 655) asserts that: " Injuries of the pelvis must be considered as dangerous as injuries of the head." DEMME (Studien, B. II, S. 176) gives the same opinion. Guthrie (Lectures, etc., 1847, p. 60) observes that: "Although frequently fatal, they are not usually so at the moment." Dr. LOHMEYER (Die Schusswunden, 1859, S. 147) declares : " Death is the most frequent result of shot fractures of the pelvis." Dr. OCHWADT (Kriegschir. Erf, 1865, S. 351) announces that: "Accord- ing to our observations we must consider shot wounds of the pelvis, with or without injury to the viscera, very dangerous." On the other hand, M. Hlguier (Desplaies d'armes a feu, etc., 1849, p. 132) contends that in comparison with wounds of the head, chest, and abdomen, " Celles du bassin sont moms mortelles, meme avec lesion des organes qu'il contient." Herr BECK (Kriegschir. Erf., 1867, S. 250) has found "the results various, but not as fatal as generally supposed;" and Dr. Neudorfer (Handbuch, etc., 18G7, S. 763) errs in the opposite direction in declaring that: " Shot wounds of the pelvis, without injury to the viscera, are never fatal, and not even dangerous, but as a rule heal slowly." Professor Haxnovkr (Die Danischen Inoaliden, 1870, S. 20), than whom few have more carefully studied the remote results of injuries, has arrived at the conclusions enunciated in the text. 236 INJURIES OF THE PELVIS. iciiai'. vu. Though the limits that would be assigned to this subject by the usual nosological classifications have been transgressed, the materials relating to it have by no means been exhausted. The Catalogue of the Surgical Section will direct the student, in addition to those that have been presented, to many interesting examples in the Museum, of shot fractures of the ilium and of the destructive and reparative processes consequent on them, and particularly to the specimens marked 2483. 3525, 3872, and 6313. One of these, of which there is no available drawing, illustrates the splitting of a ball upon the outer lamina of the ilium,1 and closely resembles the preparation (Fig. 180), already alluded to, as figured by M. Legouest. In treating of the injuries of the hip joint there will be occasion to revert to some of these illustrations. Many interesting abstracts of war cases of shot fracture of the ilium have appeared in the journals or in surgical treatises: Surgeon J. Bryan, U. S. V., has related2 the case of Private J. B. Edgar, convalescent after necrosis following a shot fracture of the crest of the right ilium. The lamented J. Mason Warren recorded3 a difficult ball extraction in the case of Private W. 0. Young, 1st Massachusetts, through a track leading for several inches through ne. i8o—Han split and resting the gluteal muscles, to a chipped fracture at the inner edge of astride of the outer table of the right .. . .. ,.-.. 1*1 ilium (Musie du vai-de-Grdce.) [After the great sciatic notch, an excruciating neuralgia being relieved lbooukst.] o ' n O D by the removal of the missile. Other instances will occur to those who study the annals of war surgery4 or follow the current of periodical surgical literature.5 1 Professor P. F. Eve states (Nashville Jour, of Med. and Surg., 18G7, Vol. II, p. 232) that this splitting of the ball upon the ilium occurred also in the case of Governor G. MacDuffie, of South Carolina, wounded in a duel. The position of the missile was not detected, and the statesman died from irritation induced by its presence, in 1851. 2 Bkyan (J.), Gunshot wounds in the Army—Injuries of the Pelvis, in Boston Med. and Surg. Jour., 1862, Vol. LXVI, p. 49. 3 Warren (J. M.), Surgical Observations, with Cases and Operations, Boston, 1867, Obs. CCCXXVIII, p. 551. 4 The eleven following cases, in which the results are recorded by authors, may be added to the fifty-five determined cases enumerated in the note to page 21G : BORDENAVE (Pricis de plusieurs observations sur les plaies d'armes a feu en diff. parties, in Mim. de I'Acad. Roy. de CJi ir., Paris, 1753, T. II, p. 522) relates a successful ease of a shot fracture of the ilium, treated by Planque. Hexxex (Princ. of Mil. Surg., 1829, p. 450) cites a case treated by Dr. Thomson: An office^ wounded in the ilium bya ball, "where it remained above two years, until violent inflammation having been excited by dancing, it was luckily discovered, and extracted with considerable difficulty"—recovery. Guthrie (Commentaries, 6th ed., Loudon, 1855, p. 597) gives four cases of recoveries of fractures of the ilium: Colonel Wade, woundedat Albuhera. in 1811; General Hercules Pakenham, wounded at Badajos, April 6, 1812; Colonel Wilson, shot at Chippewa, July 5, 1814 ; and a soldier wounded at Salamanca; also one fatal case, John Bryan, wounded near Qnatre-Bras, June 17, 1815. Laruey (H.) (Hist. chir. da siige de la citadelle d'Ancars, Paris, 1833, p. 167) records a case of recovery after comminuted shot fracture of the ilium. Joiseut (Plaies d'armes a feu, Paris, 1833, p. 224) narrates the case of R------, a recovery from shot fracture of the ilium. Vasi.ix (£tude sur les plaies d'armes a feu, 1872, p. 98) cites two cases (Obs. XXVII and XXVIII) of shot fractures of the ilium. at the engagements at Villiers sur-Mame, and near Orleans, December 2, 1870; the former case was fatal, the latter terminated successfully. M. Chexi' (Camp. oVOrient, op. cit, p. 200 et seq.) gives abstracts of the cases of twenty pensioners, with shot fractures of the ilium ; and (Camp, d'ltalie, op. cit. T. II, p. 507) similar abstracts of cases of no less than forty-five men pensioned for disability arising from this cause. 5KlMliALL (G.) (Boston Med. and Surg. Jour., 1849, Vol. XL, p. 40) relates the case of Private G. Church, Massachusetts Volunteers, wounded at Molino del Rey, September 27, 1817. by a ball which fractured the ilium. Surgeon II S. Satterlee, U. S. A., made an immediate but unsuccessful search for the ball. The patient was discharged from hospital in five months. Epileptic paroxysms frequently recurring, in October, 1848, Drs. Guiteau and Kimhai.l enlarged a fistulous sinus leading toward the anterior superior spinous process and extracted the ball. The epileptic seizures thence- forward ceased, aud the patient was convalescent at the date of the report. Hamilton" (F. H.) (Am. Med. Times, 1864, p. 217, and Treatise on Mil. Surg.. If 65, p. 328) records six fortunate (uses of shot penetration in the inguinal region, in five of which the pelvic bones were supposed to be interested ((.'ases of Grant, Knoll, Haynes, a soldier of the 51st Georgia, and Private T. Walter): [Grant's case was a shot perforation of the ilium, treated at Frederick ; a piece of dead bone was extracted. He was examined for pension, but dropped for some informality; he had incontinence of urine. Knoll was trans- ferred to Fort Wood for exchange. Haynes recovered from a shot fracture of the left ilium, was pensioned, and, in March, 1873, suffered from weakness and numbness in the back and left lower extremity. Cf Walter and the Confederate soldier no records appear.] Mercer (Chicago Med. Jour.. \-"i>i. Vol. XXVII, p. 676, and note 1 to p. 107, ante) gives a case of elimination of a fragment of ilium by the anus after a shot fracture. Bkioham [('. 15.) (Boston Med. and Surg. Jour., 1871, X. S.. Vol. VII, p. 58) records a case of grooved shot fracture of the left ilium, with faecal fistula and lodge- ment of the ball in the buttock, in the case of J. M------. aged 26, treated at the '•International Ambulance,1' at Nancy. Rankin (Surgical Cases, in Am. Jour. Med. Sci.. 1864, Vol. XLV1II. p. 67) prints a case of recovery from a shot fracture of the left ilium: Case of Private Rosenbury, Co. K. 93d Pennsylvania. Wells (\V. L.) (Med. and Surg. Reporter, IKiif, Vol. XV. p. 433) publishes the case of Private J. Strunk, Co. <;, 142d Pennsylvania, wounded at Petersburg, June 21, 186-1, treated at McClellan Hospital for a shot fracture of the right ilium, died January 29, 1865, after diffuse su;-; u- ration. o MEAGHER (W.) (Gunshot Wounds of Prlds: in Am. Med. limes, 1862. Vol. IV. p. 6) reports a fatal shot perforation of the ilium, with intestinal lesions. TEKRY (C.) (Confederate Stales Med. awl Surg. Jour., 186), Vol. I, p. 77, Obs. 46 and 17) records two examples of recovery from shot fracture of the wing of the ilium. BUTLER (\V. H.) (Buffalo Med. and Surg. Jour., 1861, V<>1. Ill, p. 45'.i) records a case of shot fracture of the ilium, with ve>.;al complications. ROBlllNs (Proc. Clinico-Path. Sic., in .4m. Jour. Med. Sci., 1868, Vol. LV, p. 124) prints a report of the same case. SECT. I.] SHOT FRACTURES OF THE PUBIS. 237 It was found to be peculiarly important, in this group of injuries, to explore the shot canal thoroughly before inflammatory swelling supervened, and to remove all splinters and foreign bodies; but the treatment may be more conveniently considered after examining the injuries of other pelvic bones.1 Shot Fractures of the Pubis. — Eighty-six cases appear on the returns as partial or complete shot fractures of this bone. The average fatality of these injuries was much greater than attended corresponding lesions of the ilium, as forty-three, or half of the patients, died. Fourteen of the cases, at least, were complicated with lesions of the bladder, and at least eleven with lesions of the rectum ;2 and other • ,-i "il • • • •,] fil • i ,• I'1|(}- 181.—Ball embedded iu the ramus of cases were associated with injuries either ot the penis, testis, the left pubis, spec. 1603. prostate, spermatic cord, femoral vein, or crural nerve. In the case of Corporal F-----, related on page 184 (Case 588), the ball was found embedded in the horizontal ramus of the pubis,3 near the rim of the acetabulum, as represented in Figure 181.4 No other part of the bone lias enough spongy texture to readily admit of the impaction of projectiles, and, in most of the preparations that have been preserved, balls have notched5 the horizontal or perpen- dicular ramus, as in the specimen represented by Figure 182, from a case of perforation of the bladder and rectum, that will be related hereafter. The pubis is a tough bone, and, according to specimens 11 -1-1 11-j_!11j_Tj_ 1 PIG- 182.—Inner surface examined by me, seldom much splintered by shot, in two examptes of right pubis, the hori- . _ .. -ill n i zontal ramus notched by a of its iracture bv crushing- weisrhts, that have come under my observa- musket ban. spec. 3751. •J C> ^ . J [Half-size.] tion, the absence of comminution was also remarkable.6 The distri- 1 The Museum of the Boston Society for Medical Improvement (Cat, 1847, p. 45) possesses a shot fracture of the ilium from Waterloo, Specimen 199. The Musie Dupuytren has the two perforations figured on p. 218 (Fins. 150, 151, supra), presented by Baron Dupuytren (Cat, 1842, p. 24). The Musie Vrolik (Cat, 1865, p. 327) possesses the left innominate of a soldier, the external lamina cleanly perforated, the internal more splintered ; the ball entered the peritoneal cavity. Flscher (II.) figures (Kriegschir. Erf, Tap. IV, 24) a fine specimen of shot fracture cf the posterior crest of the left ilium. The Museum of the College of Surgeons of Edinburgh (Cat, 1836, p. 24) possesses an ilium, Specimen 198, XX. D., struck by a small rifle ball. In the Hunterian Museum, in Series LXIV, Specimen 2916 A is the greater part of the right ilium shattered by shot, from a British soldier, wounded at Sebastopol, August 17th, who died September 2, 1855. (Desc. Cat, Supplement I, 1863, p. 91.) 2 This is probably much less than the real proportion of visceral complications. Many cases are reported of wounds of the bladder and rectum " with Fracture of the pelvis," but without specification of which bone of the pelvis. 3DUVEUNEY (Traiti des mat des os, 1751. T. I, p. 283) has, according to Malgaigne, priority in describing fractures of the pubis also. Accord- ing to hie observations, and those of NIVET (Bull, de la Soc. Anat, 1837, p. 194), of Mabet (Obs. sur lesfract des os du bassin, in Mem. de I'Acad. de Dijon, 1774, T. II, p. 85), of A. CoorER (A Treatise on Dislocations and Fractures of the Joints, 4to, 1823, p. 105), of Whitakeu (Am. Jour. Med. Sci., 1857, Vol. XXXIV, p. 283), uncomplicated fractures of the pubis are not dangerous ; but the shot fractures are rarely uncomplicated. 4 The examples of shot fractures of the pubis recorded by authors are not very numerous. Ttlpius (Observationes mediae, Lugduni Bat., 1716, Lib. IV, Obs. XXX, p. 323) relates a successful case of shot fracture of the os pubis, with injury of the bladder. GUTHRIE ( Wounds and Inj., etc., 1847, p. 67) refers to a case treated by Dr. WALTZ, and recorded in Graefe and Waltiier's Journal: the ball passed through the cs pubis and bladder; slow recovery. Beutheuaxd (Camp, dfi Kabylie, 1862, p. 298) records two fatal cases of shot fractures of the pubis: Ricois, trumpeter, 54th voltigeurs, wounded June 24, 1857, died August 27th ; and P------, 75th of the line, wounded June 27th, died July 21, 1857. Both succumbed from purulent infiltration and pyaemia. Lohmeyer (Die Schusswunden, 1859, S. 141) records a rapid recovery of a soldier of the 6th Schleswig-Holstein battalion, wounded October 4, 1850, from a shot fracture of the descending ramus of the os pubis; and a fatal instance, at the same engagement, in a soldier of the 11th battalion, in whom the tuberosity of the ischium was likewise mvolved, and deathjensued from pyaemia. BECK (Chir. der Schussverletzungen, 1872, S. 554) describes a fracture of the horizontal ramus of the left os pubis from a splinter from a hand grenade ; death from septicaemia. H. Fischer (Kriegschirurgische Erf, 1872, S. 184) gives two fatal cases of shot wound of the os pubis : one of the patients died of pyaemia ; in the other case the hip joint was involved. RUPI'RECHT (Militdrarztliche Erfahrungen, 1871, S. 60) relates a case of fracture of the os pubis, fatal in thirty-three days from pyaemia. Dow (T. C.) (Nashville Jour. Med. and Surg., 1867, Vol. Ill, p. 161) relates the case of J. B------, Co. II, 3d Tennessee, wounded February 24, 1865, a shot fracture of the left os pubis, complicated with wound of the bladder. An operation for urinary fistula was practised by Professor P. F. Eve, M. D., two years later. Dr. CllISOLM (Manual of Mil. Surg., 3d ed., 1863, p. 352) records a recovery from a complicated shot fracture of the right os pubis, in the case of Private Moore, Co. E, Palmetto Sharpshooters, wounded June 29, 1862, before Richmond. Dr. MACLEOD (Notes on the Surgery of the Crimean War, 1858, p. 275) gives two .cases of recovery after shot fractures of the pubic bone. Professor HANNOVER (Die Ddnischen Invaliden aus dem Kriege 1864, S. 20) records a recovery after shot fracture of the pubis, with false anchylosis of the hip. A total of fifteen cases, with seven deaths, or 46.6 per cent. 6 Dr. J. H. Packard (Proc. Path. Soc. Phila., 1862, in Am. Jour. Med. Sci., 1862, Vol. XLIV, p. 109) records also an autopsy in a case of shot fracture of the pubis, in which this notching of the bone without. Assuring was observed. "Compare also a specimen in Dr. Neill'S Cabinet, figured by Professor GROSS (System, 5th ed., 1872, Vol. I, p. 969, FIG. 430). and an article by Dr. J. W. LODGE (Extensive Fracture of the Pubic Bones, in Am. Jour. Med. Sci., 1865, Vol. L, p. 404). INJURIES OF THE PELVIS. IC1IAP. VII. FlO. 183.—Anterior halves of the ossa innominata, die left pubis notched by a ball. Spec. 4076. bution of the ligaments and fascia partly account for this. When the loss of substance or displacement is not great, repair appears to progress rapidly, and caries seems to follow shot fracture less frequently than in the ilium. In fourteen or more of the cases, bone splinters were picked out early; in seven, balls were removed; in two, other foreign bodies were extracted. Peritonitis supervened in seven cases, and nine patients, at least, perished from pysemia. The last complication being more .frequent in shot fractures of the ilium than in those of the pubis, while the mortality of the latter was double that of the former, the causes of the difference are explained by the greater frequency of sloughing of the pelvic fascia, of injuries of vessels and nerves, and of urinary and fsecal extrava- sation, in the pubic fractures. The illustrated Gases 691 and 698 exemplify what appears to be the most common form of shot fractures of the pubis: Case 690.—Private H. C------, Co. H, 15th New York Heavy Artillery, aged 29 years, received a wound at South Side Railroad, on March 31,1835, from a conoidal ball, which entered the left groin two and a half inches internally to the anterior superior spinous process of the ilium, and emerged at the right natis. fracturing the left ramus of the pubic bone, and cutting across the membranous portion of the urethra. He was sent to Washington, and admitted into Emory Hospital on April Eth. The catheter could not be introduced, and on the 6th the urine escaped from the posterior wound. On the 12th, diarrhoea set in, and death followed on April 14, 1835. The autopsy revealed "sphacelus of the peritoneum and a deposit of plastic lymph on the internal coats of the bladder." A portion of the bones of the pelvis, showing the lesion in the pubic bone, was contributed to the Museum, with the foregoing history of the case, by Acting Assistant Surgeon L. M. Osmun (FlG. 183). A permanent cure after a shot fracture of the pubis was obtained in the following casc\ which derives interest also from the difficulties attending the detection and extraction of the ball: Case 691.—Lieutenant-Colonel Charles L. Pierson, 39th Massachusetts, was wounded at an engagement near the Six- mile House, Weldon Railroad, August 18, 1864, and was taken to the 3d division hospital of the Fifth Corps. Surgeon L. W. Read. U. 8. V., reported "a gunshot wound penetrating the pelvic cavity." The Massachusetts Adjutant General1 states that the wound was considered mortal. The following day the colonel was sent to the depot at City Point, where Surgeon W. L. Faxon, 32d Massachusetts, described the injury as a dangerous shot wound of the abdomen. On September 10th, the late Assistant Surgeon J. Sim Smith, U. S. A., saw the patient, and included this case in an important report made by him on the usefulness of the Nelaton probe, relating the circumstances as follows: "Lieutenant-Colonel Pierson, 39th Massachusetts, who had been wounded August 18th, by a ball, which had penetrated the pubis on the right side, near the symphysis, and entered the pelvis, stated that at the time he was shot he was standing erect, and that after receiving the wound he walked some distance. When I saw him, he was lying on his back, with his thighs flexed upon the abdomen, which was tender and tympanitic, with an ecchymosis extending over the iliac and hypogastric regions. He had well-marked symptoms of peritonitis and cystitis, with a profuse and fetid discharge from the wound. After complete anaesthesia had been induced, a flexible catheter was passed into the wound to ascertain the course of the ball. It was found that after it had passed through the pubis and penetrated about two inches obliquely to the left, it had turned still more to the left and passed transversely across the pelvis. A Nelaton probe, with a flexible shaft bent to suit the course of the wound, was then entered without difficulty for about eight inches, and upon its removal the metallic lustre upon the porcelain bulb was very distinct. Being still uncertain as to the exact locality of the ball, the probe was again introduced, and it was found that pressure made upon the left side, behind the trochanter major, caused the probe to be thrust from the wound. Upon cutting directly down behind the trochanter, the ball was found lying almost in direct contact with, and upon the outer side of, the femur. The extraction of the ball was followed by a free discharge of fetid pus, and in a day or two his condition improved, and he is now recovered." The missile (FlG. 184) was sent to the Museum by Dr. Smith. Promoted to a colonelcy this officer was honorably discharged January 4, 1335, and pensioned. The Pension Fig. 184.—Conoidal ball Record states that, on March 5, 1865, the wound was still open and discharging, and the disability battered in fracturing the was rated at three-fourth", r.nd probably not permanent. The wound subseuueiftly healed soundlv riirht pubis. Spec. 2241. , A -. ,_ -.ar-o ,i i i i V • and. alter Vlay la, 18oo, this colonel ceased to draw a pension. There was a single example of tetanus among the forty-three fatal cases of this uroup. It appears not to have occurred among the two hundred and eleven fatal cases 1 St HOLLER (\\~.}_(Annual Report of the Adjutant General of the Commonwealth of Massachusetts for the year ending December 31, 1864, Bo.stmi, 1865. p. 8.")0;: '' Lt.-Col. Pierson, now colonel, received a wound at that time supposed to be mortal, and was helped off the field." RKCT. i.l SHOT FRACTURES OK THE PUBIS. 2.°)9 of speciliod shot fractures of the ilium, though a number of instances arc recorded in the category of fatal shot injuries of the innominate bones in which the part injured is not indicated. Case 692.—Private T. B. Ballou, Co. C, 21th Michigan, aged 23 years, was wounded at Gettysburg, July 1, 1863, by a conoidal ball, which entered at the right hypogastrium one inch from the liuea alba, passed backward and downward, and, fracturing the right pubic bone, emerged from tho right nalis one inch from the anus. He had urinated half an hour previously or the ball would have penetrated the bladder. The patient was admitted into ('amp Letterman Hospital. Acting Assistant Surgeon W. I>. Jones reported that: "On August 7th, he had a severe attack of gastric remittent fever, with vomiting and persistent nausea. Several splinters of bone were removed from the anterior wound, also some pieces of clothing and part of a button. The patient was allowed a generous diet; quinia and sweet spirits of nitre were administered, and poultices were applied." He was transferred to the Cotton Factory Hospital, Harrisburg, on October 12th, and died November 26, 1803, as reported by Acting Assistant Surgeon W. S. Woods, of traumatic tetanus, The four following instances of tetanus following shot injuries of unspecified portions of the innominate were reported: Casks 693-096.—Captain Henry C. Hatfield, 34th Ohio, received a lateral shot perforation through the pelvis, at Fayetteville, Virginia, on September 10, 18(52. With other wounded he was sent to Gallipolis, Ohio, having been transported forty-five miles in a wagon and the remaining distance in a bateau. Tetanus appeared on the 15th, and proved fatal on September 19, 1802.—Private G. Cummings, Co. II, 80th New Vork, aged I>1, wounded at Spottsylvania, May 10, 1804; tetanus super- vened May 17th, and resulted fatally May 19, 1801.—Private W. T. House, Co. D, 46th Tennessee, wounded at Nashville, December 16, 1804; tetanus and death, January 6, 1805.—Private J. M. Soules, Co. G, 2d New York Mounted Rides, wounded June 18, 18C4, at Petersburg, and died July 4, 1804, from tetanus. As will be more fully exemplified in the next Section, vesical complications often attended shot fractures of the pubis. In the following case of shot fracture of both pubes, complicated by lodgement of the ball, the bladder was only indirectly implicated: Case 697.—Private D. D------, Co. D, 14th Connecticut, aged 22 years, was admitted, from City Point, Virginia, to Stanton Hospital, Washington, on March 30, 1865, for a wound received at Hatcher's Run on March 2.";th. A conoidal musket ball had entered the upper third of the right thigh anteriorly, passed upward and inward into the pelvis, striking the descending ramus of the right pubis just below the symphysis, contusing the corresponding bone on tbe left side, passing over the membranous portion of the urethra, striking against and knocking off a fragment of the spine of the ischium, impinging on the sacrum at the insertion of the coccygeus, and finally lodged in the gluteus maximus. The shock of injury was reported to have been inconsiderable, and the patient complained of no other inconvenience than pain and tenderness in the hypogastrium, with a persistent inclination to evacuate the bowels. The external wound, apparently healthy, discharged dark, bloody pus of a decided faecal odor; the functions of the bladder were-normal; the patient hopeful; pulse good, at about ninety. The pelvic irritation and tenesmus were temporarily relieved by an enema of soap and water, and cold-water dressings were applied to the wound. During the week following, there was but little change in the patient; irritation of the rectum and peritoneum super- vened, with costive bowels. These symptoms were again relieved by the injection. The discbarge from the wound assumed more the character of laudable pus, but still preserved its fascal odor. The patient's condition remained unchanged till April 15th. The position of the ball, which at first was not sufficiently distinct to justify an incision, now became more evident, the tumefaction around it having increased until the irritation began to affect the general system. Determining to remove the ball, Surgeon B. B. Wilson, U. S. V., chloroformed the patient, and made an incision over its point of lodgement; but the missile, which was distinctly felt previous to the incision, could not be found. The presence of tlie ball at a distance of about seven inches from the orifice being revealed by means of a Nelaton probe, several ineffectual efforts were made to grasp it. A small fragment of necrosed bone was removed. On the morning of April 10th the ball was found in the bed, having gravitated out during the night; the urine was high-colored and loaded with mucus; pain and tenderness extended over the whole abdomen. The administration of morphia in solution and sweet spirits of nitre, with stimulants and a nutritious diet, afforded partial Fig.185.—Pelvis, showing a shot-fracture of the pubes. Spec, relief till A'pril 20th, when pyaemia set in. On the 23d, the symptoms 4171' had increased; involuntary evacuations took place; the patient sank, aud died on April 25, 1865. The autopsy, twenty-four hours subsequently, revealed marked cystitis and peritonitis, with commencing gangrene in those portions cf the peritoneum covering the bladder and rectum. The pelvis (Fig. 185), with the missile attached, and the history of the case, were contributed by Surgeon B. B. Wilson, U. S. V. The ball, mounted in the left sciatic notch, does not appear in the figure.1 There were no cases which could be strictly classified as excisions of the pubis, though, in several cases, splinters of bone were picked out primarily, and, in others, carious 'Dr. D. Webster Prentiss has published (Am. Jour. Med. Sci., 1865, Vol. I, p. 400) an extended account of this case, with remarks. m INJURIES OF THK PF.LVlr Fig. 18fi.—Caries of theramus of the right pubis. Spec. 3819. [Half-size.] bone was removed, or necrosed fragments were cxtnvted.1 The more important of these oases were associated with lesions of the ischium or bladder, and will ho detailed hereafter. In one of them, a fragment of the pubis became the nucleus of a calculus. A case of caries, illustrated by a specimen, may conclude the subject for the present: Case (i'JS.—Private Daniel L------, Co. F, 23d Ohio, aged 22 years, was wounded by a conoidal ball at Halltown, August 25. IHil. He was treated in field hospital at Sandy Hook until the tilth, when he was admitted to the hospital at Frederick. The following notes of the case were furnished by Acting Assistant Surgeon T. O. Cornish: "The patient could tell nothing of his condition and treatment until he came under my charge, on September 17th. At this time he was evidently sinking; the brain was sluggish and the mind wandering; pulse 120; skin sallow. Tonics, stimulants, and anodynes were administered, and poultices applied to the wound. On the 18th he had a chill, and the unfavorable symptoms increased daily until death resulted, on September 20, 18(54. An examination, made eighteen hours after death, revealed an injury of the superior border of the horizontal ramus of the right pubis. Pus had penetrated through the obturator foramen into the cavity of the pelvis, and also into the hip joint; the femoral vein was not examined. All the viscera were apparently healthy, The pelvic portion of the peritoneum was congested." The specimen (FlG. 183), which con- sists of the right pubis, exhibiting a carious condition of the horizontal ramus after partial gunshot fracture, was contributed by Acting Assistant Surgeon R. W. Mansfield. Shot fractures of the Ischium.—These injuries were somewhat less frequent and less fatal than analogous lesions of the pubic bone, the aggregate of instances recorded being seventy-three, of which thirty-one, or 42.4 per cent., resulted fatally. Eight cases were complicated by lesions of the bladder, and four with wounds of the rectum. One of the fatal cases illustrates what large projectiles may occasionally be buried and concealed in the deep tissues. The adjoining wood-cut (Fig. 187)• represents a fragment from the apex of a 20-pounder shell. A soldier, attempting to crack nuts upon the unexploded missile on the field of Antietam, by way of carrying out a wager with a comrade, had terrible proof that the charge had not been withdrawn. This fragment "tore Ins perineum, lacerated for two inches the membranous portion of the urethra, and upturned the left ischium.2 The unfortunate man soon perished from shock. This bulky mass was found between the ramus of the ischium13 and the adductois of the thigh. One border of the speci- men is a section drawn longitudinally through the centre, showing a diameter of more than three and a half inches. The other border is at nearly right angles, three inches from the apex." The walls are an inch and one-fourth thick, and the specimen weighs thirty-two and one-half ounces. It was contributed to the Museum by Surgeon E. McDonnell, U. K. V. Vic. lfc~.—l-'ragnieut of a shell extracted from the ischiatic region, 'spec. 4457. I Reduced one-half.] 'In I8d3, Dr. oscak Hkyfeldek (Lehrbuch der Resectionen, \Vien, S. 317) tabulated five instances of so-called resection of the pubis. With sundry inaccuracies, the following instances appear to be referred to: Mauet (Mem. de I'Acad. de Dijon, 1774, T. II, p. 85): A cart-wheel passed over a young lad}', aged 18 years, and fractured the «,s pubis; an incision was made and that portion of the right os pubis removed which forms the symphysis and the descending ramus joining the ischium; reproduction of new bony substance followed, which entirely supplied the loss of the removed portion. C00PEIJ (A.) (Surgical Essays, Am. ed., Philadelphia, 1821, Vol. I, p. 162), on March 13, 1817, successfully removed, with Madieu's and Hey's saws, a large exostosis from the os pubis of a German, H. W. Bronner, aged 21. Professor GlOUGIO Reoxoli, of Pisa, in 1830 (GISXTHEK, Lehre von den Blutigen Operationen, I860, B. IV, S. 2), removed an exostosis of the descending ramus of the os pubis by three blows of the chisel and mallet j recoverj- in one month. Lisfkanc (Pricis de mid. opirat, Paris, 1846, T. II, p. 550) remarks: "J'ai vu DurUYTUEN extirper une esquille volumineuse resultant d'une fracture de la branche horizontale du pubis." Mayek (Deutsche Klinik, 1856, S. 202), in 1847, scraped a portion of the descending ramus of the os pubis with a coarse file for caries, with indifferent results. He intended to excise the descending ramus, but the interference of the patient's relatives and of another physician prevented it. 2 Tellium, iaxiov, strictly the cotyloid cavity; a term derived by some etymologists from iaxvs, strength, and by others from (cr^w, I arrest, Gennanice. Sitzbein. 3 Sl'KOMKYElt (op. cit, p. 42) has the following observations on shot-fractures of the ischium : "Comminuted fractures of the ischium were equally dangerous. * * I have seen one case of injury of the ascending branch of the ischium end favorably after extraction of large tertiary sequestra. The contusions of the ischia also had very bad consequences, and gave rise to obstinate suppuration and hectic fever." SECT. 1.1 SHOT FRACTURES OF THE ISCHIUM. 241 In favorable cases, patients recovered tardily from shot fractures of the ischium,1 convalescence being hindered by caries and abscess-formations. A single instance may exemplify this, and other illustrations may be selected from the fatal cases, in order that pathological preparations may show the varieties of fracture :2 Cask 699.—Private J. A. Ship, Co. F, 44th Virginia, aged 19 years, wounded at Antietam, September 17, 1862, was sent to Frederick and admitted into general hospital. Acting Assistant Surgeon A. V. Cherbonnier reports that "a conoidal ball had entered the left groin and emerged in the posterior middle third of the thigh, fracturing the tuberosity of the ischium in ita course. On admission, the patient suffered excruciating pain; there was a thin and very offensive discharge from the wound. Chloroform was administered and large fragments of the ischium were removed, about half a pint of pus being discharged during the operation. The wound was dressed with a yeast poultice, and the patient was supported by means of quinia, brandy, and a good diet. He improved after the operation, and by December 20th was in good condition; the wound was filling up and suppurated slightly. On December 24th, a small abscess opened near the pubes. Necrosed bone was discovered by meaas of the probe; but the patient's health was good and the wounds improving. He was transferred, December 29, 1862, to hospital No. 1." He steadily convalesced, and was trans- ferred for exchange March 4, 1833. Case 700.—Private T. Carson, Co. I, 27th Pennsylvania, aged 40 years, was wounded at Mission Kidge, November 25, 1863, and made a prisoner. On his release, he stated that a musket ball had passed through both buttocks, and that it was thought that the tuberosity of the ischium, and perhaps the trochanter of the left femur, were fractured. He was confined at Atlanta until exchanged, February, 1864, and was then sent to hospital at Chattanooga, entering on February 18th. The external orifices of the wounds were healed. The patient died from exhaustion on February 28. 1864. Assistant Surgeon John D. Johnson, U. S. V., sent to the Museum a prepa- ration of the fractured ischium (FlG. 188), and reported that at the autopsy there was extensive necrosis of the ischium, with erosion of the cartilaginous rim of the acetabulum, and slight caries of the great trochanter, with wasting and alteration of the surrounding soft tissues. Case 701.—Private C. W. M------, Co. B, 14th North Carolina, aged 21 years, was wounded at Antietam, September 17, 1862. by a musket ball, which entered the cleft of the nates one and one-fourth inches above the anus, passed in the vicinity of the hip joint, and emerged in front of the great trochanter; he also received four gunshot wounds of the other leg, one missile chipping the crest of the tibia. He was left upon the field, and was subsequently removed to hospital, where he was treated until the 29th, when he was transferred to Frederick. Assistant Surgeon R. F. Weir, U. S. A., reports: "Buck's apparatus was applied; there was but little pain. On October 14th, the patient was still comfortable, though his appetite was poor and pulse 118. A slight haemorrhage occurred on the following day, ceasing, however, of its own accord. He failed rapidly, and died at midnight, October 17,1862. Upon a dissection of the parts the missile was found to have grazed the tuberosity of the ischium and ploughed through the great trochanter, splitting off the head, neck, lesser trochanter, and four inches of the shaft of the femur; ossific matter was abundantly deposited between the fragments and along the edges." The specimen (Fig. 189) was contributed to the Museum by Dr. Weir. On the outer surface of the tuberosity is a circular portion of necrosed bone with a clearly defined line of separation, having a diameter of one and three-fourths inches, the evident result of contusion. Fig. 188.—Shot fracture of the left3 ischium.—Spec. 3401. Fig. 189.—Necrosis of the left ischium after shot contusion. Spec. 882. [Half-size.] 1 The following are some of the references by modern military surgeons to shot fractures of the ischium: BlLGUER (Chirurgische Wahrnehmungen, Berlin, 1763, S. 365) relates that Private Menz was shot at Lauersd'irf, in 1759, by an iron ball, which fractured the right ischium; profuse suppuration ensued; two months later a large piece of bone and the ball were removed; suppuration continued for six weeks, when the wound closed. JOBEBT (Plaies d'armes a feu, Paris, 1833, p. 224) remarks that he saw at St. Cloud a case of fracture of tuber ischii, which had not yet quite healed in six months. CHKKU (Stalistique mid. chir. de la camp, d'Italic, Paris, 180'.i, T. II, p. 507) details the case of Avenant, 84th line regiment, wounded at Solferino, June 24, 1859, by a musket ball, which fractured the ischium ; several pieces of bone escaped ; recovery took place with false anchylosis of the hip joint. MATTHEW (op. cit. p. 33) gives the particulars of three cases of shot-fracture cf the ischium; two recovered in about six months; a third proved fatal after profuse suppuration ; in the latter the descending ramus of the cs pubis was found fractured. BAUDENS (Des plaies d'armes d, feu, 1849, p. 229) gives an abstract of the case of Menry; shot fracture of the ischium ; splinters successfully removed. SCHWARTZ (Beitrage zur Lehre, a. s. w., 1854, S. 136 and 138) gives two fatal cases of shot fractures of the ischium ; in one the internal iliac vein was injured. Demmb (Studien, u. s. w.. 1851, B. II, S. 173) cites four cases of fractures of the ischium ; two fatal, and two recoveries. Among the pensioners examined by Dr. IIaxnoveh (Die Diinischen Invaliden aus dem Krieg., 1854, S. 20) was one shot in the ischium, who suffered from atrophy of the lower extremity of the injured side. Beck (Chirurgie der Schussverletzungen, 1872, S. 552 and 556) mentions three successful and one fatal case of shot fractures of the. ischium. SOCIN (Kriegschir. Erf., 1872, S. 97) records a case of fracture of the ischium with a favorable result. ClIIPAULT (Fracl. par armes a. feu, 1872, p. 74) relates two cases of recovery after shot fractures of the ischium ; Obs. LXXV1II, Fcque, 33d regiment, wounded at Poupry, December 2, 1870, splinters extracted from left ischium, rapid convalescence; Obs. LXXIX, Benehey, 39th regiment, Nonneville, December 2, 1870, removal of fragments from 6hot fracture of left ischium, recovery. 2 At the Museum of the Pennsylvania Hospital, Specimen 1113 shows a fracture of the ischium by a round ball, a fragment an inch long being broken off the postero-inferior part of the rim of the obturator foramen ; the patient died from haemorrhage from the divided femoral vein.—(Cat., 1869 p. 26.) The Warren Anatomical Museum possesses a Specimen, 1052, presented by Dr. R. M. Hodges, of comminution of the tuberosity of the right ischium and incomplete fracture of the left pubis by a pistol ball. The patient, who underwent a thigh amputation also for shot injury of the knee survived twenty-two days.—(Cat, 1870, p. 178.) In the same collection, Specimen 1054 is a shot fracture of the tuberosity of the left ischium, also presented by Dr. Hodges. In the Edinburgh Museum, Specimen 197, XX, D, is a shot perforation of the ramus of the ischium. The patient survived the injury a considerable time, and died from hydatids of the liver.—(Cat, 1836, p. 24.) 3 Erroneously described in the Catalogue of the Surgical Section, p. 223, as the right ischium. 212 INJURIES OF THE PELVIS. [chap. vu. Fig. 190.—Shot fracture of the right ischium. Spec. 1240. [Reduced to one- third. J Impaction of balls in the ischium appears to take place in a fair proportion of cases.1 The Museum possesses two examples of the sort, and others are recorded in which the missiles were extracted : Cask 702.—Private Silas W-----, Co. A, 23d New Jersey, aged 21 years, was wounded at Chancellorsville, May 3,1863. He was treated in the regimental hospital until the 8th, when he was sent to Douglas Hospital, AVashington, whence Acting Assistant Surgeon C. Carvallo made the following report of the case: "Theball entered the right gluteal region, perforated the innominate bone near the sacro-iliac symphysis, and entered the pelvic cavity without apparently injuring the viscera; the patient could pass water without difficulty or pain, the urine being of a natural color; his bowels were in good order but somewhat costive. May 12th, he became feverish; thirsty; dry tongue and skin, and accelerated pulse; a solution of nitrate of potash was administered. He continued feverish, and, on the 17th, an emulsion of turpentine was given, which relieved him consider- ably at first and smoothed his tongue, but it soon became dense, hard, and furred, as before. On the 19th, he had a slight chill, ascribed to the cold draught of an open window, and quinia, morphia, and stimulants were given. On May 20th, there was great stupor and the patient was delirious, talking while asleep. An abscess was opened at the roots of the second and third phalanges of the right foot; there was also a metastatic abscess in the left elbow. Turpentine emulsion was given three times a day, and sulphate of quinine one hour after each dose of the emulsion. On May 23d, secondary haemorrhage occurred, supposed to proceed from the sciatic artery, or from a muscular branch of the gluteal arteiy. Stupes of lint com- pressed into the wound stopped the haemorrhage after the escape of some live or six ounces of blood. On the next day there was stupor, and stertorous breathing, and incontinence of urine; the wound discharged serous-purulent blood, and the gluteal region Avas infiltrated with the same. He died at one o'clock p. M., May 24, 1883. At the post-mortem examination, five hours after death, the hall was traced to the pelvis, Avhere it lay loosely in the bone; there was no wound of the pelvic viscera, nor any evidence of pyaemia in the lungs, liver, spleen, or kidneys." The specimen (FlG. 190) is from a wet preparation of the right ischium,2 much shattered directly behind the acetabulum by a conoidal ball, which is mounted in the notch through which it penetrated. The preparation was transmitted, with Dr. Carvallo's memoranda, by Assistant Surgeon W. Thomson, U. S. A. Case 703.—Dr. Redfern Davies, a volunteer surgeon from Birmingham, England, makes the following report of a case of shot fracture of the ischium and death from chloroform, in a Confederate soldier, first treated at Middletown, and then transferred to hospital No. 1, at Frederick, where Dr. Davies was stationed: " William L------, Co. E, 23d North Carolina, aged 24 years, was wounded at South Mountain, September 14, 1862. The ball entered his groin very near the femoral artery and made its exit at the tuber ischii, fracturing the latter. Admitted October 22d; had bad bed-sores, laying the spine bare, and severe chronic diarrhoea, and had lost flesh. October 2Sth, chloroform was administered to remove the fragments of the ischium. No cardiac disease existed so far as known, but the heart was not examined. The chloroform was administered by Dr. A. [Acting Assistant Surgeon W. S. Adams] on a pocket handkerchief, which was pressed firmly against the mouth of the bottle, which was then inverted. Plenty of air was given, and the handkerchief was wet with chloroform but once. About a minute after the administration of the chloroform was begun almost complete relaxation was produced and two stertorous respirations were observed, when the handkerchief Avas immediately removed. The pulse up to this time was undisturbed; the patient then took some ten or twelve deep and rather rapid inspirations, with quickened pulse, when respiration suddenly ceased; the pulse continued for six or eight beats, which were slower and feeble, and then suddenly ceased. Artificial respiration was immediately resorted to by Marshall Hall's ready method, which produced distinct respiration, but no pulsation. Having kept it up for about twenty minutes without result, the case was given up as hopeless. Post-mortem, three hours after death: The body warm; no rigor mortis whatever; the chest and abdomen were opened and the blood was observed to flow from the veins, not being coagulated. In the pleural cavities there was no effusion; in the pericardium there were about two fluid ounces of effusion, without any pericarditis. On removing the calvarium, the veins of the dura mater and the pia mater were very much engorged with dark- colored uncoagulated blood; in the arachnoid space there was about two ounces of fluid. The substance of the brain was unusually firm on section and normal in appearance; there Avere from four to six drachms of fluid in the lateral ventricles; the cerebellum, pons Variolii, and medulla Avere normal. The right and left auricles of the heart Avere immensely distended Avith very dark uncoagulated blood; the ventricles full of the same, but not distended. The coronary openings were so large that the tip of the little finger could be introduced; all the valves Avere healthy, but the substance of the heart was someAvhat flabby, especially on the right side. Six hours after death there was still no rigor mortis." The specimen (FlG. 191) of the fractured ischium, sIioav- ipg a round ball firmly embedded in the tuberosity, Avas sent to the Museum. A small fragment of bone just above the missile, and against Avhich it appears to have impinged, is necrosed. The ischium is not completely fractured, but the region of lodgement is much splintered. A sample of the chloroform used was sent to the laboratory of the Surgeon General's Office. The case will he reverted to in the Chapter on anaesthesia. Fig. 101.—Round ball impact- ed near the tuberosity of the right ischium. Spec. 819. 1 Respecting balls lodged in the ischium, Dr. NEUDOUFEK relates (Handbuch der Kriegschirurgie, 1807, S. 806) the case of M. Ilausel, 3d Jae«-ers. wounded at Custc zz.i in June, 18CC; the missile fractured the ischium and lodged; seA'eral unsuccessful attempts were made to extract the ball• the patient died February 9, 1868. At the autopsy the ball was found lying loosely in a cavity formed by new osseous exudation. Dr. NeudOrfkk remarks : "Had I risked the removal of the inner portion of the Avreath of osteophytes, the ball could have been readily removed at the first attempt and the patient would probably be aliA'e to-day." Dr. NEUDOKFEK presents (FIG. 07) a beautiful drawing of the pathological preparation. • 2 Through a clerical error in the report, and a misprint in the Catalogue of the Surgical Section, 1866, p. 2-!7, tho lesion has been ascribed to the ilium instead of the ischium. SECT. 1.1 SHOT FRACTURES OF THE ISCHIUM. 243 The greater number of the cases in which preparations were preserved were examples of partial fracture, followed by caries and necrosis. These cases appear to have been frequently complicated by pyemia. Shot contusions were followed by caries in two cases: Cask 704.—Private W. Keith, Co. A, 14th Infantry, was struck by a musket ball at Gaines's Mills, June 27, 1862. Surgeon J. L. Le Conte, U. S. V., records that he was sent to Chester, Pennsylvania, where it was found that the missile had entered just above the ramus of the pubis, tAVO inches to the right of symphysis, passed between the bladder and rectum, and emerged at the left sacro-sciatic notch. A chronic subacute inflammation of the bladder ensued, and a portion of the injured ischium became necrosed. Surgeon Charles Page reports that this soldier Avas discharged, for the disabilities above described, December 29, lH!i3. His name is not on the Pension List. Case 705.—Private Michael L------, Co. K, 18th Wisconsin, aged 19, was Avounded at Corinth, October 3, 1862, by a mini6 ball, which entered the right groin three inches from the spine of the pubis and passed through the obturator foramen, grazing and carrying away a portion of the neck of the ischium, and emerging at the right buttock one aud a half inches from the natal fissure. On November 30th, lie Avas admitted to hospital at St. Louis, and Avas doing Avell up to December 13th, Avhen symptoms of pyaemia appeared, Avhich developed quickly, and he died on December 22, 1862. The specimen (Fig. 192) Avas contributed, Avith the foregoing history, by Surgeon John T. Hodgen, U. S. V., and consists of the right ischium and pubis. The inner face of the ischium above-the tuberosity and beloAV the acetabulum is grazed by the passage of the ball. The fractured surface is carious; the outer border has a slight osseous deposit upon it. In the following cases, and in eight others, portions of carious or necrosed bone were removed, and in eight cases balls were extracted:1 -, Co. K, 14th Connecticut, aged 37 years, was Avounded at Fredericksburg, December FIG. 192.—Kiglit ischium injured by a ball. Spec. Hit 2. Case 706.—Private J. L. D. O- 12, 1862. by a round ball and two buckshot, Avhich passed through the penis and scrotum into the left ischiatic region and emerged just above the sacrum. He Avas admitted into the field hospital of the 1st division, Ninth Corps, and was transferred to Douglas Hospital, Washington, December 26th. Assistant Surgeon C. C. Lee, U. S. A., reported as follows : "At the time he was wounded he was sitting on the ground with his legs bent under him, and Avas shot by a sharpshooter about fifty feet to his front. When admitted, the wounds in the penis and scrotum Avere suppurating, and the tunica vaginalis of the right testicle Avas completely exposed; these wounds cicatrized sloAvly, especially that in the penis, Avhich Avas retarded by frequent painful erections. By March 18th, all the wounds were closed except that in the right ischiatic region, where the suppuration Avas kept up by necrosis of the ischium, which the bullet had grazed in its passage, several sequestra of bone having come away and others still separating. The patient had been feeble and required constant stimulation; he also had an occasional attack of severe diarrhoea. Xo change occurred until April 5th, when pleuro-pneumonia supervened, accompanied by such debility and collapse that the patient, already enfeebled by the profuse suppuration, rapidly sank, and died on April 10, 1863. The treatment consisted of removal of fragments, dressing, and administration of tonics and stimulants, Avith nourishing diet. The autopsy, made fifteen hours after death, revealed the following: In the chest there Avere recent adhesions on both sides, densest on the right side, Avhere the disease had been chiefly observed before death; nearly a pint of serum Avas effused in the right pleural cavity and about three ounces in the left. The left lung Avas crepitant, the right densely congested and sank at once in Avater. Liver fatty and enlarged, spleen and kidneys normal, intestines sodden and congested; no ulcers detected. The ischium Avas found to be fractured near its junction with the pubes, but so many fragments had been removed, and the remainder of the bone Avas carious to such an extent, as to obscure the original line of fracture; the necrosis extended to Avithin one-sixth of an inch of the hip joint, Avhich Avas yet intact." The specimen (Fig. 193) consists of the right ischium, badly fractured betAveen the acetab- ulum and the tuberosity. The shattered bone is carious, and much diminished by absorption and loss of fragments. It Avas contributed by Assistant Surgeon W. Thomson, U. S. A. Case 707.—Private W. S. Fulton, Co. F, 98th Ohio, Avas Avounded at Jonesboro', September 1, 1864, and Avas first treated in a field hospital of the Fourteenth Corps by Surgeon W. C. Daniels, U. S. V. The patient Avas transferred, on October 30th, to the general hospital of the Army of the Cumberland, at Atlanta, and placed under the care of Assistant Surgeon M. C. Wood- worth, U. S. V. Subsequently he Avas sent to Nashville, and thence, on January 26,1805, to Gallipolis, AA'here he died February 11, 18G5. The reports of the field surgeons and of Surgeons Breed and Herbst, U. S. V., at Nashville, substantially agree Avith the more minute account given by Surgeon L. R. Stone, U. S. V., at Gallipolis. " The ball," Dr. Stone relates, " entered the right hip one inch posterior to the great trochanter, and emerged at the left groin, having fractured the right ischium, and perhaps the ramus of the corresponding pubis." 1 Professor P. F. Eve (Cases of Gunshot Wounds, in the Nashville Jour, of Med. and Surg., 1867, Vol. II, p. 229) relates a case of extraction cf ball from near the tuberosity of the ischium, four years after the reception cf the injury: W. C. Draughon, 14th Tennessee, was wounded at Seven Pines, May 30, 1862, the ball entering the lower part of the belly; the missile could not be found; the wound healed, but re-opened several times, and a small piece of bone was discharged. In September, 1864, the bladder became irritable, and two rough calculi, one the size of a pea, were discharged. In March, 1866, pus freely escaped during efforts at micturition or defecation. After several unsuccessful attempts, the ball was finally removed on April 30, 1866, by a long pair of forceps, and the wound healed completely in a few weeks. Fig. 193.—Caries and necrosis of tho ischium from shot fracture. Spec. 1060. 244 INJURIES OF THE PELVIS. [CT1AP. VII. Pelvic cellulitis, with deep suppuration, commonly attended shot fractures of the ischium, and, with its attendant chills, appears to have been sometimes confounded with pyaemia, also a frequent complication. Shot fractures of the ischium were in several instances associated with injuries of the femur, the latter then ordinarily becoming the dominant lesion: Case 708.—Private J. B- -, Co. F, 131st Pennsylvania, aged 29 years, having been wounded FIG. 194.—A portion of the left ischium con- tused and fissured by a musket ball. Spec. 987. FlG. 195.—Internal view of the left pubis and ischium, showing a partial shot fracture of the body of the latter. Spec. 1212. at Fredericksburg on December 13th, Avas sent to Washington, and admitted into Harewood Hospital December 18, 1862. Surgeon Thomas Antisell, U. S. V., reports that "A conoidal musket ball had entered at the sacro-iliac symphysis, passed through the gluteal muscles on the dorsum ilii, and lodged in the perineum Avithin an inch of the anus, from Avhich position it Avas extracted. The patient died from the conjoined effects of haemorrhage and extensive suppuration." A preparation from this case, a portion of the left ischium, contused and carious on its inferior posterior surface, Avas contributed to the Museum by Acting Assistant Surgeon W. A. Harvey, and is figured iu the adjoining Avood-cut (FlG. 194). Case 709.—Private Frank G------, Co. K, 105th Pennsylvania, aged 28 years, was Avounded on May 3,1833, by a bullet, Avhich struck over the symphysis pubis and came out at the left buttock. He Avas admitted to Carver Hospital on May 9th, and "remained Avithout bad symptoms, although unable to use his limb, until the 18th, when he began to complain of pain in the hip and to lose his appetite. On the 16th, one-fourth of a grain of morphia, with one grain of quinine and a little blue mass, was given every three hours. This had no other effect than to irritate his stomach and to cause vomiting. On the 17th, tincture of iodine Avas freely painted over his hip, and a poultice was applied. On the 18th, morphia Avas again administered, and the patient Avas transferred to a Avater-bed. The pain in the hip Avas not, hoAvever, relieved by these measures. On the 20th, the irritability of stomach being great, and but little nourishment being taken, lime Avater and milk Avas administered Avith good effect. A liniment containing chloroform and aconite Avas applied over the parts. The sufferings of the patient became much less than they had been, but he was continually sinking, and finally died on the 21st, at about 7 o'clock A. M. At the autopsy, the course of the bullet Avas traced from its point of entrance over the symphysis pubis. It had passed across the ramus of the bone, furroAving it slightly across the obturator foramen, and through the body of the ischium. It then passed through the soft parts. The bones injured Avere taken out and preserved. Pus Avas found in the hip joint." The above history Avas contributed by Acting Assistant Surgeon B. F. Craig, who treated the case. The pathological preparation, showing the fracture of the ischium (FlG. 195), Avas transmitted to the Museum by Surgeon O. A. Judson, U. S. V., in charge of Carver Hospital. Case 710.—Private J. W. S------, Co. H, 155th Pennsylvania, aged 19 years, Avas Avounded at Hatcher's Run, February G, 1865, and Avas admitted to the field hospital of the 1st division, Fifth Corps, on the same day, and, on the next, removed to City Point. On the 14th he Avas transferred to Point Lookout, Avhere he was treated until July 24th, Avhen he Avas sent to Washington, where he was treated in various hospitals until May 1, 1866, when he Avas transferred to the post hospital under the charge of Assistant Surgeon W. Thomson, U. S. A., Avho reports that "When admitted the patient Avas very Aveak and pale, and suffering from an old gunshot fracture of the ischium, and also from diarrhoea, Avith distressing nausea and vomiting after taking food or medicine. He stated that he had reclined on the right side altogether for many months; there Avas considerable oedema of the right arm, side, and leg, with pitting on pressure. The discharge from the wound Avas not profuse, but offensive and dark colored. These untoAvard symptoms increased steadily, despite all attempts to support the vital poAvers, and he died from exhaus- tion on May 20, 1866. Autopsy, seven hours after death, revealed: The right lung almost entirely carnified, Aveighing nine ounces, and compressed by three pints of serous fluid. There Avere considerable pleuritic adhesions in the side. Left lung healthy, Avith very slight effusion Avithin the pleural cavity; heart very small, Aveighing six ounces; liver enlarged, hard, and paler than normal; kidneys and spleen healthy. Stomach the seat of numerous small ulcers which entirely perforated the mucous membrane; these Avere mostly toAvard the lesser curvature and rather nearer the pyloric orifice. No lesion of the large or small intestines." The specimen (FlG 193) Avas forwarded to the Museum by Dr. Thomson, and consists of a Avet preparation of the left hip joint. The fumu*> was partially fractured on the posterior surface below the trochanter minor, at Avhich part several of the fragments Avere attached, and a loose fragment from Avhich is mounted with the specimen. The ischium is perforated through the tuberosity on nearly the same plane as the obturator foramen.—(Cat., p. 228.) Fin. 196.—Bones of the left hip joint, showing shot fractures of the ischium and femur. Spec. 2557. Case 711.—Private D. H. Anderson, Co. G, 115th Indiana, Avas Avounded at Blue Springs, October 10, 1833. He was sent, on October 12th, to Asylum Hospital, Knoxville, where Surgeon C. W. McMillan, 1st East Tennessee, reported that "the ball entered two inches behind the left great trochanter, fractured the ischium, and made its exit at the left border of the anus. Secondary haemorrhage occurred from a small arterial branch in the shot canal on October 18th, and Avas controlled by compres- sion by pledgets of lint, saturated by solution of the persulphate of iron." He died October 20, 1863, from pyaemia. The cavity of the pelvis Avas found filled with fetid pus at the autopsy. SECT. I.] SHOT FRACTURES OF THE ISCHIUM. 245 FIG. 197.—Portion of tho right os innominatum, the edge of tlie cotyloid cavity chipped by a bullet. Spec. 1391. A number of the fractures of the ischium and of the pubis were complicated by wounds of the genital organs: CASE 712.—Private J. B. F------, Co. D, 42d Virginia, aged 25 years, was Avounded at Petersburg, April 2, 1865, and was admitted to field hospital, 3d division, Ninth Corps, on the same day, Avhence he Avas transferred to Douglas Hospital, Washington, on the 6th, Avhere he is reported to have received "a gunshot wound of the penis, scrotum, and upper portion of the right thigh, the bullet having grazed the os ischium in its course. The case progressed Avithout any very unfavorable symptoms until tbe 15th, Avhen he Avas seized Avith a severe chill; several chills occurred on the following day, and, on tbe 17th, he had two chills, and also pleurisy of the left side, with excessive pain. On tbe 20th he had a chill, and tbe subsequent sweats Avere increased in severity. He died from pyaemia on April 21, 1865. At the autopsy, the pleural cavities were found to contain about a pint of yellow-colored liquid, with floating shreds of lymph, and the lungs Avere filled Avith pysemic abscesses in various stages, their exterior surface covered Avith flakes of yelloAV lymph." The preparation of the injured bone (Fid. 197), with the ischiatic portion of the acetabulum chipped by a bullet, and scrotum, was contributed, with the foregoing history, by Assistant Surgeon W. F. Norris, U. S. A. Excisions of Portions of the Ischium and Extraction of Foreign Podies.—As indicated by some of the preceding abstracts, the extraction of bone splinters often formed a part of the primary dressing of shot wounds attended by fracture of the ischium, and the removal of carious or necrosed bone was frequently required in these cases.1 In some cases, as in the two following, foreign bodies were extracted together with the bone sequestra: Case 713.—Private O. T. Whitaker, Co. H, 103d Ohio, aged 22 years, Avas Avounded at Resaca, May 14, 1864, and Avas admitted to general hospital, Chattanooga, from the field on the 17th, and transferred to No. 1, Nashville, on June 2d, Avhere Surgeon B. B. Breed, U. S. V., reported: "Gunshot fracture of the tuberosity of the right ischium; the ball entered the right buttock, passed downward and inward through the perineum, and emerged at the external aspect of the upper third of tbe left thigh. On November 28th, the patient Avas placed under the influence of chloroform, and Acting Assistant Surgeon M. L. Herr removed a portion of a bayonet-scabbard, one and a half inches long and about three-fourths of an inch thick, by an incision in the perineum. The lower portion of the bayonet itself, an inch long and one-fourth of an inch in thickness, together with the tuberosity of the ischium, Avere also removed through an incision on the lateral aspect of the natis directly opposite the ischium. At the time of the operation there Avas a profuse discharge of pus, with necrosed scales of bone, from three fistulous openings, one in the perineum, one in tbe right natis, and another in the internal surface of tbe right thigh; his constitutional condition was good. Water dressings Avere applied, and the wound healed rapidly." The patient Avas transferred, on May 6, 1S65, to hospital at Jeffersonville, Avhence he Avas discharged the service, June 1, 1885, and pensioned. Examiner J. Strong, jr., of Elyria, reported, June 14, 1865, that: "Pus and bone were discharged for eight months. He can noAV move Avith difficulty on crutches. The muscles and tendons are very weak and contracted. Disability total, and probably temporary." This pensioner was paid on June 4, 1873. Case 714.—Private A. Piatt, Co. B, 104th New York, avus Avounded at Gettysburg, July 1. 1863, by a conoidal ball, Avhich entered about three inches to the right of the anus, penetrated the gluteal muscles, and fractured tbe ischium behind the acetabulum, and injured the rim of the cotyloid cavity enough to allow the head of the femur to slide up on to the dorsum of the ilium. He Avas treated in a field hospital of the First Corps until July 13th, Avhen he Avas transferred to West's Buildings Hospital, Baltimore; thence, on the 23d, to Patterson Park Hospital. On Sep- tember 2d the ball Avas extracted, and several splinters of bone Avere removed by Acting Assistant Surgeon G. W. Fay. The patient recovered, Avith two inches shortening of the limb, and Avas transferred to the Veteran Reserve Corps on October 31, 1863. On November 14, 1863, be Avas discharged and pensioned. The missile and bone fragments removed, contributed to the Museum by the operator, are represented in the wood-cut (Fig. 11)8). Examining Surgeon F. J. Ames, of Mount Morris, reported, October 2, 1866: " Ball entered at the right of the termination of the spinal column, passing through the gluteal muscles, and so injured the right hip joint that it is now com- pletely obliterated, the head of tbe femur riding upon the haunch-bone. The limb is shortened three and a half inches, and he is unable to perform manual labor. Disability total." This pensioner died April 15, 1870. 1 The category of so-called excisions of portions of the ischium is not large. MAUNOIU (Questions de chirurgie: Expose des div. mcth. chir. x x de I'extraction des corps itrangers introduils ou formis dans les diffirents cavitis, Montpellier, 1812, p. 164) relates a case of caries of the ischium he treated, in 17G9; with the actual cautery he extracted a fragment of the ischium as large as a small chicken-egg. FlUCKE, of Hamburg, removed, with a chisel, the carious tuberosity of the ischium, according to Dr Gt).\THEK (Lehre von den Blut. Operat., 1860, B. IV, S. 2). At the operation the pudic artery was divided and tied by Dr. G0XTHER ; the patient recovered. DEIIME (Studien, AViirzburg, 18(51.15. II, S. 174) gives the case of Czonkola, shot at Solferino, June 24, 1859. Dr. NEUDOUFE!!, on September 29, 1859, resected the tuberosity of the ischium, with a surprisingly successful result. Oberstabsarzt BlUFEL (in Langf.XBECK's Archiv. fur Klin. Chir., 1809, B. XI, S. 419) records the case of a lieutenant of the 41st Prussian infantry, wounded at Kreppelhof, June 27, 18fifi, three inches from tho right trochanter; trismus and other tetanoid symptoms supervened, and continued until August. On October 10th, a cloth-ivad and bone splinter were removed, and a few days later the ball was found impacted in the inner side of the tuberosity, surrounded by new osseous depositions, which were gouged out and the ball released. Fig. 198.—Flattened bullet and twelve bits of necrosed bono from the right ischium. Spec. 1795. 216 INJURIES OF THE PELVIS. [CHAT. VII. FIG. 199.—Sacrum and last lumbar vertebrae, with a de- formed round ball lodging in the spinal canal. Spec. 1198. Shot fractures of the Sacrum.—Though placed more superficially than the innominate bones, the sacrum1 is less liable to fracture from ordinary external violence than the latter, because of its thickness, spongy texture, and the mode in which it is braced by the pelvic girdle and the vertebral column.2 These conditions afford no exemption from shot fractures, to which tho bone is exposed in proportion to its magnitude, though much shielded by its surroundings, except on the spinous surface. Pare3 states that he had many times seen the sacrum fractured by bullets and the sub- jects recovered, but if the fracture involved the spine, cl peine le malade peut eviter la mort, the old master appearing less sound than usual in his prognosis. Three interesting cases of shot fractures of the sacrum are recorded4 in the Fourth Chapter of the First Surgical Volume. Two of these are illustrated by pathological preparations, one of which is represented in the wood-cut (Fig. 199). The third was an example of recovery after the extraction of a ball impacted in the bony pyramid. The total number of cases reported was one hundred and forty-five. In three of them the result has not been determined. Of the remain- ing one hundred and forty-two, sixty-two, or 43.7 per cent., were fatal. It was common for one or both the projecting posterior spines of the ilium to be fractured simultaneously with the sacrum, as in the preparation illustrated by Figure 200, and in those represented on page 222, and elsewhere in this Section. Among the cases of recovery from shot fracture of the sacrum were four in which the bladder was penetrated. In nine instances the rectum was wounded, and eight of these cases resulted favorably. In addition to the complications attending shot injuries of the innominatum, paralysis and other disorders referable to lesions of the nerves were common after shot fractures of the sacrum. One or two examples of recovery may precede the fatal cases that furnished specimens of the various forms of these fractures: Cask 715.—Private William Woodbury, Co. C, 15th Massachusetts, aged 30 years, was wounded at Antietam, Septem- ber 17, 1862. He was treated in the Hoffman House Hospital, near the field, and at Satterlee Hospital, Philadelphia, and Avas discharged from service March 24, 1863, and pensioned. Examiner Oramel Martin, of Worcester, reported, May 14, 1863, that "the ball struck the right ilium two inches beloAV its crest and three inches back of the anterior superior spinous process, passed through the bone and upper part of the pelvis, and out at the upper part of the attachment of the left ilium with the sacrum. The Avound still discharges Avhere the ball entered, and several pieces of bone have been discharged. Stooping causes him pain." This pensioner was paid to March, 1873. Case 716.—Lieutenant S. W. Russell, Co. B, 49th New York, and A. D. C. Sixth Corps, aged 26 years, Avas wounded at Rappahannock Station, November 7, 1863. On the 9th he Avas admitted into Armory Square Hospital, and on February 3, 1 ■-i<>-l. Avas transferred to Seminary Hospital, GeorgetOAvn, under the charge of Surgeon W. H. Ducachet, U. S. V. The case is noted upon the hospital register as "gunshot wound of the back. The ball entered the crest of the ilium on the left side and passed through the ilium of the right side, slightly injuring the lumbar vertebra." On February 19th, he avus transferred to Kalorama Hospital on account of varioloid; Avas furloughed for sixty days March 7th, and returned to duty May 16, 1864. He was discharged from service June 27, 1865, and pensioned. Pension Examiner Julius Nichols, of Washington, reported, June 30. 1865. that "the ball entered the left hip, passed across the upper portion of the sacrum, and emerged from the right hip. The-surface of the sacrum Avas fractured. The Avound is unhealed. He will probably recover. Disability total for tAVO years." This pensioner Avas last paid June 4, 1873. -------------------------------.------------9-------------_----_---------------.-------_--------- 1 Sacrum, sacer, from having been offered in sacrifice, or from its propinquity to the genitals; German, Ueiligenbcin oder Kreutzbein. PAULU8 iEGlXKTA (Adams's translation, 184C, Book VI, Sect, XCVIII, Vol. II, p. 455) speaks of simple and compound fractures of this bone, and their treatment. 2PA1i>.-IER, Article Fractures du sacrum, Diet, des sci. mid., 1830, T. XLIX, p. 318; Malgaigne, Mem. sur les fractures du sacrum et du coccyx, Jour, de chir., 1>-4G. s pAnf., CEuvres, ed. Paris, 1599, Licrc des fractures, Chap. XIII, p. 443. 4 Ciises of Corporal L. P-----, p. 447; of Private Michael H-----, p. 419 (Spec. 1198); and of Lieutenant W. A. C. Ryan, p. 401. FIG. 200.—Shot fracture of the sacrum and ilium. Spec. 1353. SECT. 1.1 SHOT FRACTURES OF THE SACRUM. 217 Fig. 201.—Shot perforation of the sacrum. Spec. 3568. Pyemia appears to have been nearly as common a complication as in shot injuries of the ilium. It was reported as the cause of death in eight of the sixty-two fatal cases, or 12.9 per cent. Cases that furnished specimens1 may be mainly selected as examples: Cask 717.—Private H. A. Lutes, Co. K, 74th Indiana, aged 21 years, Avas Avounded at Cbickamauga on September 19, 1863, by a conoidal musket ball, Avhich entered at the centre of the dorsum of the left ilium, passed transversely across the sacrum, fracturing its spinous process, and emerged at tho posterior crest of the right ilium. The patient had involuntary) discharges from the bowels, but no paralysis of the" lower extremities. The Avound Avas dressed simply; tonics aud stimulant's were administered Death, October 12, 1863, of pyaemia. Assistant Surgeon J. C. Norton, U. S. V., reported the case. Cask 7IS.—Private George F------, Co. A, Purnell Legion, aged 23 years, was wounded at Cold Harbor, June 3, 1861, and Avas treated in the depot and division field hospitals until June 12th, Avhen he Avas transferred to Washington and admitted to the Douglas Hospital. At this time he Avas suffering from partial paraplegia. He died from well-marked pyaemia on June '21st. The discharge from the wound was a dirty serous fluid. Autopsy : The ball Avas found in two pieces in the sacro-sciatic notch, having perforated the sacrum to the right of tbe median line; both lungs contained extensive pyaunie patches filled with yelloAV fluid; the liver and spleen Avere softened, and the latter enlarged. There had been icterus before death. The specimen (Fig. "201) consists of the sacrum, perforated a little to the right of the median line, at the junction of the fourth and fifth vertebrae, the internal Avound being the larger, and Avas contributed, together with the foregoing history, by Assistant Surgeon W. Thomson, U. S. A. Case 719.— Private W. M. Basto, Co. H, 137th New York, aged 25 years, Avas wounded at Wauhatchie on October "28. 1863. He Avas admitted from the field to a hospital at Chattanooga on the 29th. A missile had entered just above the left trochanter major, struck the innominate just above the acetabulum, causing a fracture, which extended toward the anterior superior spinous process and horizontally across the dorsum, passed through the sacro-iliac synchondrosis, exposing the cauda equina, and comminuting tbe sacrum. There ensued paralysis of the lower extremities, and involuntary evacuation of the bowels, accompanied with frequent chills. Death, November 8, 1863. Cask 720.—Private B. R------, Co. K, 37th Wisconsin, aged 41 years, was Avounded at Petersburg, July 30, 1864, by a conoidal ball. Assistant Surgeon William Thomson, U. S. A., reported that " He Avas admitted to Douglas Hospital on August 3d, and died, after symptoms of pyaemia, on August 10th. There was no paraplegia before death, but for three days after admission the catheter was required, after Avhich time his Avater passed freely. The internal organs Avere not examined, but death Avas preceded by chills and other character- istic symptoms." The specimen (Fig. 202) Avas sent to the Museum by Dr. Thomson, Avith the foregoing memorandum. Case 721.—Private A. S. Maine, Co. A, 7th NeAV Jersey, aged 23 years, received, at North Anna, May 24, 1864, a perforating wound of the pelvis by a musket ball, and was sent to a field hospital ofthe Second Corps, where Surgeon O. Everts, 20th Indiana, noted the character ofthe Avound, and observed that there were no indications of injury of the peritoneal cavity or of the bladder or rectum. The patient Avas sent to Wash- ington on May 30th, and Avas treated at Mount Pleasant Hospital. Assistant Surgeon C. A. McCall, U. S. A., reported that the ball entered the groin beloAV Poupart's ligament, near the anterior inferior iliac spine, and, passing backward, made its exit through the sacrum. The case progressed very favorably, considering the extent and gravity of the injury, until August 30th, Avhen a chill ushered in a fatal attack of pyaemia. Quinia Avas given, Avith stimulants and a sustaining regimen, and the threat- ening symptoms appeared for a feAV days to be held in check; then chills recurred Avith greater intensity, and the patient died September 10, 1864. No autopsy Avas made; but the symptoms pointed unmistakably to pyaemia as the cause of death. Case 722.—Private James M. S------, Co. I, 22d New York, aged 19 years, Avas wounde'd at West Point, Virginia, May 7, 1862, and Avas treated in the regimental hospital until the 14th, Avhen he was sent to Judiciary Square Hospital, Washington, Avhence Acting Assistant Surgeon Calvin G-. Page reported as follows: "Gunshot Avound of the lumbar region near the nates, and also through the lower part of the right chest. When admitted, there Avas a large discharge of pus from the Avounds, to Avhich poultices were applied. Tonics, stimulants, and opiates were also administered. On the 18th, there was some fever; the bowels were loose, pulse full, and urine scanty, Avith some dysuria. Frictions of the Avhole surface Avith alcohol and water were ordered. On the 22d, the urine Avas still bloody; the bowels Avere regular; the patient was flighty at night; the pulse Avas full; he perspired freely at night, and had a small appetite. He died on May 23, 1862. Post-mortem section of the injured parts shoAved a deep wound of the sacrum, ploughing the bone." The portion of the sacrum injured is represented in the Avood-cut (Fig. 203). It was sent to Fig. 203.-Right half .,,,,*„,.„„ J r of the sacrum grooved the Museum by Dr. Calvin G. Page.2 by a ball. Spec. 230 'Herr Fischer (II.) (Kriegschirurgische Erfahrungen, Erlangen, 1872, S. 132, and Taff.l IV, 23) describes and figures a shot fracture of the sacrum in the case of Bielefeld, 53d Prussian Infantry, wounded August 8, 1870, died October 5, 1870. The Musie Dupuytren contains a preparation of the pelvis (NO. 15, Cat, 1842, p. 24) with a ball lodged in the second right sacral foramen; the specimen is figured by M. Legouest (Chirurgie d'Armee, 2™ 6d., p. 419). Dr. SntOMEYER (Maximen der Kriegsheillcunst, 1855, S. G54) has a sacrum from a patient wounded at Frcdericia, who, eight months after'he injury, was convalescent, when dancing brought on a fatal attack of pyaemia. 2 The Catalogue of tlie Surgical Section, p. 227, erroneously credits the specimen to Surgeon Charles I'agc. FIG. 202.—Upper two-thirds of sacrum obliquely fractured by a mus- ket ball. Spec. 3586. 218 INJURIES OF THE PELVIS. [CHAP. VII. Flo. 204.-Sacrum grooved transversely bv a musket ball. Spec. 1G42. A case of transverse perforation of the sacrum—the fatal issue proximately due to bed- sores, an instance of crash with remarkable absence of shock, two examples of embedded balls, and a case fatal from secondary haemorrhage,1 may continue the survey of this group: Cask 723.—Corporal Amos E. C------, Co. 11, 110th Pennsylvania, aged 18 years, Avas Avounded at Chancellorsville, Ma v 3, 1863. Acting Assistant Surgeon Carlos Carvallo reports that "a conoidal musket ball, Avhich entered the left buttock behind and above the great trochanter of the left side, emerged through the left side of the sacrum. The patient remained in the hands of the enemy for nine days, during Avhich time his Avounds Avere entirely neglected. On June 14th, he was sent to Washington and admitted to Douglas Hospital, being very nervous, Aveak, and anaemic. There Avere bed-sores at the long projections of the hips, back, and sacrum, so that it Avas impossible to lay him in a comfortable position. The ball avus extracted by Acting Assistant Surgeon J. E. Smith. The trunk Avas supported by rings of India-rubber and gutta-percha, padded Avith cotton and feathers. The medical treatment Avas expectant. The case progressed as follows: June 24th, anorexia. 25th, boAvels costive. 26th, epididymitis of the left testicle, caused by the pressure resulting from the Aveight of the right thigh Avhile lying on his left side. 28th (morning), catarrh of the stomach; (evening), acute bronchitis, fever, flatulence, pain in the stomach. 29th, bowels costive, bleeding of the gums, dysphagia, gums red and inflamed. July 7th, the inflammation has nearly subsided. The patient died July 9, 1863. On post-mortem examination pleuritic adhesions Avere found, but no signs of peritoneal inflammation. The sacrum (FlG. 204) was perforated, Avith loss of substance, at the junction of the fourth and fifth vertebrae. The fractured bones Avere carious, and there was a slight osseous deposit on the inner surface of the sacrum." Case 721.—Surgeon L. A. James, 4th Ohio Cavalry, reported that Private W. Ball, 1st Ohio Cavalry, at Elk River, July 2, 1863, had the upper part of the sacrum crushed in by an unexploded twelve-pound shell, Avhich lodged in the left iliac fossa, Avhence, Avith some difficulty, it Avas extracted. This man lived four hours after the reception of the injury, being perfectly conscious until a short time before dissolution. Case 725.—Private G. A. L------, Co. I, 1st Pennsylvania, aged 23 years, Avas Avounded at Spottsylvania, May 10, 1834, and taken to a field hospital of the Fifth Corps. On the 14th, he Avas transferred to Carver Hospital, Washington. Acting Assistant Surgeon U. Sweet reported as folloAvs: "The missile entered about two inches to the left of the sacrum, passing a little doAvmvard and to the right, fracturing the sacrum, and remaining in the Avound. When admitted, the patient Avas not much emaciated; there Avas great pain and tumefaction ofthe abdomen; the boAvels were constipated, and there was complete retention of the urine. The bladder was greatly distended with urine; the pulse about 140; tongue thickly coated Avith dark-colored fur; sordes on the teeth. There Avas partial paraplegia. The catheter Avas introduced and the bladder relieved. The missile Avas searched for unsuccessfully. Opiates Avere then administered. He continued to sink, and Avas perfectly unconscious. The pulse was at 160. He died May 15, 1864." The specimen, contributed to the Museum by Dr. SAveet, is represented in the accompanying wood-cuts (FiGS. 205,208). Case 726.—Private H. J. Nearing, Co. A, 15th Noav York Cavalry, aged 22 years, Avas Avounded near Winchester, July 24. 1864. The regimental Assistant Surgeon M. A. Halstead and Surgeon J. Boone, 1st Maryland Volunteers, reported a shot wound of the right hip, penetrating the sacrum. The patient Avas sent from Sandy Hook Hospital, on July 30th, to Baltimore, and entered Jarvis Hospital the next day. Assistant Surgeon D. C. Peters reports that there Avas " secondary haemorrhage to the amount of six ounces from a traumatic aneurism, on August 7th," and that the bleeding was " restrained by persulphate of iron and compression; but recurred on August 8th, and Avas restrained by the same means. Death, August 10, 1864, from spinal meningitis." Acting Assistant Surgeon B. B. Miles made an autopsy twenty-four hours after death, and reported that "the ball Avas found to have struck the right side of the sacrum and then to have lodged. The parts surrounding the injury were in a gangrenous condition. The loAver part of the spinal cord was softened and of a dark appearance." Case 727.—Private Peter K------, Co. G, 91st NeAV York, aged 32 years, having been wounded at the engagement at the South Side Railroad on April 1st, Avas sent to Washington, and admitted to Douglas Hospital on April G, 1865. A conoidal musket ball had entered the buttock nearly on a level Avith the second vertebra of the sacrum, about four inches to the left of the spinous process of the vertebra, passed through the sacral portion of the spinal canal, and lodged in the right Aving of that hone, near its junction Avith the ilium. There Avas complete paralysis of the bladder and of the rectum, Avith constant hematuria; but no paralysis of tho loAver extrem- ities. On April 8th, the patient failed rapidly, and became partially insensible. He died from exhaustion April 9, 1865. The specimen (FlG. 207) Avas contributed by Dr. W. F. Nonis, 1'. S. A. Fig. 205.—Sacrum and last lumbar A-ertebra. A ball is impacted in the left sacral foramen. Spec. £902. FlG. 206.—Posterior view of the same specimen. Fig. 207.—Sacrum, with a ball impacted at the left second inter- vertebral notch. Spec. 2542. 1 KOCH (Notizen uber Schussverletzungen, in Langenbeck's Archir, 187:!. li. XIII, S. 56'J) notes two cases from N'oisseville analogous to (Jasits 725, 7-Jd, viz: Fischer, 1st Prussian Infantry, ball lodged in sacrum August 31st, death October 8, 1870; Mercier, C2d French Infantry, shot fracture of sacrum August 31st, death from haemorrhage from gluteal artery, November 11, 1870. SECT. 1.1 SHOT FRACTURES OF THE SACRUM. 249 Shot fractures of the sacrum1 are represented in the Museum by not less than sixteen specimens, of which eight of the most interesting have been already figured. A few other examples may be added: Case 728.—Private P. McC- Co. H, 1st Louisiana Cavalry, aged 20 years, was Avounded at Carrion CroAV Bayou, Louisiana, November 3, 1863. He Avas treated on the field until the 8th, when he Avas admitted to University Hospital, NeAV Orleans, Avhere he died November 22, 1863. The folloAving report of the case, together Avith the specimen, Avas furnished by Assistant Surgeon P. S. Conner, U. S. A., in charge: "Gunshot fracture of the sacrum; the missile passing obliquely from the left, entered near the median line at the junction of the second and third lumbar vertebras, and escaped into the pelvis through the right portion of the second vertebra. The sacrum Avas completely fractured transversely at that point." The specimen (Fig. 208) is figured in the adjoining Avood-cut. Case 729.—Private W. M. R- -, Co. F, 58th Virginia, aged22years, received aAvound in the abdomen at Winchester, July 20, 1864; a musket ball penetrated the back five inches above the t]le sacrum" .Spec. 3001. anus and one inch to the left of the median line and lodged. The Avound was dressed in the field hospital, and, on the 22d, he Avas admitted into the hospital at Cumberland, and the case reported by Surgeon J. B. LeAvis, U. S. V., as follows: "The Avound looked irritated and Avas attended Avith much pain; it Avas examined under the use of chloroform and the ball traced obliquely upAvard and forward, having broken doAvn the sacrum and spinous processes of the lower lumbar vertebras. The discharges Avere very thin and fetid; he suffered much, but there was no paralysis or loss of sensation ; he has had retention of urine, requiring the daily use of the catheter; he did not rest well, but felt Avell otherwise. July 25th, he Avas very restless aud suffered great agony from the wound, the ecchymosis and discoloration of Avhich Avere disappearing rapidly; suppuration Avas profuse and offensive. But little change occurred in the condition of the patient up to August 6th, when light tetanic spasms occurred, Avith delirium and unconsciousness, and continued Avith increasing severity, and, on the 8th, opisthotonic spasms recurred at frequent intervals; the pupils Avere largely dilated and fixed, and he was unconscious and unable to take food or medicine. The case was complicated with diarrhoea, requiring the use of astringents and opiates, for Avhich diarrhoea mixture Avas given during the day and solutions of morphia at night; cold-Avater dressing Avas applied to the Avound; tonics and stimulants Avere administered, and nourishing diet ordered. He died August 8, 1834. Seciio cadaveris twelve hours after death: Rigor mortis Avell marked; the back in the vicinity of the wound Avas livid and offensive; the ball Avas found about three inches from the point of entrance, above and to the right of the spinous process of the lumbar Arertebra, embedded in the muscular tissue; the spinous processes Avere broken through and the spinal column in a suppura- ting condition. The cerebrum and cerebellum Avere also suffused and injected Avith blood throughout their entire extent; the right kidney was partially broken doAvn by an abscess, and the left Avas congested and enlarged; old adhesions of the peritoneum and boAvels marked the extreme of inflam- matory action. No other viscus Avas examined." Dr. LeAvis forwarded the specimen (FlG. 209), Avhich consists of a Avedge-shaped portion of the sacrum, sliOAving a fracture into the vertebral canaj at the second sacral vertebra, and the first and second spinous processes broken away. Case 730.—Private Peter C------, Co. E, 73d Pennsylvania, aged 26 years, Avas Avounded at Chancellorsville, May 3, 1863, by a conoidal musket ball, Avhich perforated the third sacral vertebra at its junction Avith the ilium and embedded itself within the pelvis. He was sent to Washington, and admitted into Douglas Hospital on May 7th. Acting Assistant Surgeon H. L. W. Burritt describes the progress of the case: "There was no paralysis or disturbance of function. Water dressings, morphia, and a nourishing diet constituted the treatment. There Avas no constitutional indication of serious injury till May 19th, when a slight fever occurred, followed by much prostration. On the folloAving day, the consti tutional disturbance Avas more marked—the pulse being 100, the tongue of a dark-brown color, and the skin hot but moist. The bowels and urine were natural; the discharge of pus free, Avith no discoloration from the wound, and the patient slept Avell. On May 21st, he became much worse—the pulse being at 120, with jaundice, sordes, loose boAvels, dry skin, obtuse mind, moaning and restlessness; the pulse rose to 125. On May 22d, the skin Avas dry and of a dark- yellow color; decubitis dorsal; there was a free dark discharge from the Avound; the tongue Avas dark, aud there was hiccough; death, May 22, 1863." At the necropsy, eighteen hours subse- quently, "the ball was found embedded in a portion of the clothing, and enclosed in a sacculated membrane just Avithin the pelvis, none of the viscera of which Avere injured. Both the ilium and sacrum Avere fissured and comminuted, several large pieces being driven hnvard. The case is remarkable for the absence of peritonitis and paralysis, the patient being able to get in and out of bed to stool, and having no tenderness or tympanism of the abdomen even to the last." Assistant Surgeon W. Thomson, Avith these comments, transmitted the pathological specimen (FlG. 210). FlG. 20!).—.Shot penetra- tion of the sacral canal. Spec. 4258. FIG. 210.—Sacrum and adjoin • ing portion of right ilium, and bullet which perforated the for- mer. Spec. 1245. 1 AVhile references to shot fractures of the pelvis abound in the writings of military surgeons, observations in which the seats of the lesions are described with precision are not very numerous. DESl'OUT (Traiti des plaies d'armes a feu, Paris, 1749, p. 323) mentions the recovery of a soldier of the Nivernois regiment, shot in the upper portion ofthe sacrum; a large incision was made and the ball removed with pincers. BlUOT (Hist, de I'etat et deprogres de la chir. mil., 1817, p. 138) gives the case of Sarbeuf, 10th brigade, shot through the sacrum and rectum ; several pieces of bone came away; recovery in about one month. Hen.nex (Princ. of Mil. Surg., 1829, p. 44!)) states that Mr. HammicK showed him a preparation from a patient 32 250 INJURIES OF THE PELVIS. Lciiap. vu. Excisions of Portions of the Sacrum.—About half an inch of the lower end of the sacrum may be removed without opening the sacral canal. The spinous apophyses may also be resected. The interval between the apophyses and the lateral foramina is only about half an inch, so that it is not easy to resect the lamina. The spinous processes or lower extremity are most readily excised by the cutting-bone forceps; the remaining parts of the bone are more convenietly attacked by the rugine, gouge, or cockscomb saw. Case 731.—Surgeon N. R. Derby, U. S. V., was Avounded, during the Red River Expedition, in April, 1864. The folloAving notes of the case appear upon a monthly report of No. 1 hospital, Alexandria, Louisiana, signed by Surgeon James Robarts, IT. S. V.: "The Avound was produced by a large round ball, Avhich entered over the rough surface of the first sacral bone and near the posterior right sacral foramen. The finger passed through a circular opening into a cavity ofthe pelvis. The direction was forward, doAvnward, and outAvard; the situation of the ball was not found. Three pieces of the sacrum and some pieces of clothing were extracted at the time ofthe examination, which was made Avhilethe patient Avas under the influence of chloroform. On April 30th, the patient Avas conveyed, on a water-bed, to the hospital steamer R. C. Wood." On May 12th he was admitted into the hospital at Mound City, whence he Avas transferred to Jeffersonville, June 1st. Surgeon Derby Avas mustered out of service July 27, 1865, and pensioned. Examining Surgeon W. M. Chamberlain, of New York, reported, May 5, 1866: "The ball entered the cavity of the pelvis through the sacrum. The injury has resulted in partial sensory and motor paralysis of the right loAver extremity, obliging him to Avalk with a crutch and cane; there is also some neuralgic disturbance." Case 732.—Private Charles A. Trask, Co. H, 13th Massachusetts, Avas wounded at Antietam, September 17, 1882, by a fragment from a spherical-case shot, Avhich fractured the pelvis and lodged in the sacrum. He Avas conveyed to a field hospital, where the missile Avas extracted. On September 20th he was transferred to HagerstoAvn, and, on the 29th, to Cham- bersburg, Avhere he died in the early part of October, 1862. The missile (FlG. 211), showing a Fig. 211.—Shell fragment ex- 6' J r ' ., . traded from the sacrum. Spec. section of the orifice for the fuze, and Aveighing two and two-thirds ounces, was contributed to the 44S9- Museum by Surgeon E. McDonnell, U. S. V. Case 733.—Private W. Bell, Co. F, 121st Pennsylvania, Avas wounded at Gettysburg, July 1, 1863. A ball entered just below the left posterior superior iliac process and lodgeil. The patient was sent to Broad and Cherry Streets Hospital, Avhere Surgeon John Neill, U. S. V., reported the general health excellent, a fortnight after the injury. "On introducing the finger an extensive fracture of the sacrum was recognized, a large piece being movable; the ball had passed doAvnward and toAvard the right. There was no paralysis or paresis, and the evacuations were natural. Several large fragments of bone were removed, evidently belonging to the sacrum. By October 1st he had made a good recovery, without a bad symptom." He Avas discharged July 10,1865, and pensioned. The Pension Examining Board reported, May 1,1872, substantially, that the ball, passing through the sacrum, lodged in the right hip; and that there Avas loss of bone, adherent cicatrix, numbness of both legs, especially the left, and pain on change of Aveather. Case 734.—Corporal M. Moore, Co. G, 8th Ohio, aged 23 years, was Avounded at Gettysburg, July 3, 1863, and Avas taken to the Second Corps hospital. Surgeon Isaac Scott, 7th West Virginia, reports that "a ball entered the pelvis a little to the left of the spine, and betAveen the fourth and fifth sacral vertebrae." The patient Avas transferred to McKim's Mansion Hospital, July 13th. Acting Assistant Surgeon A. Hartman reports that "there Avere several secondary haemorrhages externally during the 14th. He also complained of pain in the abdomen, and became delirious. Death resulted July 15, 1863. Sectio cadaveris: The course ofthe ball was in a line draAvn from the point of entrance to the crest of the pubis. There Avas considerable blood effused into the pelvis, apparently from the lateral sacral and small branches given off from the Fig. 212.—Ball found in anterior trunk of the internal iliac. The peritoneum bore evident marks of inflammation. The ball s/ec.e67iC.CaVlt'V a t6r 6a ' (FlG. 212) was found just posterior to the bladder." The missile was transmitted to the Museum by Surgeon L. Quick, U. S. V. shot by a musket ball through the side of the sacrum, three inches above the point of the coccyx ; the missile penetrating obliquely upward, and being passed by stool two months after the injury; this patient survived two years. [Compare note 1, p. 107, supra, where it is erroneously stated that H kxxicx specifies only the cases there referred to. This is probably one ofthe instances he had in mind in writing: "Other cases of a similar nature have come to my knowledge."] The same author (I. c, p. 450) gives the case of an officer shot through the sacrum at the siege of Badajos in 1812, the injury resulting fatally. Lauuev (D. J.) (Mini, de chir. mil. et camp., 1817, T. IV, p. 298) quotes a case from the Sallzburg Gazelle of 1812; a ball entered through the os pubis and escaped through the sacrum; urine and fiscal matter escaped from the posterior wound, and urine only from the anterior; the patient recovered. LAUUEV (I. c, T. I\T, p. 309) also relates the case of a German soldier shot through the sacrum in 1800; the ball lodged in the bladder, and was removed by Dr. LANOKXBECK ten years afterward. Guthrie (Lectures, etc., 1847, p. 67) records that a French officer was shot at Salamanca through the sacrum, urine escaping from the entrance and exit wounds; death followed in three days, from peritonitis. llOUX (Considirations cliniques sur les Blessis qui ont iti recus a VHopital de la Chariti, 1830, p. 33) gives the case of a man of 20, shot through the sacrum; paralysis ofthe bladder and rectum ensued, and death in seven or eight days. HUTIN (Fragmens historiques et midicaux sur V Hotel national des Invalidcs, Paris, 18.31, p. 75) tabulates three instances, in which invalids were admitted to that hospital with balls embedded in the sacrum. JobeUT (Plaies d'armes a feu, 1833, p. 220) relates the case of T------, shot in the base of the sacrum, in the revolution in Paris, July, 1830; the ball Avas removed, and the patient slowly recovered. CllENU (Statistique med. chir. de la camp, d'ltalie, 1869, T. II, pp. 510, 512) records four cases of shot fractures of the sacrum resulting favorably. BECK (Kriegschir. Erf., 1867, S. 253) cites one successful and one fatal case of fracture of the sacrum ; in the latter, the ball lodged in the bone, and an unsuccessful attempt to forcibly remove the missile was made; death from pyaemia. The same writer (Chirurgie der Kltussrerletz.. 1S72, S. 553-555) adduces four eases of shot fractures of the sacrum with fa\'orable terminations. Professor SOCIN (Kriegschir. Erf., 1872 S. !>8> relates two cases of shot fractures of the sacrum; recovery in three and eighteen weeks ; in the latter case the ball lodged; ball and many bone splinters were removed. CHirAULT (Tract par armes a feu, 1872, p. 77) relates two cases (Obs. 82 and 83); recovery after shot fracture of the .sacro- spinal processes. Puuman.v (Funfftzig sondcr- und wumderbahre Schusswunden Curen, 1721, Obs. VII) records the case of .Sergeant Eulcnberg, shot through the sacrum, at .Stettin, July, 1677; four days after, the ball passed at stool. SECT. 1.1 EXCISIONS OF PORTIONS OF THE SACRUM. 251 Dr. Francis H. Brown, in a valuable paper,1 read before the Middlesex Medical Society, has recorded two cases of shot fracture of the sacrum, in one of which a shell fragment was deeply embedded in the body of the bone and was with some difficulty extracted: Case 735.—Private J. O. Churchill, Co. E, 11th Massachusetts, Avas wounded near Bristoe Station, August 30, 1862, and sent to Judiciary Square Hospital at Washington. Surgeon Charles Page, U. S. A., reports a shot Avound directly over the sacrum. On passing the finger through the lacerated soft parts, a fragment of metal Avas felt an inch below the surface, thoroughly impacted in the body of the sacrum, and requiring considerable force for its dislodgement. There Avas retention of urine, and a catheter was introduced; once relieved, the bladder resumed its normal functions. The patient had no paralysis or other indication of spinal concussion. He avus able to sit up at the expiration of a fortnight, and in a month Avas about the Avards. He was trans- ferred to the Filbert Street Hospital on December 11, 186-2, and discharged from service March 20, 1863, for a "shell Avound of sacrum." His name does not appear on tho Pension Rolls. What was formerly regarded as an indispensable implement in extract- ing bullets from bone, the old-fashioned tire-fond, was rarely or never used, and, indeed, was not included in the outfit of the field or dressing cases of the surgeons of either army. That it is occasionally requisite is shown by the following case, in which the screw of a ramrod served as a substitute: Case 736.—Private J. McDonald, Co. K, 11th Connecticut, was Avounded near Petersburg, June 18, 1864. He Avas admitted to the hospital ofthe 2d division, Sixth Corps. On examination by Surgeon S. F. Chapin, 139th Pennsylvania, the ball Avas discovered '/firmly embedded in the body ofthe sacrum, beyond the reach of forceps, and Avas extracted by means of a common ramrod, a piece of which remains in the bullet as when taken out." There Avas great prostration from shock, and the patient died the same day, June 18, 1^64. The specimen, as represented in the Avood-cut (Fig. 213), Avas forwarded by Dr. Chapin banIex1racted>nb>ldia to the Museum, Avith the foregoing memoranda. ramrod. Spec. 1123. Case 737.—Surgeon J. J. Chisolm relates (Manual of Military Surgery, 3d ed., 1863, p. 356) that "in the case of Private E. J. Afatthews, of the 26th Alabama Regiment, a youth of 14 years, Avho, Avhen returning from a fifth charge against a Yankee battery during one ofthe battles of Richmond, Avas shot in the back, the ball entered through the sacrum an inch from its spinous processes aud one inch beloAV the level of the crest of the ilium. Eight months after the reception of the Avound he applied to me for relief, as he had a constant discharge of pus from both the wound in the back and a fistulous passage in the left groin. Upon examination with a probe, which passed in four inches, traversing the sacrum, the foreign body Avas detected, the bulb of the probe entering the cup of the mini<5 ball. By using a gouge, the orifice through the sacrum Avas enlarged sufficiently to allow the ball being draAvn from the pelvic cavity. The case recovered." Besides the seven foregoing examples of operations upon the sacrum for the removal of injured or diseased bone or the extraction of impacted projectiles, five others have previously been incidentally noticed,2 and the examination of injuries of the bladder and rectum will present several others. There were in all twenty-five such operations.3 In one instance the trephine was employed: Case 738.—Private H. F. Norcross, Co. C, 25th Massachusetts, aged 20 years, Avas wounded at Drury's Bluff, May 16, 1864. He Avas sent to Hampton Hospital. Assistant Surgeon Ely McClellan, U. S. A., recorded a shot penetration in right gluteal region. The patient Avas removed to De Camp Hospital, June 10th; to Readville on October 19th; and to Dale Hospital, Worcester, on October 25, 1864. The track of the ball had been traced to the right side of the second sacral segment, and the missile was apparently deeply embedded in the bone. On March 9, 1865, Acting Assistant Surgeon E. B. Lyon reported that " there Avas an open sinus on the right buttock communicating Avith the lodgement of the ball in the sacrum, and discharging freely. The constitutional condition Avas comparatively good. Ether was administered, and an oblique incision, six inches in length, Avas made, exploring the orifice in the sacrum. A trephine was then used to enlarge the orifice iu the bone. The ball Avas divided and removed in seventeen parts. Simple dressings Avere applied. On March 31st, the Avound Avas healing kindly." He Avas discharged from service July 10, 1865, when Surgeon C. N. Chamberlain, U. S. V., rated the physical disability at one-fourth, resulting from a "gunshot perforation of the sacrum, Avith loss of tissue and an extensive cicatrix." This soldier was pensioned. The Examining Board of Boston reported, September 18, 1873: "Wound of upper part of right buttock, near the cleft. In consequence of the cicatricial tissue he suffers pain and lameness. The cicatrix is tender, and open most of the time, and is discharging at present. The disability continues at one-half." 1 BROWN (F. H.), Surgical Cases, in Boston Med. and Surg. Jour., 1863, Vol. LXVII, p. 492. The second case, that of Private Durfee, is noted further on. 2 Another report in the case of Pt. W. Ambrosher, printed on page 458 of the First Surgical Volume, and in the Cincinnati Lancet and Obs., 1864, Vol. VII, p. 595, indicates that the sacrum shared in the injury, and that the removal of fragments reported was from the spinous process of the sacrum. 3 The few following cases are recorded by authors: Puiimann (Funfftzig sonder-und wunderbahre Schusswunden Curen, Franckfurt, 1721, Obs. XXV, p. 191) relates tho case of M. Fricdrieh, of Captain Gotzen's company, shot through the sacrum, at Greifswalde, November 23, 1678, and states that he removed a large piece of the os sacrum on the third day, and eighteen small pieces during the first four weeks. Professor Rothmund (RlED, Die Resectionen der Knochen, Niirenberg, I860, S. 242) is said to have successfully removed a necrosed piece of the os sacrum, three by four and a half 252 INJURIES OF THE PELVIS. [chap. vu. Shot Fractures of the Coccyx.—This form of injury has received some attention from military surgeons on account of Andouill6's disquisition, already noticed, which is printed in the second volume of the' celebrated Memoirs of the French Academy of Surgery.1 It is hardly necessary to observe that the osseous lesion is ordinarily a subor- dinate element in the gravity of shot injuries of this group. Van Onsenoort and Oilier2 extirpated the coccyx for caries, and Nott3 and Simpson4 performed the same operation with impunity for neuralgia, and Mr. Bryant5 has safely separated the muscular attachments. Seventeen cases of shot fracture of the coccyx, of which six, or 35.3 per cent., were fatal, were reported during the War. In twelve cases, with five deaths, the coccyx was the only bone involved; four cases, terminating favorably, had attendant fractures of the sacrum; two, one of which was fatal, were associated with fractures of the pubis. In four of the seventeen cases, the rectum was penetrated; in three of these four cases, the bladder was also injured. The two fatal cases of this group6 fall in this last category, which, moreover, comprises all the instances in which shot fracture of the coccyx was associated with injury of the bladder. Cases 739-744.—Five of the six cases of shot fracture of the coccyx alone that terminated favorably, Avere those of Private G. W. Busch, Co. A, 82d Illinois, wounded at Chancellorsville, May 2, 1863, discharged April 4, 1865; Private W. L. Fischer, Co. D, 1st Mississippi Marine Brigade, wounded at Rodney, December 4, 1833, discharged from service May 31,1864; Private P. Doyle, Co. G, 16th Kentucky, wounded at Atlanta, July 20, 1864, duty, January 7, 1865; Corporal E. H. Shermer, 105th Co., 2d Battalion V. R. C, Stone River, December 31, 1862, discharged April 12, 1864; Private B. Jones, Co. D, 176th Noav York, wounded at Cedar Creek, October 19, 1864. The sixth case Avas that of Denegan, which will be detailed separately. Of these five, Busch alone is pensioned; the application of Doyle is pending. Private Busch Avas treated in hospitals at Chattanooga, Nashville, Jeffersonville, and Mound City. It is from the last-named hospital that Surgeon Horace Wardner, U. S. V., returns the fullest account of the case. Pension Examiner Churchman, of Chillicothe, reports that in this case tlie ball Avas extracted from the vicinity of the left sciatic nerve, and that the left lower extremity is permanently lamed in consequence of injury to the nervous trunk. Private Shermer's case was complicated with Avound of the rectum and faecal fistula, and discharge of necrosed bone. Private Jones appears on the records of Jarvis Hospital as a transverse shot perforation of both buttocks, with fracture of the coccyx, complicated by secondary haemorrhage, arrested by compression. The haemorrhage Avas referred, by Assistant Surgeon D. C. Peters, to " traumatic aneurism of the internal pudic artery." Case 745.—Private S. Denegan, Co. E, 58th Massachusetts, aged 22 years, was Avounded at Cold Harbor, June 1, 1864, and sent to Alexandria, Avhere he Avas admitted into St. Paul's Church Hospital, June 7, 1834. Acting Assistant Surgeon A. W. Tryon reports: "A gunshot fracture of the coccygeal bones, wounding the rectum; the ball entered the gluteal muscle about four inches to the right of the os coccygis and passed directly across, making its exit from the gluteal muscle of the opposite side about the same distance from the coccyx. Blood and pus from the wound flowed through the anus, and small quantities of faecal matter worked out at the openings of the Avound. The patient had been much debilitated by a severe persistent diarrhoea. He Avas supported by milk-punch made Avith brandy. Quinia, iron, and tannin, Avith opium pills, were administered. On June 20th, the edges of the Avound became gangrenous, and a patch directly over the coccyx, an inch above the ramus, sloughed out, making another opening. Bromine was applied to the livid edges of the Avound, and a separation of the slough soon followed, and the Avound began to exhibit a healthy action. On July 1st, he Avas greatly improved. July 6th, he Avas suddenly taken with a chill in the afternoon, and at night he had another. Next morning erysipelatous inflammation, extending along the integument of the hips and doAvn on his thighs, Avas progressing very rapidly. A high febrile movement accompanied this attack. Tavo grains of sulphate of quinia, Avith half a drachm each of simple syrup and tincture of the sesquichloride of iron, Avas ordered eA'ery four hours, Avith a local Avash of acetate of lead and opium. On the folloAving day the febrile movement was not so high, and milk-punch Avas resumed. The erysipelatous inflammation kept extending, but soon began to fade and go doAvn around the Avound. In about ten days it entirely disappeared. The patient's appetite and strength improved. The tincture of inches, with the osteotome. Mr. Jc,hn Coupeu (Misc. Cases, in Clin. Lect. and Rep. of Lond. Hosp., 18C7-8, Vol. IV, p. 270) records a case cf extrac- tion of an iron ball from the sacrum, twenty-one years and a half after the reception of the injury. The man was struck at Moodkee, in December, 1845. Several unsuccessful attempts to extract the ball from its lodgement near the middle of the sacrum were made. In 186"7, the missile was success- fully extracted, and weighed four hundred and fifty grains, and was thickly coated on the surface with sulphurets. Champeaux (Gazette Salutaire, 1769, No. 31, p. 3) relates the case of a woman injured by a fall, which caused necrosis of the sacrum ; the bone was laid bare and more than twenty pieces of bone were removed by means of the forceps. 1 Andouille (Mim. de I'Acad. de Chir., 1753, T. II, p. 488) states that in Flanders, at the battle of Raucou, October 11, 1746, a Hannoverian soldier was struck by a musket ball, which entered at the junction of the pubis with the ilium, notched the bone, traversed obliquely the cavity of the clvis. perforated the rectum, and destroyed the lower part of the sacrum and part of the coccyx. 2 Van OxsesOOkt's case is cited by VELPEAU (Mid. opirat, 1839, T. II, p. 641), and by RlED (Die Resectionen der Knochen, 1860, S. 242), O. HETTT.LDEU (op. cit., S. 318), and others who appear to quote VELPEAU. Van Oxsf.XOOUT'S Operative Heelkunde, Amsterdam, 1822, is styled cin sehr gutes Compendium, by BEUXSTEIX. OLLIEU (Traiti exp. et clin. de la Regineration des Os, 1867, T. II, p. 180). sNOTT, New Orleans Medical Journal, 1844, Vol. I, p. 58. 4 Simi-sox (J. Y.), Medical Times and Gazette, 1861, Vol. I, p. 317. 6 Cuyaxt (T.), Medical Times and Gazette, 1860, Vol. I, p. 303. 6 These cases, . I Tweedy and of Baggs, will be detailed in the Second Section of this Chapter, with fatal shot wounds of the bladder. SECT. I.] SHOT FRACTURES OF THE COCCYX. 253 iron and quinine Avas continued in the same doses, repeated at longer intervals. The opening into the rectum seemed to have closed before the attack of hospital gangrene, for there Avas no fioecal matter in the wound and no discharge of pus by the anus. Several pieces of bone Avere removed, and about the middle of August the patient had sufficiently recovered to stand up, though Avith pain. He had no further draAvbacks, and by October could hobble about. The wound did not close till about the last of November. He still Avalked Avith great difficulty. At the request of the patient ho Avas discharged December 17, 1864." This man's name is not on the Pension Roll. Some others of the eleven cases resulting favorably presented complications of interest: Cases 746-750.—The five cases of recovery from shot fracture of the coccyx associated Avith fractures of the sacrum or pubis Avere those of Colonel A. S. M. Morgan, 63d Pennsylvania, wounded at Fair Oaks, May 31, 1862, mustered out and pensioned April 18,1863; Private Frank Davy, Co. K, 100th New York, wounded at Fort Wagner, July 18,1863, discharged and pensioned January 30, 1835; Private D. A. Barton, Co. G, 21st Wisconsin, Avounded at Resaca, May 14, 1864, discharged and pensioned December 8, 1864; Corporal G. Simonson, Co. B, 16th Michigan, wounded at Spottsylvania, May 8,1864, discharged June 16,1865, and pensioned; Corporal J. Daly, Co. F, 56th Massachusetts, Avounded at Cold Harbor, June 2,1864, mustered out July 14,1865. In the case of Colonel Morgan, Pension Examiner G. McCook, of Pittsburg, reports that the rectum was injured, and that the disability is permanent. The particulars of the case of Private Frank Davy are correctly related, under the title of "Sergeant Hank Davy," in the American Med. Times, 1864, Vol. VIII, p. 301, and in his Treatise on Military Surgery, 1865, p. 351, by Medical Inspector F. H. Hamilton, U. S. A. The case Avas complicated by fracture ofthe pubis, abscess, and secondary stercoral fistula. Pension Examiner Loomis, of Buffalo, reported, in February, 1865, that the pubis was carious and the motor functions of the left loAver extremity considerably impaired. In Private Barton's case, Examiner J. T. Canaday, of Brooklyn, Iowa, reported, July 6, 1871, that "the ball carried aAvay a portion of the coccyx. I find the sacral nerves damaged, so that locomotion to any considerable extent is impossible." In the case of Corporal Simonson, Examiner D. Clarke, of Flint, reported, May 7, 1863, that the "ball entered the left hip about three inches back of the crest of the ilium, passed nearly horizontally through the loAver part of the os sacrum, separating the coccyx, and emerged through the right hip at about a corresponding point, injuring the spine and plexus of nerves, especially on right side, causing irregular and imperfect innervation, with partial paralysis of right leg, with inability to raise Aveights, and difficulty in rising from a reclining to an erect position, with spasmodic action of the limbs, and, at times, inability to walk." There were six fatal cases of shot fracture of the coccyx: Cases 751-754.—Three of the six fatal cases of shot fracture of the coccyx Avere those of Private H. Glynes, Co. B, 10th Vermont, wounded at Cold Harbor, June 1st, died June 18,1864, at Armory Square, Washington; Private L. F. McCreary, Co. H, 9th Alabama Cavalry, wounded at Lafayette, Georgia, June 24th, died September 18, 1864; Private W. M. Tliaker, Nelson's Battery, Avounded at Pocotaligo, October 22, 1862, died November 12, 1862, with erysipelas and pneumonia. Of one of the remaining fatal cases some details Avill be given here, and the others will be described in the next Section. Corporal J. K. Phillips, Co. B, 6th Maine, aged 26 years, Avas wounded at Boonesboro', July 9,1863, and admitted to hospital at Frederick on July 12th. Assistant Surgeon M. Hillary, U. S. A., reported that "the ball entered the right buttock, passed through transversely, making its exit on the opposite side. The patient complained of pain in the right gluteal region, and the surrounding parts were slightly SAVollen. On the 18th, the right buttock Avas still more swollen, the skin Avas glossy, and there Avas great heat and tension. A cataplasm Avas applied, and, at 3 o'clock P. M., after consultation held Avith Dr. Wier, an incision, eight inches long, was made down to the fascia, Avhich Avas also incised upward and doAvmvard Avith the probe-pointed bistoury. The tissues had a gangrenous aspect, and a quantity of gas escaped from the incision. On the 19th, gangrene rapidly extended, involving the entire right gluteal region. Active stimulation Avas of no avail, and the patient died in the evening of July 19, 1863. At the autopsy, three hours after death, the muscles of the gluteal region Avere found disorganized, the connective tissue hanging in shreds like tow. Near the sciatic notch the parts assumed a more normal appearance. On tracing, Avith difficulty, the track of the ball, it Avas found to have become subcutaneous in the middle, where a portion of the coccyx Avas broken off; the track continued through the left buttock. Some bits of tin, such as are used in the Belgian rifle cartridge, Avere picked out of the shot track." In the case of Baggs, related further on, a ball is said to have been found embedded in the coccyx. Though less rare1 than simple fractures, shot fractures of the coccyx are sufficiently uncommon2 -to justify reference to every authentic individual case. In the foregoing examples, attendant visceral lesions were less frequent than would be anticipated from the anatomical relations. The variety of the complications of shot fracture of the coccyx precludes the establishment of any special rules of treatment. The early removal of sequestra or foreign bodies is, of course, indispensable. Free, though cautiously directed, incisions, to prevent the burrowing of pus, may be requisite. Extreme attention to 1 Baudexs (Clinique des plaies d'armes a feu, Paris, 18.16, p. 4tC) relates that a soldier of the 3d line was shot, at Staoli, by a ball which carried off a portion of the os coccyx and lacerated the anus; ball removed by counter-incision ; recto-vesical fistula; recovery. 2 PURMAXN (Funfftzig sondcr- und wunderbahre Schusswunden Curen, Franckfurt, 1721, Obs. XXXI, S. 237) relates that, at the siege of Wolgast, 1675, Private P. Giinther, of General Gotze's regiment, was shot through both buttocks and the os coceendicis et ilionis; wound very painful; ball removed by incision from left buttock; recovery. 251 INJURIES OF THE PELVIS. [CHAP. VII. cleanliness, to the prevention of frecal accumulation in the rectum, and the confinement of inflammation-products in the shot canal, and watchfulness of the state of the bladder, are precautions that must not be overlooked. Shot Fractures of the Pelvic Bones in general.—The reason advanced by Mr. Birkett, in his excellent paper1 on injuries of the pelvis, in support of the assertion that "it would be idle to write a systematic description of the dislocations and fractures of each pelvic bone separately," does not apply to shot fractures which are seldom combined with luxations. It has been found advantageous to group the cases of shot fracture of the several bones,' although not infrequently more than one were interested. In Table VII, an approximate expression is given of the extent to which the fractures of the several bones exceed the number of individual cases of shot injury. Referring to Cases 692-696, it may be remarked that tetanus appears to have been an infrequent complication of shot fractures of the pelvis. There is some ground for supposing that it oftenest attended lesions in the sacral region : Case 755.—Private H. A. Durfee, 55th Ohio, Avounded at Bull Run on August 30, 1862, Avas sent to Washington and admitted into Judiciary Square Hospital. A ball had entered on a level Avith the fifth lumbar vertebra tAvo inches to the right of the median line, and Avas not found. From the date of his Avounds the patient had entire paralysis of the nerves of motion and sensation ofthe left lower extremity; the right Avas moved as in health, andAvas normally sensitive to any stimulus. Two days after entrance, and six days after the Avound, opisthotonos occurred. This condition lasted, more or less marked, until his death. During the entire treatment the patient passed his urine and faeces involuntarily, in bed. He stated that he knew Avhen the urine Avas dribbling aAvay, but of the faecal discharges he had no knoAvledge. From his entrance this patient gradually failed. He died September 12, 1862. At the autopsy the hall Avas found to have perforated the upper sacral vertebra laterally from right to left, and to have lodged beneath that portion of the sacral plexus formed by the last lumbar and first sacral nerves.2 Dr. Brown remarks that the lesions of the nerves revealed by the autopsy in this case rendered intelligible the phenomena observed during life. The injury of the portion of the sacral plexus contributing to the greater sciatic and the infernal pudic nerves, and to the numerous branches to the muscles of the thigh, accounted for the incontinence of urine and of faeces, and the paralysis of the left lower extremity. Prolapsus of the rectum is referred to as a possible consequence of shot fracture of the sacrum : Case 756.—Private L. Schoenfield, Co. B, 8th NeAV York, Avas admitted from the field to regimental hospital at Stafford Court-house on September 14, 1862, for a gunshot wound of the sacrum, probably received at Manassas on August 29th. This man Avas transferred to Alexandria on September 23, 1862, and Avas sent to Washington, and discharged from service on December 3, 1862, at Avhich time there Avas prolapsus ani and pain in the legs, the disability being rated at one-half by Surgeon M. Froehlich, 8th New York. He is not a pensioner. If the diagnoses of several observers are unquestioned, shot contusions of the pelvic bones would appear to involve less serious results than like injuries of the long bones: Case 757.—Major J. S. Ritchie, 209th Pennsylvania, aged 28 years, was Avounded at Petersburg, April 22, 1865, and was taken to the hospital of the 3d division, Ninth Corps. Surgeon A. F. Whelan, 1st Michigan Sharpshooters, and Surgeon W. O. McDonald, U. S. V., regarded the injury as a shot Avound of the thigh and groin. The patient Avas sent to Armory Square Hospital, Avhere Assistant Surgeon C. A. Leale, U. S. V., made the following report of the progress of the case: "Admitted to Armory Square April 24, 1865. Ball entered below the tuberosity of the ischium, passed through the gluteal muscles, along the inner aspect ofthe femur near the inner and upper space of Scarpa's triangle, avus deflected by the fascia lata, and made its exit at the crest of the pubis one inch from the symphysis ; the bladder Avas not injured. Suppuration had taken place along the whole length of the Avound, and a large abscess had formed beloAV Poupart's ligament. The anterior AA'ound was slightly enlarged and the pus evacuated, and opiates, stimulants, and beef-tea Avere given. In July, the ischium Avas found to be necrosed. I removed tAvo pieces of bone from the posterior, and one piece from the anterior wound. Several pieces of cloth have come away Avith the pus at different times. The posterior Avound extends several inches from the surface and passes through the gluteal muscles to the bone. The anterior Avound has nearly closed. Has had no unpleasant symptoms of hnver extremity." Surgeon D. W. Bliss reported that this officer Avas discharged July 11, 1835. He Avas pensioned. Examiner J. L. Suesserott stated, April 11, 1866, that "the abdominal parietes have been greatly Aveakened, and hernia may yet result." This pensioner was last paid March 4, 1873. i BlUKETT (J.), Injuries of the Pelvis, in Holmes's System of Surgery, 1870, Vol. II, p. 709. 'Bltowx (P. II.), Surgical Cases, in the Boston Med. and Surg. Jour., 1863, Vol. LXVII, p. 49.\ SECT, i.i SHOT FRACTURES OF THE PELVIC BONES. 255 It would seem that it was a common error to regard too lightly the divisions of the soft parts attending shot fractures; but experienced surgeons recognized the gravity of extensive lesions of the 'muscular tissues' There were sometimes shot perforations of the ilium which proved fatal from shock, though unattended by any visceral lesion, as in the following case : Case 758.—Corporal Thomas Young, Co. I, 99th Ncav York, was wounded during the siege of Suffolk, April 14,1863, by a conoidal ball, which struck the left breast a little internal to the nipple, and passed downward and backward under the great pectoral muscle, and made its exit through the crest of the left ilium at a point almost midway between its anterior and posterior snines. He Avas at once carried to the regimental hospital. From the moment of the infliction of the injury there was extreme collapse and that general appearance of alarm and anxiety so indicative of penetrating Avounds of the abdominal cavity. He seemed to suffer no pain, but complained of an incessant desire to micturate, which continued unrelieved after the urine was drawn off by the catheter. The treatment consisted in stimulants, opium, enemata, and simple dressings, with occasional fomentations. He never rallied, but sank and died Avithin tAventy-four hours from the receipt of the injury. Surgeon J.Wilson, 99th NeAV York, states, on the monthly report, "I traced the course of the ball after death. It passed at first almost directly dowinvard, tearing up the great pectoral, external and internal, oblique and transversalis muscles; Avinding backward and outward, it fractured the crest of the ilium, and emerged by a ragged opening about midway betAveen its anterior and posterior superior spines, at the point Avhere the transversalis muscle Avas torn. The peritoneal cavity Avas opened to a very limited extent, but none of the viscera Avere Avounded, nor Avas there any haemorrhage into the pelvic cavity to account for the frequent and painful efforts to micturate, as taught by Baudens. There Avas slight effusion into the peritoneal cavity, but only a trace of inflammatory action." The following is a synopsis of the reported cases of shot fracture of the pelvis : Table VII. Humerical Return of Fourteen Hundred and Ninety-four Cases of Shot Fractures of the Pelvis reported during the War. CLASSIFICATION OF MEN INJURED. Shot Fkactubes. Total. Re?ov- Deaths. Re?ult cries. unk'wn. CLASSIFICATION OF BONES INJURED. Shot Fractures. Total. Re?ov- Deaths. Re?ult enes. unk wn, Ilium.................. Pubis.................., Ischium................, Sacrum................. Coccyx................. Two or more pelvic bones Unspecified pelvic bones... 799 72 59 110 13 46 395 595 38 39 59 7 21 159 194 34 20 48 6 25 217 10 Ilium... Pubis ... Ischium Sacrum . Coccyx . 829 86 73 145 17 608 43 42 80 11 211 43 31 62 6 10 19 Unspecified pelvic bones. 395 159 217 19 Aggregates................. 1,494 918 544 32 Aggregates................. 1,545 943 32 Excisions of Portions of the Pelvic Pones.—The observations that have been adduced, and others that might be cited, teach emphatically the importance of removing detached fragments of bone after shot fracture of the pelvic bones, and of using energetic means for the removal of impacted balls. They equally demonstrate the occasional necessity of the excision of carious bone and of the removal of necrosed sequestra.1 Such instances- as Case 687 indicate that what is requisite may sometimes be accomplished by gouging out the diseased cancellous walls of the shot canal, a plan of evidement that M. Oilier and his disciples have reduced to a method. Sub-periosteal excisions "may also be advantage- ously employed. In one instance, M. Oilier has known the ischio-pubic ramus to be 1 Regarding resections of the pelvic bones, consult the systematic treatises and magazine articles already cited, and particularly: Jaeger (Operatio resectionis, Erlanga-, 1832, p. 18); LISFRANC (Precis de midecine opiratoire, Paris, 1846,T. II,p. 543); MALLE (Traiti d'anatomie chirurgicale, Paris, 1855, p. 220, Resection des os du bassin); FEIGEL (Chirurgische Bilder., Stuttgart, 1856, S. 404, Die Resection am Darmbeinrande, Tafel XXIV); Emmeut (Lehrbuch der Speciellen Chirurgie, Stuttgart, 1862, S. 553, Resectionen der Huflbeinc); RlED (F.) (Die Resectionen der Knochcn, Niirenberg, I860, S. 242); Heyfeldeu (O.) (Lehrbuch der Resectionen, Wien, 1863, S. 313); GUNTHER (Lehre von den Blutigen Operationen, 1860, S. 2); SEDILLOT (Traite de mid. operat, Strasbourg, 1865, 3-» id., p. 498); OLLIER (Traiti exp. et din. de la Reginiration des Os, 1867, T. II, 180); LARGHI (Operazioni sotto-periostee e sotto-capsulari, Torino, 1855). 256 INJURIES OF THE PELVIS. LCIIAP. VII. regenerated after an operation of this sort. The instruments most generally serviceable in these operations are the gouge and the gnawing-bone forceps (Plate XLI, Fig. 3). Some practical surgeons attach great importance to the projection forward of the jaws, like the teeth of a rodent or the beak of a rapacious bird. The pattern in the new Army cases is excellent, and preferable to the form advised by the late Professor Nelaton. On the other hand, the curved gouge of M. Legouest is handier (Plate XLI, Fig. 4) than that supplied in our Army set. It will seldom be necessary to divide the laminar portion of the pelvic bones to a greater extent than can be accomplished by these instruments. Where it is necessary, as in removing the crest of the ilium or the tuberosity of the ischium, Heine's osteotome (Plate XLI, Fig. 1) is more convenient than Hey's or the chain-saw. It is hard to think of a condition in which the trephine would be a serviceable instrument. Injuries of the Pelvic Ligaments.—In several instances, in which missiles traversed the pelvic ligaments and there was reason to believe that the sacral, sciatic, or crural nerves were uninjured, chronic rheumatic pains, with local tenderness, ensued, symptoms that might plausibly be referred to the lesions of the fibrous tissue. The denegation of the sensibility of ligaments, s<3 long maintained by Haller and his disciples, though refuted by Bichat, had a lingering influence upon pathologists, until, from 1857 to 1866, Riidinger, Kolliker, Sappey, and Heriocque1 demonstrated the distribution of the nerves, arteries, and veins of the ligaments as satis- factorily as other histologists had demonstrated those of the cornea. The pelvic ligaments have been studied in their obstetrical relations, and with refer- ence to luxations; but their mechanical lesions have been little investigated, and no information meriting fig. 2i4.-Ligamentons preparation of an aduit male record was communicated during the War on the pelvis. Spec. 19, .Scot. IV, A. M. M. O subject, which is alluded to here to indicate the desirableness of further observation and research.2 1 Consult WlXSLOW (An Anatomical Exposition of the Structure of the HumanBody, 6th ed., Edinburgh, 1872, Vol. I, p. 153); WEITBREICHT (Syndesmologia sive Historia Ligamentorum Corporis humani, Petropoli, 1742); MONTFALCON (Art. Ligament, in Diet des Sci. Med., 1818, T. XXVIII, p. 179); HENOCQUE (Art. Ligaments, in Diet, encyclopid. des Sci. Mid., 1869, 28 s6rie, T. II, p. 557). On the nerves of ligaments, compare RiJDlNGER (Die Gelenk-nerven des menschlichen Korpers, Erlangen, 1857); Rauber (Vater'sche Korperchen der Bander und Periostnerven, 1865); Kolliker (Handbuch der Gewebelehre, 4te Auflage, 1863); Saitey (Traiti d'Anatomie Descript, 1867, T. I, p. 556); ADAMS (W.).(On the Reparative Process in Human Tendons after Division, London, I860). 2 PAULUS JEgixeta (Sydenham Society ed., London, 1846, T. II, p. 454); PETRUS DE AUGELATA (Chirurgise, Liber VI, cap. 7, Venetiis, 1480, de fractura ossis ultima caude); VERDUC (Pathologie de Chirurgie, 1703, p. 400, de la fracture de l'os sacrum et du coccyx, and p. 401, de la fracture de l'os innomine); Petit (J. L.) (Traiti des maladies des os, 3° ed., 1735, T. II, p. 106); Manxe (Traiti ilimentaire des maladies des os, Toulon, 1789 p. 183, de la fracture des os du bassin); Duverney (Traiti des maladies des os, 1751, T. I, p. 279); Creve (Diss, de fracturis ossiumpelvis, Mongunt, 1792); Lutexs (Manuel des operations chir., Gand, 1826, p. 107, Fracture des os du bassin); DORSEY (Elements of Surgery, Philadelphia, 1818, Vol. I p. 141); Adelmaxn (De fracturis ossium pelvis, Fulda?, 1835); Maret (Obs. sur les fractures des os du bassin, in Mim. de IAcad, de Dijon, 1774 T. II p. 8r>); BOYER (Traiti des mat chirurg., Paris, 1845, 3"" ed., T. Ill, p. 145); SANSON (Fractures des os du bassin, in Diet, de mid. et de chir., in XV, Paris, 1832, T. VIII, p. 484); JACOBI (De fracturis ossium pelvis, Lipsiae, 1861); HEINRICH (De fracturis ossium pelvis, Halis Saxonum, 1858); Sevkii.i.e (Nouvelle doctrine chirurgicale, Paris, 1812, T. II, p. 249); MALGAIGNE (Traiti des fractures et des luxations, Paris, 1847, T. I, p. 034 ; and Mim. sui- tes fractures du sacrum et du coccyx, in Journal de chirurgie, Juin, 1846); LAUGIER (Art. Plaies du bassin, in Diet, de med, in XXX, Paris, 1833 T. V p. 69); CLOQl et and A. BERARD (Fractures des os dubassin, in Diet de mid., in XXX, Taris, 1830, T.V, p. 71); Hafa (De fractura ossium pelvis. Diss., Halis Saxonum, 1864); PETIT (CEuvres compliles, Paris, 1864, p. 150, de la fracture des os des iles et pubis); NELATON (£limens de Path, chir., Paris. 1844, T. I, p. 702, Art. XII, Fractures des os du bassin); RICHTER (A. L.) (Fractura pelvis, in BLASIUS, Handwbrterbuch der gesammten Chirurgie, Berlin, 1837, B. II, S. 487); STROMEYER (Maximen, Hannover, 1855, S. 646, Verletzungen des Beckens); DEMME (Studien, u. s. w., AYUrzburg, 18C1, B. n, S. 154, Die Schusswunden des Beckens); CHENU (Rapport, etc., pendant la campagne d'Orient, Paris, 1865, p. 198, Blessurcs de la rigion iliaque et fessiere); STROMEYER (Erfahrungen uber Schusswunden im Jahre 1606, Hannover, 1867, S. 44); BECK (Kriegschirurgische Erfahrungen wdhrend des Feldzuges 1866, Freiburg i. B., 18G7, S. 247); IDEM (Chirurgie der Schussverletzungen, Freiburg i. B., 1872, S. 544); SOCIX (Kriegschirurgische Erfah- rungen, gesammelt in Carlsruhe, 1870 und 1871, Leipzig, 1872, S. 97); FISCHER (H.) (Kriegschirurgische Erfahrungen, Vor Met;, Erlangen. 1872, S. 131); Legolest (Traiti de Chirurgie d'Armee, Paris, 1872, p. 415); Vaslix (Etude sur les plaies d'armis a feu, Paris, 1872, p. i;8); I'.vxo (Traiti ilimentaire de Chirurgie, Pari.. 1869, T. I, p. 383); EXCEL (Beitrage zur Statistik des Krieges von 1870-71, Berlin, 1872). .1. J •r i'-J- '. ' ''•** ■''■ CliLi •" J'; 1Ji: >V!'. ''"! 01 f->t or me i \;j, j--.1.' ■ ■core ]..<• r.r< con". • ' • , a , ! ' r ■ n t'Tiiv ; i;.< ! Yoios.-ior iK-;•;..' tm<. On L-'la-ve XLI, FlG. 4) than th.U di"!;!:-- tJ;" lamiinM ■"■ '-Iiom ■':i.i. : ' i. iii-.-1' i :-".h -i. '.1.3. 1 •■■■ '■■,1 •■;.."'::"■. ■ iiiUlO -: •.■■' t.'io •;;.:■ i''.:-s;.i.w. ■' :c'-;'.'.Me instri. '-'\o\u.. Winch 11 m-"-:s j;--,-: ..-..Mil, sciatic, or ■•'k-.-s, en—M • .'■•-. .ivoci. to i'. ■■:■ ':■■'■■ .-;-ition of •■ Lu !m : .«'iUa..ined by .: . ,:i r. .-.I- •.-' by 'i>ch;>.t, .ti'M-.'-; p;v;:i- ! :•:.>!';>,■ unf:!, ;: ■•]-, Kolll.!'' ■•: Hupp1. V an 1 ii'- .■liM-..!.:,:,iol.iof the M ':;.■:• : M.'m PS satis- ■■ ■ : k 'i: / !;.';tf;.i/ . I rhosc :'-.'.i"lii-'nts !i'l\ "■ !.>C! 'i ■•. mm m'!, ;:■:'• : iSOll'll- , . I, p. u: XXX. Second Surgical Vol. opp.page 256. TkV Rn,rTan.i.^m IJft.Thflq 1. Heine's Osteotome. , Scie ^ MolLet. PLATE XLI. INSTRUMENTS for RESECTION, 3.5. Gnawinglioneforceps. 4. Leoouests curved gou£e andchisel. 6 . Gouge andchisel, F.S_A..pattern. 1. ^Nelaton's bone forceps. sr.rr. n.i WOUNDS OF TIII'l CONTAINED PARTS. 257 Section II. INJURIES OF THE PARTS CONTALNED IN THE PELVIS. This Section will be mainly devoted to a consideration of the cases of injuries that were reported during the War, of the bladder and rectum, and ofthe blood-vessels, nerves, and connective tissues contained in the cavity of the pelvis, and of the derangements consequent upon such injuries. But other disorders of the pelvic organs requiring surgical intervention, such as calculus, retention of urine, fistula, and hhemorrhoids, that come only indirectly under the head of injury, will also be discussed briefly or at some length. The frequency with which active ther- apeutic measures may be advantageously employed in physical lesions of the organs of this region, contrasts strongly with the com- paratively rare occasions where such mea- sures can be hopefully employed in injuries of the contents of the other great cavities. Although exceptions have been adduced and examined at great length, it has been seen, in preceding Chapters, that wounds of the encephalon were, for the most part, followed by mortal coma,—that wounds of the parts contained in the thorax were very fatal, dyspnoea, cold extremities, and a faltering pulse being the deadly signs,—that wounds of the viscera of the abdomen proper were generally mortal, either from shock or from diffused peritonitis, revealed by collapse, intense pain, vomiting, meteorism. In the pelvic cavity, however, only those injuries involving the great blood-vessels and the part of the bladder covered by the peritoneum, are necessarily beyond the resources of art. Notwithstanding their complexity, it will be convenient to group the cases to be considered according to the part in which the most important lesion is situated, and the Section will therefore be subdivided, and injuries of the connective tissues without lesion of the viscera will be first examined, then injuries of the bladder, of the prostate, of the rectum, and of the blood-vessels and nerves. Shot Penetrations or Perforations without Visceral Injury.—Projectiles traverse or deeply penetrate the pelvic more frequently than the abdominal cavity, without 33 Fig. 21">.—Viscera, bloodvessels, ami nerves of the pelvis. Angkii.I | After • )S INJI'IIIKS OF TIIE 1'ELVIS. [CHAF. VII. injury to the viscera. The review of shot fractures of the pelvic bones has already ailordcd some examples of this.1 Sometimes, though very rarely, balls pass from the inguinal to the gluteal region, or the reverse, through the ischiatic notch, without interesting the bones, vessels, or viscera. The following are three of these fortunate exceptional instances: Casio 7.7,1.—Private Daniel Brown, Co. A, 5th Pennsylvania Reserves, aged 28 years, was wounded at Fredericksburg, December 13, 1862, by a conoidal musket ball, which entered the left groin near Poupart's ligament, passed directly through the pelvic cavity, and escaped through the gluteal muscles of the same side. He was sent to Annapolis, January 11, 186:5, and was subsequently transferred to Harrisburg, and to Patterson Park Hospital, Baltimore, on April 1, 1864. Here he is recorded as ''convalescent, and returned to duty on April 2, 1864." The patient was afterward admitted into Augur Hospital, Alexandria, at Carver Hospital, Washington, at Philadelphia on May 5th, and was discharged the service on June 11, 1864, and pensioned. On February 1, 1871, the pension examiner reports that "'there is a tender cicatrix in the groin, impairing the usefulness and motion of the limb, which is atrophied. The disability is rated as three-fourths and probably permanent." Case 760.—Private J. A. Smith, Co. D, 28th New York, was wounded, on May 1,1863, at Chancellorsville, by a conoidal musket ball, fired at a distance of not more than thirty yards. The projectile entered nearly over the left abdominal ring, traversed the pelvic cavity, and made its exit at the upper part of the right buttock. He walked one hundred yards after he was hit. There was quite free bleeding from the anterior wound. He was treated in the Twelfth Corps Hospital. There were no symptoms of peritonitis. The appetite was good, the bowels regular, the func- tions of the bladder perfect. By the 21st of May his wound was entirely healed, and he was discharged from service by reason of the expiration of his term of enlistment. Tbe drawings, reduced copies of which are presented by the adjacent wood-cuts (FiGS. 216, 217), were made at Fredericksburg by Hospital Steward Stauch, under Surgeon J. II. Brinton's super- vision, a few days after the infliction of the injury. If the course of the ball was correctly reported, the appearances are the reverse of those commonly observed, the supposed entrance wound being the largest and most lacerated. The ball evidently passed through the sciatic notch, and the small amount of mischief inflicted is very remarkable. Smith applied for a pension, and, on November 4, 1836, Dr. J. H. Helmer, of Lockport, New York, reported: "Ball entered just above Poupart's ligament on the left side, and came out through the centre of the right natis, at first (as he states) occasioning a disturbance in the bladder, which has now entirely subsided. The muscles of the limb and pelvis do not appear to have guttered from the wound. There has been no discharge of bone at any time. The cicatrices are small and colorless. I do not see wherein any disability is produced;" and Smith's application for pension was rejected November 27, 1866. Case 761.—Lieut. J. P. L----, 12th New Hamp- shire, having been wounded while on picket duty at Bermuda Hundred, November 17, 1884, was sent to the officers' hospital, Point of Rocks. A musket ball had entered near the left external abdominal ring, passed diagonally through the pelvis, and emerged at the great sacro-ischiatic notch of the right side. There was no functional disturbance in any of the pelvic viscera. The patient, making a speedy recovery, was furloughed on January 3d, rejoined his regiment on April 22d, and was discharged on April 28, 1865, and pensioned. A letter from the lieutenant, dated March 30, 1863, reports his health as very good, though he was unable to walk a great distance, or to undergo laborious exertion, and experienced a constant dull pain through the pelvis. Examiner D. B. Nelson reports, April 30, 1866, that the pensioner's spermatic cord and testes were injured from the effects of the wound. September 4. 1873, the same examiner reported that from injury of the left sp( r.natic cord there was frequent pain in tbe left testis, and permanent disability. Fig. 216.—Entrance wound of a shot perforation of the pelvic cavity. FIG. 217.—Exit wound of a shot perforation of the pelvic cavity. 'Analogous instances wero observed in the late Franco-German War. Thus Fisciiku (II.) (Kriegschirurgische Erfahrungen, 187-> S VV,) relates the case of Zirotzki, 1st Prussian Ja?gers, shot at Forbach, August 14, 1870. The ball entered to the left cccmher 12, 1862, was treated in the regimental hospital of the 13th Indiana. Surgeon A. D. Gall reports that the missile entered one inch to the right of the sacrum, passed apparently through the great ischiatic notch, and emerged half an inch above the symphysis pubis. ' Neither the intestines nor bladder were wounded. The patient was transferred, in a favorable condition, December 30, 1862, to the hospital ofthe 11th Pennsylvania Cavalry. The complicated fractures furnish some illustrations for this group.] Thus, Surgeon J. W. Foye, U. S. V., stated that a ball, after fracturing the acetabulum, innocuously passed through the pelvic viscera; and Assistant Surgeon R. Bartholow, U. S. A., reported an instance of fracture of the ischium into the cotyloid cavity, the missile passing afterward between the rectum and prostate without lesion of either.2 Other less complicated examples are found in the records of shot wounds of the pelvis. Those most carefully reported are as follows : Cases 775-779.—1. Sergeant C. H. Anderson, Co. K, 23th Wisconsin, wounded at Atlanta, July 22, 1864. Surgeon H. Culbertson, U. S. V., reported that a musket ball entered the white line two inches above the pubes, passed obliquely downward and emerged at the left great ischiatic notch, and_ lodged behind the trochanter major, without injuring the bladder, vessels, or nerves. The patient entered Harvey Hospital at Madison, and, on December 20, 1864, was sent to modified duty in the Veteran Reserve Corps. He was discharged and pensioned September 13, 1865. On December 1, 1872, Examiner J. W. B. Welcome, of New Ulin, Minnesota, reported the track of the ball as the reverse of that above described, and that injury of the sacral plexus and of the sacral ganglion of the sympathetic had caused weakness of the lower limbs and pain in the neck, chest, and head. The spermatic cord was enlarged and the testis sensitive.—2. Pi'ivate J. B. Simpson, Co. F, 42d Indiana, aged 22, was wounded at Chickamauga, September 20,1883, and treated in hospitals at Nashville, Louisville, and Madison. Acting Assistant Surgeon T. J. Pearce reported that " the ball passed through the pelvis, entering the left natis, and emerging at the right groin ; there was no injury of the viscera, blood-vessels, or nerves " This soldier was discharged and pensioned October 17, 1864. Examiner W. S. W'ilburn, of Princeton, reported February 12, 1870, the disability from the pelvic injury as slight; but the pensioner was disabled by other wounds.—3. Lieutenant J. M. Roberts, 7th Wisconsin, was wounded at Five Forks, April 1, 1865, by a ball which struck near the symphysis pubis and lodged in the buttock near the left ischial tuberosity, without injury ofthe bladder. This officer was discharged and pensioned. Examiner J. H. Hyde, of Lancaster, states, August, 1866, that the missile perforated the os pubis and emerged at the tuberosity of the left ischium, leaving the left leg partially paralyzed.— 4. Private J. Allen, Co. E, 13th Ohio, aged 23, was struck at Stone River, December 31, 1862, by a ball which entered above the tuberosity of the left ischium, and, according to Acting Assistant Surgeon A. E. Heighway, "passed between the bulb of the urethra and the bladder and escaped through the right groin." Discharged June 12, 1863.—5. Private Jacob Mark, Co. A, 5th Indiana Cavalry, was wounded at Buffington Bar, by a ball which entered an inch to the right of the end of the sacrum and emerged through the right pubic bone. Surgeon W. H. Gobrecht, U. S. V., reported, after a careful exploration, that "the rectum, bladder, and spermatic cord escaped injury. The ease progressed favorably, and the man was discharged February 13, 1864.'' Shot penetrations of the pelvic cavity without visceral injury appear, then, to be much less infrequent than corresponding wounds of the abdomen.3 1 In the cases of pelvic fracture, 681, 692, 697, 698. projectiles are reported to have penetrated deeply without wounding the viscera. 2 These cases, of Private Keuben S-----, Co. K, 13th Illinois, and of Private Martin P-----, Co. K, 6th Maine, which furnished Section I, specimens 2174 and 1659, respectively, will be detailed with shot injuries of the hip joint. 3 Thomson (Report of Obs. in Mil. Hosp. in Belgium, 1816, p. 110) adduces examples of this group observed after Waterloo: " Several cases of wound in tho region of the pelvis occurred, in which it appeared to us that balls had passed through that cavity without injuring either the bladder or intestines. In one case at Brussels, tlie ball had entered on the right side of the symphysis pubis and had passed out of the middle of the right buttock. This patient complained much of pain, and had a considerable degree of fever ; but there had been neither ficcal nor urinous discharge. In another case which wo saw at Antwerp, tho ball had taken, as nearly as possible, the same direction ; and having neither wounded the intestines nor bladder seemed to have produced very little constitutional or local injury." •2<\2 INJURIES OF THE PELVIS. |CHAP. VII. Injuries of the Bladder.—Apart from those produced by the manipulations ot the surgeon,1 injuries of the male bladder are rarely observed in civil practice. When the distended reservoir ascends above the pubes, it is exposed to external violence in the hypogastric region; but ordinarily it is screened by the strong pelvic bones. These are an insufficient protection from the projectiles of modern warfare, and hence wounds- of the bladder are not uncommon in military practice. A military surgeon, the famous Larrey,2 wrote the first systematic account of them, and those who have since treated of the subject have largely profited by his masterly observations and reflections.3 Thomson, Hennen, Guthrie, S. Cooper, C. J. M. Langenbeck, Dupuytren, Baudens, and Legouest have added some interesting observations.4 In 1851, M. Demarquay read to the Surgical Society of Paris an extended paper on shot wounds of the bladder, which was analyzed and criticized in an elaborate report by MM. Chassaignac, Girald&s, and H. Larrey. In 1855. in the second edition of his work on the bladder,5 Professor Gross discussed its physical lesions with his accustomed erudition and discernment, presenting many facts derived from American experience. In 1857, M. Houel printed an exhaustive memoir on wounds and ruptures of the bladder in general.6 Larrey was the first to place prominently in view- that while all accidental injuries of the bladder are extremely serious, those produced by shot are less dangerous than others, and suggested, in explanation, that the tissues are so crushed by projectiles that eschars are produced, protecting, in a measure, the connective tissues from urinary infiltration. He also put in evidence the important bearing on the prognosis, of the state of plenitude or vacuity of the bladder at the moment of injury. The cases of vesical injury recorded during the War were numerous and instructive, and belonged almost exclusively to the group of shot wounds. They, happily, exemplify recoveries when the outer tunic only was injured, or -one wall was pierced, or the organ was completely transfixed—and complications of pelvic fractures, of foreign bodies, and of wounds of the rectum. 1 VlDAL (Traiti de Path, ext et de Med. Operat, Troisieme 6d., 1851, T. IV, p. 709): "II y a plus des plaies de la vessie faites par le chirurgien que des plaies dues a des accidents." 2 Laurey (D. J.) (Mimoire sur les Plaies de la Vessie et sur certains Corps itrangers restis dans ce Viscere), printed in 1817, in the fourth volume of the Mimoires de Chirurgie Militaire et Campagnes, p. 284 et seq., and reproduced, in 1829, in the Clinique Chirurgicale, T. II, p. 500. In his exordium, Larrey observes: "Toutefois, il n'existe encore rien de complet sur les plaies de la vessie." This is quite true, though Cheselden (Treatise on the High Operation, 1723), Morand (Traiti de la Taille, 1728, p. 224), GAKENGEOT (Traiti des op., 1731), Dksport (Traiti des Plaies d'armes a feu, 1749, p. 319), and PERCY (Mim. du Chir. d'armie, 1792, p. 246) had reported some important cases, and the learned LOUIS had briefly summed up the principal points of the question in two pages of his Dictionnaire de Chirurgie (17G7), and CHOPART (Traite des Mai. des Voies urinaircs, 1792, T. II, p. 68) had made some instructive remarks on the subject. 'Larrey begins his memoir with the remark that "the ancients considered shot wounds of the bladder as mortal," and cites the well-known aphorism of HIPPOCRATES, S. VI, xviii, Kvstiv SiaKonivTi * * OavaTuides, Cui persecta vesica, lelhale. Larrey would have been the last to impute to his predecessors erroneous doctrines in order to achieve an easy victory in exposing their fallacy; but his followers have committed-this fault, in giving an unduly general application to his remark. The ancients generally did not consider wounds of the bladder as necessarily or absolutely fatal. Aristotle (Hist, animal., Chapt. 15) expressly states that wounds near the neck may unite, and GALEN relates a ease of recovery from wound of the bladder, and, in commenting on this very aphorism of HIPPOCRATES, contends that the latter does not use Oai/aTuxfcs in the sense of absolutely fatal, but meaning rather very dangerous. For a critical disquisition quot modis vulnera dicantur lethalia, the reader may consult Seuitz (Prodremus examinis vulnerum, Strasburg, 1633, Pars II, 78). Assuredly, after Cklsus (De re medica, ed. Lugd., 1592, L. VII, p. 671), the ancients could not regard wounds of the bladder as fatal, since a method of cystotomy is taught there. Fallopius (Op. gen., Venet., 1607, T. II, p. 397), Forestus (Obs. et Cur. chir., Francofurti, 1611, Lib. VI, Obs. V, in scholia, p. 12), Jhkuome OF Bruynswyke (Handywarke, 1525, Cap. 51), Gerssdorff (Feldtbuch der Wundt-Artzney, Frankfurdt, 1551), and Schlichtixg (Traumatologia, 1748, p. 87), and others of the middle age, taught the curability of wounds of the bladder, and for the most part advised that its wounds should be stitched up. •Hexnex (Principles, 3d ed., 1829, p. 425); GUTHRIE (Commentaries, 5th ed., 1855, p. 603, Lectures, etc., 1829, p. 64); COOPER (S.) (Article Bladder, jn Diet, of Pract. Surg., Am. ed., 1838, p. 180); Laxgexueck (O. J. M.) (Nosog. und Therap. der Chir. Krankh., 1830, B. IV, S. 589) ; Dltlytuex (Lecons orales de clin. chir., €d. 1839, T. VI, p. 482); Baudens (Clin, des plaies d'armes a feu, 1836, p. 305); Legouest (Chir. d'Armee, 2d ed, ls72. p. 421). f> Gross (S. D.) (A Practical Treatise on the Diseases, Injuries, and Malformations ofthe Urinary Bladder, the Prostate Gland, and the Urethra, 2d ed., Philadelphia, 1855, p. 124): "It is remarkable," Professor GROSS observes, "how little information is to be found, in systematic treatises on surgery, on wounds of the bladder. From their silence, one would suppose that their authors were either totally unacquainted with the subject, or that they were afraid to discuss it." 6M. Demako.U.yy> paper appears in the Mimoires de la Sociite de Chirurgie, 1851, T. II, p. 289. and is fallowed by the Rapport sur les plaies de la Vessie par Amies a feu, par MM. H. Larrey, Ciias?1, by a charge of buckshot striking above the pubes. The shot were extracted by Surgeon A. B. Palmer, 2d Michigan Volunteers. The patient was seen by Brigade Surgeon F. H. Hamilton, U. S. V., and was found to have paralysis ofthe bladder. "On introducing the catheter, the urine was observed not to be bloody. There was no evidence, therefore, that the bladder had suffered any lesion. There was no paralysis in any other portion of the body. The bladder resumed its functions completely after a few days." No analogous examples were reported. However, Mr. Blenkins declares3 that "paralysis of the bladder is not an uncommon result of blows from shot or large pieces of shell, and rupture of the bladder when in a state of distention may occur without being accompanied by corresponding injury to the external parts." Without discussing the frequency of vesical paralysis, it may be surmised that the possibility of rupture from the cause assigned is, so far, conjectural, though theoretically probable. Shot Wounds of the Bladder.—Injuries of this group, though very dangerous, were in many instances followed by more or less complete recoveries. In one hundred and eighty-three reported cases,.eighty-seven patients, or 47.5 per cent,, survived; though a large majority suffered from grave disabilities, and many from distressing infirmities, which have resulted fatally in a few cases, after years of suffering. The statement in the preliminary report,3 regarding the uniform fatality of shot perforations of the bladder above the pubes or through the pubic bones, in the cases then .examined, must therefore be partly set aside by the results of later investigation. Histories have been published of a number of very satisfactory recoveries after shot wounds of the bladder, received during the War. Dr. John A. Lidell,4 in a paper already frequently cited, details an instance, a case of perforation from the left of the hypogastrium to the right buttock, with escape of urine from the supra-pubic orifice. Professor W. H. Van Buren has recorded5 a case in which the missile pursued a similar course, traversing the distended bladder, and recovery rapidly followed, without ultimate derangement of the function of the bladder. -Professor F. H. Hamilton states6 that General Robert B. Potter was "shot through the bladder, at Petersburg, in 1865, by a rifle ball, which entered above the pubes, from which injury he has made a complete recovery." In an oblique perforation of the pelvic cavity by a ball entering in the right inguino-hypogastric region, passing through the bladder, and emerging through the sciatic notch, March 11, 186,3, the patient made a satisfactory recovery, served afterward in the Veteran Reserves, and, in 1872, was a pensioner, with comparatively slight disabilities.7 Another instance of recovery after shot perforation of the bladder, in the case of Corporal Brownlee, is related in the First Surgical Volume, p. 488. The early history of another example of 1 Hamilton (F. H.), A Treatise on Military Surgery and Hygiene, 1865, p. 323. 1 Blenkins (G. E.), Additions to article Gunshot Wounds, in the eighth edition of S. COOPEIt's Diet of Practical Surgery, 1861, Vol. I, p. 835. 1 Circular 6, S. G. O., 1865 (Reports on the Extent and Nature of the Materials available for the Preparation of a Medical and Surgical History of the Rebellion, p. 27): " Gunshot wounds of the bladder, when the projectile entered above the pubes or through the pubic bones, have proved fatal, so far as the records have been examined. There are many examples of recovery, however, from injuries of the parts of the bladder uncovered by peritonaeum." With the qualifying clause, the statement nearly represents the truth as now approximated. 4 LIDELL (J. A.) (l//i. Jour. Med. Sci., 1867, Vol. LIII, p. 365), case of Sergeant J. 11. Post, Co. H, 61st New York, wounded at Spottsylvania, May 12, 18(i4. He was discharged June 6, 180.5. He is not a pensioner. Dr. F. H. HAMILTON (Princ. and Pract. Surg., p. 117) states that he saw this man in 1869, and that his health was completely restored, though there was still a fistula at the exit orifice. 5 Van Bi.kex (\V. H.) (Gunshot Wound of Bladder, in the New York Med. Jour., 1865, Vol. I, p. 102), case of L. L. Jones, aged 46, wounded in the Xew York riots, July, 18ii3. 'HAMILTON (F. H.), Principles and Practice of Surgery, 1872, p. 118. 7 The case of Private .Samuel Stewart, Co. B, 4fith Indiana, reported by regimental surgeon Dr. Israel B. Washburn, in Am. Jour. Med. Sci., 18(56, Vol. LII, p. 118. Pension Examiner A. Coleman reported, April 13, 1807, that "there was still occasional discharge of pus with the urine; the gluteal muscles were slightly affected." SECT. II.l WOUNDS OF THE BLADDER. 265 satisfactory recovery is related by Dr. D. Rankin.1 The ball entered the left (?) iliac fossa, probably perforated the fundus of the bladder, and emerged at the right buttock; a troublesome urinary fistula ultimately closed, and the man enjoyed tolerable health ten years after the reception of the injury. Dr. J. D. Jackson has also recorded a recovery.2 The following patients are reported as having recovered with persistent urinary fistulae: Case 781.—Private R. Butchers, Co. II, 72d New York, aged 20 years, was wounded at Mine Run, November 27, 1863, and was treated on the field till December 5th, and then transferred to hospital at Alexandria. Surgeon E. Huntley, U. S. V., reported the case as a '•gunshot wound of the bladder, mainly ou the left side; ball removed on the field; simple dressings; discharged the service, October 11, 181)1, for gunshot wound ofthe bladder; disability total." Pension Examiner F. Staples, of Winona, reported, September 1, 1872, that "there is a fistulous opening from the urethra in front of the scrotum; also a sinus at the back of the scrotum, on the right of the perineum, which is from the bladder; there is necrosis ofthe pelvic bones; disability total." This pensioner was paid in June, 1873. Cask 782.—Private R. Carey, Co. I, 99th Ohio, was accidentally wounded at McMinnville, Tennessee, July 15, 183;?. Surgeon J. T. Woods, 99th Ohio, reported as follows: "The ball passed from a point immediately below the horizontal ramus of the pubis, and external to, but opening into, the sheath of ihe left spermatic cord, incising the base of the bladder and chipping bone from the tuberosity of the ischium of the opposite side, the ball emerging in this line from the soft parts. The shock was moderate and the haemorrhage slight; the hypogastric region was dull on percussion; the catheter returned from the bladder loaded with blood, but without discharge of urine. Portions of clothing, hair, and spiculee of bone were found in the track of the wound and in the scrotum. These foreign matters were carefully removed and simple dressings were applied. Various attempts were subsequently made, by manipulation with, and injection of water through, the catheter, to break up and remove the coagula and to secure a passage of urine by this channel, but all have failed. Fourteen days passed, and the posterior orifice still gave free exit to the urine without infiltration or sloughing, and without an unfavorable symptom save the indication of a probable vesical fistula. The patient is rapidly recovering." In August, the patient was transferred to general hospital at McMinnville, and Surgeon St. J. W. Mintzer, U. S. V., reported that the case was still progressing favorably, although the urine still escaped through tbe wound of exit. The patient had, however, full control over the movement of the bladder, and the wound of entrance had healed. A fistulous opening would probably remain. On September 11th, the patient was trans- ferred to Cumberland Hospital, and discharged the service October 26,1863. Pension Examiner J. Colby, of Defiance, reported, September 1, 1870, that ''the ball entered half an inch to the left of the symphysis pubis, taking its course slightly downward, backward, and to the right, passing through the os pubis, tbe anterior inferior portion of the bladder, the neck of the bladder, and os ischium, and passing out one and a half inches to the right of the lower point of the os coccyx. These wounds have never healed. The urine continually escapes from both openings, diffusing into the cellular tissue, causing inflammation and physical disturbance requiring surgical and medical assistance." Ou September 4, 1873, he reported: ''The neck ofthe bladder has never united, and the urine dribbles away and is diffused in the cellular tissues, thus passing off through fistulous openings. The principal one is in the front part of the perineum, and two others are in the right natis. Manual labor produces fever and inflammation ofthe affected parts; disability total." This pensioner was last paid in June, 1873. Case 783.—Private G. W. Hannah, Co. A, 39th Kentucky, aged 34 years, was wounded at Cynthiana, June 12, 1864, by a conoidal ball. Surgeon J. G. Hatchitt, U. S. V., reports that the missile "entered the right buttock three inches from the anus, and emerged at the left groin just above the pubic arch." On June 15th, the patient was admitted into hospital at Coving- ton, and was discharged October 7, 1864, and pensioned. January 14, 1870, Examiner S. V. Firor, after describing the course ofthe ball, states that "the wound involved the bladder, so that the urine passed out at the entrance and exit orifice ofthe ball, and still passes out at the hip, where a fistulous opening is left. The discharge of urine by the natural channel is often bloody and contains mucus, especially after an attempt to work. The pensioner has to sit down in order to pass water; he suffers more or less constant pain, which is increased by exertion." Case 78-1.—Corporal W. H. Reed, Co. A, 127th New York, was wounded at Pocotaligo, December 9,1834, the regimental surgeon, Dr. G. R. Cutter, noting a "wound ofthe hip." Removed to a hospital at Beaufort, Surgeon John Trenor, jr., U. S. V., records that " the ball had penetrated the bladder and lodged." Assistant Surgeon W. R. Way, U. S. V., corroborates this report, and states that the patient was discharged May 17, 1865. The Examining Pension Board at New York reports, June 12, 1872: "Ball entered the left groin over the femoral artery, penetrating the neck of the bladder. There is a deep depression at the point of entrance. The ball has never been removed. The urine passed through the wound for three months after the wound was received. About three years ago the wound opened, a piece of bone came out, and at that time the urine again passed through the aperture. The limb is very weak, and he is unable to perform any hard labor with that limb, or to walk any distance without great pain. Disability total, and permanent." This pensioner was last paid in July, 1873. The presence of dead bone was the irritating cause, in most instances, of the persistence of fistules. But sometimes there appears to have been no foreign source of irritation, and the sinuses remained open, apparently from the transformation of their walls into tissue indisposed to union. No attempt to procure union by operative interference was reported. 'Rankin (D.) (Surgical Cases, in Am. Jour. Med. Sci., 1864, Vol. XLVIII, p. 67): Case of Private W. Rosenberg, Co. K, 93d Pennsylvania, wounded at Fair Oaks, May 31, 1863; discharged and pensioned October 25, 1862. Dr. Rankin records the recovery prematurely. Examiner (>. P Lineaweavcr, of Lebanon, reporfVd, October 11, 1870, that the cicatrix ofthe entrance wound was in the right iliac fossa; that the pensioner had suffered for three years from urinary fistula ; but that the sinuses then closed firmly, and no other vesical trouble remained hut slight incontinence. In May, 1873, this invalid applied for increased pension. 2Jacksox (J. D.), Am. Jour. Med. Set, 186'J, Vol. LVII, p. 281. 34 2''><) INJURIES OF THE PELVIS. [CHAP. VII. Cam. /-■".—Private C. Schaffer, Co. B, 4th Iowa Cavalry, aged 22 years, was wounded in a skirmish near Memphis, December 14. ls61. Assistant Surgeon J. M. Study, V. S. V., reported from Adams Hospital that "a ball passed throngh the right ilium, perforated the bladder, and that the wound was treated by simple dressings." On May 23, 181')"), the patient was transferred to the Overton Hospital, where .Assistant Surgeon J. P. Wright, recorded the entrance of the ball as above, and added that it emerged through the left pubis. This soldier was discharged June 14, 1835, and pensioned. Examiner S. N. Pierce reported, June 13, I860, that "the urine passes from the bladder through the openings caused by the ball. There is profuse suppuration front the wound; emaciation, and prostration—so great that the pensioner is confined to his bed and requires the services of an attendant. Disability is rated as total, aud permanent." The records farther show that this pensioner died July 24. 1SIJ9. Cask 7s6.—Private J. H. Wesson, Co. H, 6th Tennessee Cavalry, was wounded at Salem, Mississippi, October 8th, and sent to Washington Hospital, Memphis, November 1, 1863. Assistant Surgeon J. P. Wright, U. S. A., reported that "a ball had perforated the sacrum, rectum, bladder, and os pubis. There was a fistulous opening near the symphysis, which discharged urine. Several small pieces of bone were removed in the course of treatment, and the patient improved." On April 10, 1864, he wtis sent to a small-pox hospital for varioloid; was returned on May 4, 18(34; was transferred to Gayoso Hospital on May 15, 1865, and discharged the service September 27, 1865, his disability rated as total. There is no pension record in the case. Case 787.—Private M. A. Wetherwax, Co. D, 4th New York Heavy Artillery, aged 20 years, was wounded at Petersburg April 2,1865, and sent to the Slough Hospital, Alexandria, April 8th. Surgeon E. Bentley, U. S. V., reports: "Gunshot wound through buttock, penetrating the bladder. The treatment pursued consisted of simple dressings, opiates, and low diet." This man was discharged the service August 31, 1865, and pensioned. On April 15, 18!i7, Pension Examiner R. C. McEwen reported the "existence of a urinary fistula, through which urine passes during micturition. The left testicle is inflamed, large, and tender on pressure, causing pain in the groin and inability to stand long on the feet. The patient resorts to opiates for relief of pain, and at times has considerable swelling of the feet and limbs. He is unfitted for manual labor." The disability is rated as total, and of uncertain duration. On February 28, 1868, Examiner J. G. Bacon, of Saratoga, reported that "the ball entered the right buttock, passed obliquely across the lower portion ofthe pelvic cavity, and emerged at the anterior surface of the right thigh two inches below the groin. The bladder was injured, and a urinary fistula followed, which still remains, its outlet being near the junction of the penis with the scrotum. The left testis is enlarged and inflamed, causing great and continued pain, which requires the constant use of opiates. The general health has deteriorated very much, owing to the severe nature of his injury. He passes blood frequently, is greatly debilitated and emaciated, thinks he will not long remain on earth." Dr. Bacon recommended an increase of pension, which was allowed, to date from June, 1866, and was last drawn by the pensioner June 4, 1873. Other patients recovered after suffering from recto-vesical fistulae, which closed early in some instances, and, in others, remained pervious for long periods. Some of these cases will be detailed here, and others with wounds of the rectum: Case 7S-\—Private P. Janisch, Co. E, 20th Wisconsin, aged 24 years, was wounded at Prairie Grove on December 7, ]S(52. The case is briefly noted by Surgeon Ira Russell, U. S. V., at Fayetteville, and Assistant Surgeon W. Short, 26th Indiana, at Springfield, Illinois, as a severe shot wound of the hip, for which the patient was discharged May 13, 1863. Dr. James Diefendorf, of Milwaukee, in a letter to the Surgeon General, May 16, 1866, reports the facts of the case as follows: "The ball entered one inch to the left ofthe anus, passed through the rectum and bladder beneath the ramus of the ischium, and emerged in the right groin, causing recto-vesical fistula. Fascal matter was discharged from the opening for about four months; after that it took the natural course. Urine still continues to discharge from the fistula. The patient was obliged to use a catheter for six months. He was treated in Smith's Hospital for three months, where Dr. Carpenter introduced a catheter regularly for six weeks. He says that when he left the Fayetteville Hospital he was not allowed to take the catheter, which he had then learned to pass for himself. He is at present able to perform some light work. Urine continues to discharge from the groin, more particularly in the morning, when the bladder is somewhat distended; in the after part of the day it passes by the urethra Avith an occasional leakage." This man was pensioned. He presented his photograph to this office (Card Photo- graphs, S. G. O., Vol. I, p. 22). showing a small fistula opening externally one inch below the right inguinal ring. Examiner W. C. Spalding, April 21, 1870. reports: "There is now a fistula formed from the groin through the neck of the bladder and rectum, so that the urine, while the bladder is being emptied, passes through the groin, penis, and rectum. His general health is poor." The disability is rated as total, ofthe second grade, and permanent. This pensioner was paid June 4, 1873. Case 789.—Lieutenant G. W. Blake, Co. K, 2d Iowa, was wounded at Corinth on October 3, 1862. He was attended by Surgeons A. B. Campbell and H. Wardner, U. S. V., and by Acting Assistant Surgeon W. R. Burke. The early history of the case is compiled from casualty lists and an unsigned clinical report. A ball entered just above the left pubis, half ah inch from the symphysis, passed backward, downward, and outward, perforating the bladder and rectum, and escaped through the sacrum and gluteal muscles an inch and a half from the upper edge and one inch from the spine ofthe sacrum. He was treated iu a field hospital of the Army of West Tennessee, and at Cairo. A catheter was introduced through the urethra, but no effort was made to close either shot opening. From both orifices fasces and urine escaped freely; there was considerable inflammation about the external wounds, which subsided in a few days. After a time both wounds closed, and the fa?ces and urine passed through the natural channels. The patient was furloughed October 19,1862, and discharged from service May 27, 1864, and pensioned. On June 10, 1864, Pension Examiner P. M. McLaren reports "the original wounds of exit and of entry are healed; but there is an opening through the upper part of the scrotum in which the probe detects dead bone, and from which dead bone is being discharged." This pensioner was paid in June, 187:!. Case 7l>0.— Private W. Estee, 5th Massachusetts Battery, was wounded at Gettysburg. July 2, 1863. A musket ball perforated the pelvis from the right buttock to the right groin. Gas and fycal matter escaped by the anterior wound. On Julv SECT. II.] WOUNDS OF THE BLADDER. 267 13, 1863, he was sent to Jarvis Hospital, Baltimore. Assistant Surgeon D. C. Peters, U. S. A., who has printed an account of the ease elsewhere,1 observed that "the abdomen was tender and tympanitic, the knees drawn up, the breathing difficult. A catheter introduced into the bladder brought away a small quantity of urine mingled wth soluble f';ecal matter. With cataplasms, enemata, diluents, and the free use of opiates, the patient improved. There was a stercoral fistula, but it closed in a few weeks, and the functions of the bladder and bowel were completely restored." On September 18th he was furloughed, and, on Decem- ber 7th, entered Mason Hospital, Boston, convalescent. He was discharged and pensioned December 23, 1863. In December, 1872, Examiner (i. 8. Jones stated that there was dysuria; otherwise, tbe pensioner's health was satisfactory. Case 791.-—Private ,1/. Mooney, Cq, E, 19th Virginia, was wounded at Chapin's Bluff, November 18, 1863, and sent to Chhnborazo Hospital. The ward-surgeon recorded the following notes of the case: "A ball entered near the lower part of the sacrum, one inch to the right of the median line, passed forward and downward through the base of the bladder and the prostatic portion of the urethra, emerging under the arch of the pubis, impinging on its right ramus, and wounding the right cms of the penis. He was urinating at the time. The ball also passed through the left thumb. On admission, urine was dribbling from both wounds. On November 20th, there was considerable fever and cough; very little urine passes by the natural passage ofthe urethra. A slough had opened the rectum on tbe 26th; urine and faecal matter passed from both wounds. In December a gum catheter was several times passed into the bladder, disclosing spasmodic contraction of its sphincter; the excretions were regular and the appetite good, but there was considerable emaciation. On December 30th, a little urine passed by the urethra." The case progressed as follows: "January 15, 18C4: Fascal matter but no urine passes by the posterior wound; a little urine from the anterior wound ; patient furloughed. 30th: Anterior wound closed; urinates only by the urethra. February 2d : Anterior wound reopened and urine escaping therefrom ; constitutional symptoms present. ICth : Faeces ceased to discharge; the anterior wound closed. March 1st: The anterior wound reopens, but closes by the 10th. 15th: Posterior wound open and faecal discbarge from the same; there is also diarrhoea. 20th: Serous discharge from the posterior wound. 30th: Less irritability of the bowels. April 10th: Transferred to Chimborazo No. 2; both wounds open; sero-purulent discharge; frequent attacks of diarrhoea, and exfoliation from the pubes. The treatment pursued was mainly expectant." In very few instances were the recoveries complete. Making every allowance for exaggerations in the pension reports of disabilities, where the ulterior histories can be traced, it is rare to find the functions of the bladder perfectly restored after shot injury: Case 70-2.— Private G. W. Pitt, Co. G, 37th Wisconsin, aged 29 years, was wounded at Petersburg, July 23, 1864. and sent to a Ninth Corps hospital. Surgeon M. K. Hogan, U. S. V., reports that " a conoidal musket ball entered one inch behind and above the trochanter major, passed inward, fracturing the ilium and penetrating the bladder, and lodged, and could not be found." The patient was sent, by City Point, August 1st, to Mount Pleasant Hospital, furloughed on August 12th, and transferred, November 12th, to Harvey Hospital, Madison. Surgeon H. Culbertson, U. S. V., reports that the wound was then healed, and that the ball had been extracted from the anterior inferior spinous process of the ilium. The soldier was discharged March 18. 1865, and pensioned. In May, 1865, Examiner A. M. Dunton reports that the pensioner is quite lame and unable to labor. He rates the disability at three-fourths, and of uncertain duration. On September 4, 1873, Examiner G. M. A. Brown reported that "a fragment of shell passed across and through the muscles of the left hip. The use of the leg is much impaired. Disability continues three-fourths." This pensioner was paid June 4, 1873. Case 793.—Private L. Schroder, Co. G, 1st Louisiana, aged 41 years, was wounded at Port Hudson, June 14,1863, and was registered by Surgeon T. B. Reed, U. S. V., from a field hospital of the Nineteenth Corps, as a case of "gunshot wound of right knee and of belly." He was transferred to New Orleans, and Surgeon Francis Bacon recorded only the wound of the knee, and returned the man to duty August 16, 1863. On November 2, 1H64, this soldier entered University Hospital with chronic diarrhoea, and, on January 5, 1835, was transferred to St. Louis Hospital, where Surgeon A. McMahon, U. S. V., reported " an old gunshot wound of the bladder," and the patient was discharged February 28, 1865. He was pensioned, and Examiner G. Kellogg reported that he " suffered from anuresis and chronic cystitis." Examiner D. Mackay reported that the pensioner died October 19, 1870, "from the effect of a gunshot wound penetrating the bladder." Case 794.—Private W. H. Sibbald, Co. F, 1st New York Dragoons, aged 21 years, was wounded April 15, 1863, at Suffolk. Assistant Surgeon E. McClellan reports that he entered Hampton Hospital, April 15, 1863, with shot perforation of the pelvis, and was returned to duty August 23, 1883. On October 21, 1853, he was admitted to the 2d division hospital at Alexandria. Surgeon T. Rush Spencer, U. S. V., reported the case as a "gunshot wound of the intestines." The ward-attendant, Acting Assistant Surgeon J. P. Rossiter, notes that " a musket ball entered the left hip from behind,, and made its exit just above the symphysis pubis and a little to the right, injuring the bladder, so that urine escaped from the wound. On admission the wounds were healed, and the patient was doing well." On October 30, 1863, he was sent to De Camp Hospital, David's Island, whence Assistant Surgeon J. Sim Smith, U. S. A., reported him returned to duty, November 19, 1863. This man was discharged from service January 8, 1864, and pensioned. On January 15, 1873, Examiner G. R. Crocket reported that: "He complained of dysuria and inability to retain his urine at times, and of pain in the region ofthe bladder, and inability, from pain, to walk or stand long. The disability has increased from cystitis following gunshot wound. There is increased difficulty in voiding the urine." Besides the six cases of recovery from shot wounds of the bladder noted at the beginning of this subsection, and the fourteen cases briefly detailed, Cases 704 and 747 of the First Section of this Chapter were instances of recovery from shot fractures of the 1 Peters (D. C), Gunshot Wound of Intestines and Bladder, in Am. Med. Times, 1864, Vol. VIII, p. 3. 2(IS INJURIES OF THE PELVIS. [cllAP. VII. pelvic bones complicated by injury of the outer wall of tho bladder without penetration. To these twenty-two cases may be added fifteen, in which foreign bodies complicating shot wounds were successfully removed by cystotomy. As this series includes some of the most complete and satisfactory examples of recovery from shot wounds of the bladder that were reported, it may be well here to examine these, and to resume, on page 283, the consideration of the cases in which operations were-not performed. Twenty-one lithotomy" operations will be recorded, of which four were fatal or doubtful, and two were unconnected with the War. Foreign Bodies in the Bladder.—Shot wounds of the bladder are not uncommonly complicated by the presence of foreign bodies in the cavity of the organ. Either the projectile itself, or fragments of bone, may primarily penetrate and lodge within the viscus, or may find their way thither by ulcerative absorption. Less frequently, portions of clothing, bits of hair or of integument, or fragments of wood, are driven in. Moreover, the cystitis resulting from shot wounds is likely to induce the formation of calculi, without the presence of any foreign nuclei. Examples of all of these varieties of vesical concre- tions were observed during, or subsequent to, the War. These extraneous bodies are sometimes extracted through the wound by which they.entered, and sometimes they are discharged by the natural channel. No instances of small bullets thus escaping by the urethral canal were reported, though such have been observed;1 but several examples were given of splinters of bone eliminated by this passage.2 Most frequently, however, these foreign bodies become encrusted and have to be removed by operation. The annals of the War, or donations to the Museum, furnish twenty-one examples of lithotomy for the removal of concretions consequent on wounds of the bladder. In twelve, these were found about projectiles from fire-arms; in one, about an arrow-head; in three, upon bone splinters; in three, on inspissated mucus, or blood, or with no recognizable nucleus; in two, respectively, upon a bit of cloth and upon a tuft of hair. 'The following instances of small projectiles voided by the urethra after penetrating the bladder may be cited: 1. ELSCHOLTZ (J. S.) (Ephcm. Nat Cur.. Ann. IX and X, Niireuberg, 1693, Abs. LXXXV, p. 222) relates that a certain captain received a ball in the right side, penetrating tbe bladder; the wound healed, but there was a sense of weight around the pubes, and, after much tenesmus, a ball, "of the kind termed LaulF-Kugel, equal in size to a garden-pea," was passed by the urethra. This case is quoted by BOXETUS, Dejiarquay, DlXOX, and others. 2. MM. Chassaign ac, GlUALDfcs, and II. Lakkev (Rap. sur les plaies de la Vessiepar armes a feu, in Mim. de la Soc. de Chir., 1851, T. II, p. 339) cite from Stalpaut van deu AViel, a case said to be reproduced by THOMAS Bautholinus, which I cannot find in the editions I have examined of either of these authors. (THOMAS Bartholinus, by the way, died in 1C80, and the first edition of Stalpart's earliest publication [Zcldsame Aanmerkingen, etc.] was printed in 1C86.) The citation is as follows: "At the siege of our city (Copenhagen), a soldier in the pay of Sweden received in the epigaster (sic) a small bit of sharp iron (termed here skrax). of the kind with which cannon are still charged. The wounded man was carried, with five hundred others, to a neighboring city, and there received surgical aid. This morsel of iron was voided with the urine, contrary to general expectation, with atrocious pains, which gradually subsided. This man was promptly restored, by the care of Surgeon Cornelius, very skillful in his art. I think the iron fragment engaged in the urethra from the wounded bladder, for I do not see that it could arrive thither by an easier route." 3. Maxgetus (Bibl. chir., Geneva?, 1721, Vol. I, p. 71) relates the case of a youth, who, while hunting, received a charge of small shot in the groin. Pus and shots were voided by the urethra. The patient sank under the protracted suppuration and died. 4. To these old instances may be added a modern one, recorded by Dr. C D. Stickney (Boston Med. and Surg. Jour., 1855. Vol. LI, p. 360): Edward James, a painter of New Bedford, Massachusetts, was accidentally shot in the right of the hypogastrium by a Colt's pistol, June 7, 1854. He had excruciating vesical tenesmus, and voided urine mixed with blood. A catheter introduced soon after the accident evacuated two ounces of bloody urine. A few hours subsequently a catheter was again introduced, and the urine drawn was not bloody. Two days afterward, after much pain and straining, the ball was expelled from the urethra. Dr. L. B.vnn.ETT also observed this remarkable case. a A few examples may be added to those adduced in the text, of the elimination by the urethra of splinters of bone driven into the bladder: 1. Lakwey (Clin. Chir., 1S29, T. II, p. 518): Case of Lieutenant Burnot, 26th Infantry, wounded at Hanau, October 30, 1813. A musket ball, dividing the light spermatic cord, perforated the bladder and rectum. L'rine and faeces escaped by the posterior wound. As the wounds cicatrized the urine resumed its natural channel, and fragments of bone were voided by the urethral canal. Complete recovery ultimately ensued. BRIOT (Histoire de Vitat de la chir., 1817. p. 150; alludes to seeing this case. 2. Douglas (J.) (Edinburgh Surg, and Med. Jour., 1817, Vol. XIII, p. 313) recites the case of Captain S-----, who received a shot perforation of the bladder, at Chippewa, July 5, 1814. A piece of bone passed by the urethra. After protracted suffering, this officer completely recovered. 3. Hexnex (Principles, 1829, p. 429) records the case of T. D------, a soldier wounded at Waterloo, June 18, 1815. A ball grazed the horizontal ramus of the pubis, perforated the distended bladder, and came out at the buttock of the same side. The wound gradually healed, and, with the urine discharged from the urethra, bony grit was passed, which was collected and amounted to three drachms in weight; the largest piece was flat like a coin, and of the size of a split pea. 4. Matthew (Med. and Surg. Hist, I. c, Vol. II, p. 331) gives tire case of J. Griffith, 57th regiment, aged 26, wounded on June 18, 1855. by a musket ball, which entered the left buttock and escaped about three inches above the pubis, an inch to the right of the median line; urine escaped from both wounds; seven weeks after the reception ofthe injury three small fragments of bono passed by the urethra, and two pieces of bone escaped by the anterior wound; the patient recovered. 5. Barker (A. E.) (Med. Press and Circular, 1872. Vol. I. p. -82) relates the case of Peter S------, aged 21, observed in the clinic of Professor Buscil, of Bonn, wounded at Bapauine. January 3, 1871, an oblique shot perforation of the pelvis. A splinter of bone obstructed the urethra and was removed by forceps. SECT. II.] VKS10AL CALCULI FORMED ADOPT PALLS. '2(^) Vesical Calculi formed about Projectiles.—Examples of this sort have been recorded by Dionis, Gheselden, Covillard, Percy, and others. Several of the concretions are preserved in museums. One of the most interesting1 is represented in the adjacent wood-cut (Fig. 219). In 17(.'2, Chopart enumerated3 the examples that had been recorded prior to his time, and, in 1S50, Mr. James Dixon enumer- ated3 sixteen instances in which such concretions had been removed by lithotomy, three in which bullets, forming nuclei of stones, were found in the bladder after death, and one in which the bullet was small enough to be voided by the urethra. American experience has added thirteen instances of cystotomy for the removal of projectiles or of concretions formed about them, and three European instances may be -..-. , .. . . ,. r -j-.. . .. Flo. 210.—Vesical calculus formed about a added tO tlie COlleCtlOn by Mr. JDlXOn, making thirty-tWO musket ball (Museum der Josef's Akademie). J Q J [After PODRAZKI.] recorded examples of this group. 1 Professor POliRAZKI (Fremde Koerper, in der Harnblasc, in VOX PlTHA und BILLROTH, Handbuch, Ii. Ill, Abt. II, S. 81) states that the pyrifonn concretion is formed about a leaden ball and weighs one ounce five drachms and ten grains, and is composed of phosphate of lime, magnesia, and ammonia. It is from a soldier wounded in the pubes. Part of the projectile remained impacted in the bone; the other part was exposed in the vesical cavity, and formed a nucleus for the deposition of phosphates. Ehrlicii (Chir. Beobachtungen, B. I, S. 208) speaks of seeing it before 1795. -Chopart, Des plaies de la vessie, in his Traiti des Maladies des Voies Urinaires, 1792, p. 92. 3Dixon (J.), in Medico-Chirurgical Transactions, 1850, Vol. XXXIII, p. 197. 4 According to Covillard (Observations latrochirurgiques, 6d. THOMassix, 1791): (1.) Pellotier successfully removed by lithotomy a calculus the size of a pigeon's egg from the bladder of a nobleman, who had received a shot wound in the hypogastrium five years previously. This operation dates probably about 1G33. DlOXTS (Cours d'Operations, 1708, p. 170) relates that (2) FruSnE Jacques, in 1G98, successfully operated at Versailles on an Irishman who had carried a ball in his bladder fcr four or five years. Cheseldex (Treatise on the High Operation, 1723, Plate X) figures a calculous concretion deposited about a ball, which entered the bladder through the back part cf the thigh, and was removed by (3) Ridoute, four or liyc months after the infliction of the wound. Moraxd (Opuscules de chirurgie, 1772, T. II, p. 26) states that his father (4) "had removed from an invalid soldier, by the ordinary operation of lithotomy, a stone which had for a nucleus a musket ball, which had entered the soldier's bladder by a shot wound received in the hypogastrium many years previously, who recovered from the operation." Elsewhere (op. cit, p. 248) Moraxd speaks of having seen a ease of this description, referring probably to his father's ease. (5.) Bordexave (Pricis de plus. Observat. sur les Playes d'Armes a feu en diffirentes parties, in Mim. de I'Acad. de Chir., 1753, T. II, p. 522) relates that DuveugE saw a young man who had been shot by a pistol at the pubic attachment of the right rectus. The abdomen was tense, and there was retention of urine and a tumor in the perineum. Duverge punctured the fluctuating perineal tumor-with the trocar of FOUBEUT; a great quantity of sanguinolent urine escaped. Cutting on the canula into the bladder, Duverge with- drew the ball, a rag from the shirt, and many coagula. Tlie patient was bled nine times, and recovered after "a mediocre convalescence." Percy (Man. du Chir. de Armie, 1792, p. 24C) also adduces this case, and it has been erroneously accredited by some writers to Devergie. (6.) Garexgeot (Traiti des Operations de Chir., 2e ed., 1741, p. 170, Obs. XI) records an instance in which MARF.CHAL performed lithotomy on an officer wounded in the vesical region ten years previously, and removed a stone having a musket ball as its nucleus. (7.) C J. M. Laxgexueck (Nosol. und Therap. der Chir. Krankh., 1833, B. IV, S. 590) records a case in which a ball perforated the sacrum and rectum and lodged in the bladder. Urine and blood passed by the rectum. The entrance wound healed in a month, and, a fortnight later, urine and pus ceased to be discharged from the anus. There was frequent painful and sometimes involuntary micturition. Small calculi were discharged from the urethra six weeks after the reception of the injury. Laxgex- beck performed lithotomy and removed a calculus enclosing a ball (Kugel von Steinmasse eingeschlossen) and adherent to the wall of the bladder. This is probably the same case that LARREY (Clin. Chir., 1829, T. II, p. 529) refers to Laxgexueck, stating that, the operation was performed at the Wertheim Hospital, ten years after the injury, with success, and that the concretion was of the size of a small hen's egg. Demarquay (Mem. sur les Plaies de la Vessie par Armes a feu, 1851, Obs. VII) gives a long history of this case, stating that the subject of the operation was Charles Klein, a Prussian soldier, 25 years of age, wounded December 11, 1800, near Burgenbroek. There is reason to believe that the interval between the injury and operation was much less than that recorded by LARRET. (3.) SOUTH (Notes to Ciiei.ius'S System of Surgery, Am. ed., 1847, Vol. I, p. 529) records the operation of lithotomy ofthe elder CLINE, February 20, 1812, on a sailor, who, in July, 1811, received a shot perforation of the right ilium an inch above the sciatic notch. He was taken to a hospital at Cadiz, and suffered with retention of urine for five days, when ho was relieved by the withdrawal from the urethra of a roll the size of a goose-quill and two inches in length, consisting of fragments of shirting and of trousers. The fistula in the hip had healed in January, 1812. A month later, Clixe operated, removing an encrusted flattened ball, encysted on the left side of the bladder, and with a small portion of bone adhering to it The man recovered very quickly. The ball is in the Museum of St. Thomas's Hospital. (9.) Larrey (Clin. Chir., 1829, T. II, p. 530) relates that on August 4, 1812, he successfully performed lithotomy in the case of Lieutenant Guenou, 92d Infantry, wounded at Witepsk, August 3, 1812. The ball had entered the right groin, notched the ramus of the pubis, and passed obliquely downward and inward into the bladder. When struck with a sound, the impression of impact was very feebly transmitted to tho hand. After consultation with Ribes and others, Larrey practised perineal lithotomy, and the ball was presented to the patient in less than two minutes. It was subsequently deposited in the Museum of the Ezole de Midecine, at Paris, where it may still be seen, partly covered with earthy phosphates, "On y voit une petite portion d'os inerustce.'' LARREY remarks that this envelope demonstrated the futility that would have attended injections of quicksilver, a measure advocated by some of the consultants. After the operation, a small piece of bone and a fragment of clothing with black coagula escaped from the wound. The bladder was washed out by emollient injections, and nothing hindered convalescence except a slight arterial hcemorrhage on the second day, requiring a ligature. (10.) GUTHRIE (Lectures, etc., 1847, Case 110, p. 69, and Commentaries, etc., Cth ed., p. 609) relates the case of the soldier of the King's German Legion, wounded at Waterloo, June 18, 1815, and sent by Staff-Surgeon CA5IPBELL to the York Hospital at Chelsea, where (with Duguet, the French soldier Guthrie had amputated at the hip) he became the object.of great attention. "The ball entered a little way above the pubes and lodged. The symptoms which immediately followed were by no means severe, although he had passed a little bloody urine at first." In September, Guthrie, in the presence of a concourse of military medical men, removed a concretion composed, as Dr. MARCET ascertained, of triple phosphates deposited upon a flattened musket ball. Mr. Guthrie kept the specimen in a little box, and annually exhibited it to his class. One year, leaving it on the table after his lecture, he returned to find that some one, who never returned it, had borrowed the specimen. (11.) Larrey (Clin. Chir., 1829, T. II, p. 537) lelatcs the ease of Captain J. M. Itemy, 108th Infantry, aged 50 years, wounded at Waterloo, June 18, 1815, the projectile striking the left hypochon- Z,\) IX.IITRTKS OF THE PKLVTS. (OiiAP. VII. It is ludievcd that the particulars of the following case, briefly noted in the Museum Catalogue,1 have not heretofore been published: Cask 79.").—Lieutenant William Palmer, Co. E, 35th Massachusetts, aged 27 years, was wounded at Antietam. September 17. lS'.i'i. and taken to Locust Springs Hospital. The following report of the case was transmitted by the late Assistant Surgeon C M. McGill, U. S. A.: "A conoidal ball entered over the left ilio-pubic eminence, and, breaking the body of the left pubis, passed inward, downward, and to the right, penetrated the bladder near its summit, lodging in its cavity. Urine escaped from the wound of entrance, and the surrounding tissues were swollen. The patient complained of severe pain on the inside of the left thigh ; there was irritative fever, with diarrhoea, and rapid emaciation. The presence of the ball in the bladder was detected on September 21st. On September 25th, the patient was chloroformed and placed upon a firm table in the position for lithotomy. Aided by Assistant Surgeon C. H. Leonard, 51st New York, and others, I then made an incision, two inches in (liium, notching the anterior extremity of the tenth rib, and passing toward the pubes. He was taken to Jemappes. Much blood and stercoraceous matter passed from the wound. He was thence transferred to the English hospital at Brussels, where he was frequently visited by Larrey, then a prisoner of war. Faxial matter frequently passed with the urine. At the end of July a phlegmonous abscess formed in the right groin, and a few days after there was a copious discharge of purulent matter, with a urinous odor, by the wound. In December, 1815, the health of this officer was nearly restored : the abnormal anus had closed, and the dysuria had almost disappeared; but there was still a painful feeling of dull weight between it and tho pubis. In 1801, this symptom was aggravated, and Captain Remy went to Paris and consulted LARREY, who, in consultation with UlBES, decided to cut down upon the supposed site of lodgement of the ball. The officer was quite stout, and it required a deep incision between the white line and left pyramidalis to reach a cyst, which contained no traces of a projectile, but a little orifice admitting a probe leading to a hard body between the left pubis and the body of the bladder. Largely incising the fibrous wall of the cyst, Larrey was enabled to extract, with a polypus forceps, the foreign body, which proved to be an ounce ball encrusted with a circular layer of calculous matter. This officer recovered perfectly in a month, and Larrky heard from him long after, in the enjoyment of good health, at his home in the provinces. (12.) SOUBERBIELLE (Bulletin de la Sociite d'ltmulation, 1821, p. 450) records the case of Dapret, 135th Infantry, wounded at Liitzen, May 2, 1813, the missile striking- the left flank, notching the false rib, and passing obliquely downward and inward behind the pubes, where it lodged, and could not be detected. The wound closed, the patient convalesced, and pursued his ordinary avocations until the close of 1815, when a phlegmonous tumor formed behind the horizontal ramus of the left pubis. A few weeks subsequently the patient experienced a sensation of laceration, followed by painful micturition and the disappearance of the tumor, and passed blood and pus by the urethra. Subsequently he suffered from symptoms of calculus, and once a surgeon, on sounding him, felt a concretion ; but when preparations for an operation were made the calculus could not be felt, and the undertaking was deferred until 1821, when, at the Hospital St. Antoine, Nolj'BEKUIEM.E, having demonstrated the presence of the calculus, performed lateral lithotonij', and removed a fragment of a shell \biscai'in) weighing four ounces and two drachms, covered with successive calcareous layers, disposed in divergent rays, with a rough surface. A perfect cure rapidly ensued. I.ARltEY (Clin. Chir., T. II, p. 535) and many other authors have cited this case. (13.) Ballingall (G.) (Outlines of Military Surg., 5th ed., 1855, p. 357) remarks that "a staff-surgeon in the service underwent an operation for the removal of a ball from the bladder, which was successfully accomplished." Mr. DlXOX (Med. Chir. Transactions, 1850, Vol. XXXIII, .p. 199) states that he was informed by CUSACK that this operation was done by COI.EES, of Dublin, six or seven months subsequent to the reception of the shot-wound, and that the case is identical with that accredited to L'R AMl'TON by GUTHRIE. (14.) BALLINGALL (op. cit, p. 357) refers to "a more recent case, a ball encrusted with calculous matter, of which a cast fs to be seen in the Museum [of the Edinburgh Royal Infirmary], was successfully extracted, although in the first instance an operation was considered fruitless, in consequence, as I have been informed, of the ball, which had entered from behind, having lodged under the pubis and become partially encysted." Mr. Dixox (Med. Chir. Trans., 1850, p. 199) states that in this case Cusack operated eighteen months after a shot perforation of the sacrum and extracted the ball from, the left side of the prostate. In a discussion in the Royal Medical and Chirurgical Society, March 26, 1850 (The Lancet, 1850, Vol. 1, p. 423), Dr. C. De Morgan referred to a case obviously identical with this, occurring in the practice of Sir Charles Bell: An Irish gentleman was wounded by a musket ball in the hip. The usual symptoms of a foreign body in the bladder presented themselves, and "the body was distinctly detected by a sound. The bladder was cut into, but no foreign body was found. A subsequent operation was performed by Mr. CUSACK, and a bullet removed. It was supposed that the missile got into the bladder by ulceration, and that in the first operation it had fallen into the cavity it had originally occupied. ' Mr. W. V. Pettigrew "had seen the subject of this case lately; he was quite well." (15 ) Lewis (W.) (The Lancet, 1829-30, Vol. I. p. 31) reports the case of John Roden, a lad of 11 years, shot on November 5, 1828, by a pistol charged with a stone bullet. The missile, "after penetrating a door, entered the left thigh, and afterward passed into the bladder." Mr. Lewis extracted several pieces of wadding, but was unable to detect any other foreign body. Great inflammation, with excruciating dysuria. supervened; but, after a few weeks, the wound healed, while symptoms of calculus became aggravated. On June 23, 1829, Mr. Lewis practised lithotomy, and extracted a "marble, considerably increased in size by the deposition of calculous matter adhering firmly to it." The boy recovered without an unfavorable symptom, and subsequently enjoyed perfect health. (Pi.) Baudens (Clin, des I'laies d'Amies a feu, 1836', p. 384, Obs. IV) relates the case of a volunteer in the 67th French Infantry, who, July 15, 1831, was struck by a ball, which, after notching the pubic arch, perforated the anterior wall of the distended bladder. There was no exit orifice, and tho urine escaped by the pubic wound. A sound introduced by the urethra detected a foreign body in the bladder. Baudexs enlarged the entrance wound and practised supra-pubic cystotomy, and extracted a ball and a splinter of bone from the bladder. The patient rapidly recovered. (17.) Hunx, the old chief surgeon of the II6tel-des-Invalides (Mim. sur la nicessite d'extraire les corps itrangers et les esquilles, Paris, 1851, p. 18, Obs. VIII), records the case of a pensioner, Dupont, wounded in Spain in 18C8, the ball entering the right buttock. Thirty-two years subsequently, while a gendarme at Itheims, this man underwent lithotomy, and a calculus, having a ball for its nucleus, was successfully extracted. (18.) Mr. James Dixon (Med. Chir. Trans., 1850, Vol. XXXIII, p. 197) read to the Royal Medical and Chirurgical Society, March 2b', 1850, a paper by Assistant Surgeon E. M. MACEllEliSOX, ;;th Pvoyal Lancers, entitled A Case of Gunshot Wound, and Subsequent Extraction of a Bullet from the Bladder. The case was that of a private, W. West, 24th Regiment, aged 22 years, shot in the left buttock at Chillian- wallah. January 13, 1649. He felt such severe pain in tlie left testis as made him at first suppose that part to be the seat of injury. The ball-track, which was supposed to pass through the ischiatic notch, healed without difficulty; but there was a urethritis, ascribed at first to an old gonorrhoea; but pain on micturition increasing, a sound was passed, and a foreign body iu the bladder detected. August 30, 1849, Mr. Macphkrsox practised lateral lithotomy, and extracted from the bladder an iron ball weighing an ounce and thirty-eight grains. It was encrusted with a thin layer of sandy deposit. By the end of October the patient was convalescent. Williamson (Mil. Surg., 1863, p. 119) and other authors have cited this ease, GUTimiE (Comm.. etc., p. (J10> being unable to learn the operator's name. (19.) Dr. Neiiioreer (Handbuch der Kriegschirurgie, 1867, S. 808) records the case of Joseph Itschi, of the Prince Wasa Regiment, wounded re^iVove^fromX^madder at Solferino> June 24' 1859> b* n bal1 y this time the wound of the bladder had closed, for urine came wholly by the catheter. The patient was very pule and feeble, his pulse; was rapid and weak, he had little appetite, and a slough formed, notwithstanding the most careful dressing, at the root of the penis anteriorly. I was ordered away from the field hospital of the Ninth Corps, in which this officer lay, x>n the 8th of October, at which time I considered his case, although a critical one, yet one that was likely to recover." It appears from the report of Surgeon T. II. Squire, 89th New York, that the sloughing continued to extend, and in spite of the most careful sustaining measures the patient sank exhausted, and died October 13, 1*62. The extracted missile was sent to the Museum ; one aspect is represented by tbe wood-cut (Vw,. "221), and the opposite by Fid. 3 of Platk VI1. The ball, irregularly compressed at its base and presenting near the apex two ragged depressions, weighed one ounce and two grains Troy. At the bottom of the conical cavity in the base of the ball is a white encrustation, which was more considerable before the specimen had been handled aud trans- conical ball taken from ferred. It consists of ammoniaco-magnesian phosphate. Tbe bone fragments were lost. tlle "ladder. Spec. 4394. The late Dr. P. A. Felton, of Colonel Dockcry's Arkansas regiment, is reported1 to have performed, unsuccessfully, the high operation of lithotomy, in 18G2, at an Iuka hospital, for the removal of a ball from the bladder of a soldier wounded about two months previously. Dr. J. L. Forwood, of Chester, Pennsylvania, has had the good fortune to success- fully remove musket balls from the bladder in two cases, which have been briefly related in a report to the Surgeon General:~ Case 796.—Private T. Lindsay, Co. F, 69th Pennsylvania, aged 43 years, was wounded at Oettysburg, July 2, 1883, while in a kneeling posture, by a ball which, after passing through his canteen, entered the thigh. Surgeon II. Janes, LT. S. V., reports that he was treated at Camp Letterman, from August 5th to November 5, 1863, for a gunshot wound penetrating the pelvis, and was then transferred to Newton University Hospital, Baltimore. Surgeon C. W. Jones, U. S. V., reports that "a ball passed into the pelvic region, causing incontinence of urine, and impairing the motions ofthe hip joint," and that the patient was discharged from service January 18, 1804. On his return home to Chester, Pennsylvania, he suffered many of ffie symptoms of stone in the bladder, for which he was treated from time to time, until February, 1836, when an operation for strangulated hernia, the result of dyspnoea, became necessary. On April \'i, 1886, the operation of lithotomy was performed by Dr. J. L. Forwood, when, most unexpectedly, an irregularly shaped ball, coated with a phosphatic deposit, was removed from the bladder. This concretion and nucleus weighed 763 grains. The operation was successful. There is no pension record in the case. The specimen is in Dr. J. L. Forwood's cabinet. Case 797.—Private T. S. Mason, Co. K, 193th Pennsylvania, aged 50 years, was wounded near Hatcher's Run, March 31, 1805. Surgeon W. L. Faxon, 32d Massachusetts, reported that "a conoidal ball entered through the pubic arch and lodged in the bladder." The patient was removed to City Point, and thence to Lincoln Hospital, at Washington, where Surgeon J. C. McKcc, U. 8. A., reported that " a mini6 ball, entering just above the pubis, over the bladder, penetrated and lodged," and that the patient was discharged from service June 9, 1865, and pensioned. This pensioner returned to his home in Chester, Pennsylvania, and, in December, 1867, Examiner M. Emanuel, of Linwood, reports : " liall is still lodged in the cavity of the abdomen, causing continued discharge from the seat of the lodgement. He is unable to lift, and incapacitated for manual labor. In February, 1869, the wound healed up and the patient thought himself well; but in February, 1870, vesical trouble, with bloody urine, appeared. On April 16th, the operation of lithotomy was performed by Dr. J. L. Forwood, who removed a conoidal musket ball weighing one ounce and a quarter, and having two small pieces of phosphatic deposit attached. On May 30th, the patient was up and about, but the wound had not entirely healed. There were no symptoms of calculus until six weeks before the operation, notwithstanding there seems but little doubt of the ball having been in the bladder prior to that time. September C, 1373, Examiner Theodore S. Christ, of Chester, reported ihat "in this case the ball entered just above the pubes and lodged. Five years and sixteen days after the reception of the injury, I assisted Dr. Forwood iu removing the ball from the bladder." 3 This specimen also is in Dr. Forwood's large collection. In a letter dated November 21), 1873, Dr J. L. Forwood expressed his intention to " present the two minie balls, taken from Mason and Lindsay, to the Army Medical Museum, with their surgical histories, at once." It is much to be regretted that these 1 Wai.LIS (J. D.), Nashville Jour, of Med. and Surg., 18117, N. S., Vol. II, p. 502. An unknown soldier received, at Corinth, October 4, 18(i2, a penetrating shot wound above the right pubis. Four weeks afterward urine escaped from the wound, and symptoms of calculus appeared. It was supposed that a ball, lodged in the muscular coat of the bladder, had made its way by ulceration into the cavity. About November 20, 18C>2, Dr. Felton practised suprapubic lithotomy and removed a large r.uind ball, prib.ibly from shrapnel. The patient survived the operation only 24 hours. J Forwood (J. L.), Cases DCCIII and DOCVI, in Circular 3, S. (\. <>., 1871, pp. 2").1, 2fil. 3Dr. Christ adds that there is au interesting account of this cue in the PiULiielphU Press of April 18, 1870. INJURIES OF THE PELVIS. I'' hap. vn. rare specimens will not be received in season to permit engravings of them to be prepared for insertion in this place. If practicable, they will be figured in a later portion of tbe Section. The following, though not strictly a " War case," was, at one time, treated at the military hospital at Fort Cottonwood, and is interesting in this connection.1 and must serve as the fifth of the series of cases of bullets extracted by lithotomy: Ca.sk Ag.—James Mitchell, aged !M years, a Scotchman, employed on the Leavenworth and Denver Railroad, received accidentally, in April, 1864, a pistol shot, penetrating the left sacro-iliac synchondrosis and lodging. He was taken to the post hospital at Fort Cottonwood, and placed under the care of Assistant Surgeon James W. LaForce, 7th Iowa Cavalry. The patient stated that during his six weeks' sojourn in hospital he suffered great pain in the rectum, and had difficulty in micturition. In October, 1864, he went to his home in Iowa. In June1, 1865, he consulted Dr. J. C. Hughes, at Keokuk, who carefully explored the bladder and rectum without finding any foreign body. In February, 1333, he again consulted Dr. Hughes, and a. sound introduced into the bladder at once revealed the presence of a large calculus. On February 22, 1868, in the presence of the medical class ofthe Iowa University, Professor J C. Hughes performed the bilateral operation for lithotomy of Dupuytren. The calculus was too large to be removed, although the prostate was divided as freely as was consistent with safety. The concretion was therefore crushed by a hthotrite. After extracting the fragments, the bullet that had formed tho nucleus was found and removed. The fragments consisted of phosphates, and, when aggregated, formed a calculus of the size of a large hen's egg. The long-standing irritation induced by the concretion had resulted in the formation of sinuses, one; of which constituted a recto- vesical fistula, and there were suspicious indications of a tuberculous diathesis, and at the date of the report, one year after the operation, the prospect of recovery was unpromising. [Since the foregoing abstract was placed in type, a photograph of a section of the concretion removed in this case has been received at the Museum through the kindness of Professor Hughes. It is carefully copied in the accom- panying wood-cut (FlG. 222). In a letter to the editor, Dr. Hughes states that " the stone was crushed in its removal, but has been put together with as much care as possible. I trust the photographer's print will prove satisfactory. I had lost sight of the case and its history, further than the publication referred to, the patient having left the city. Upon enquiring of an acquaintance of his, who resides here, I learn to-day (November 26, 1373) that he died of small-pox, in 1871, in one ofthe eastern cities."] The remarkable instance of successful removal of a fragment of a grenade from the bladder, by Surgeon J. F. Randolph, is already well known.2 Whatever else may be thought of the reduction of the pension of the subject of this operation, it is gratifying to know that, nearly ten years subsequent to the operation, he enjoyed such good health that this saving in government expenditure was deemed suitable. Cask 7i>3.—The principal facts, already published, are as follows: "Private Conrad Lotes, Co. A, 23d Indiana, was wounded at Vicksburg, June 25, 1853, attended by his regimental surgeon, M. Brucker, and Surgeon G. R. Weeks, U. S. V., and sent, on the hospital transport R. C. Wood, to St. Louis. A portion of a hand-grenade had entered the right buttock two inches from the end of the coccyx and penetrated the bladder. On April 2, 186-1, the foreign body was removed by lateral lithotomy, at Jefferson Barracks, by Surgeon J. F. Randolph, II. S. A. The patient recovered rapidly, and was discharged and pensioned June 17, 1864." His ulterior unpublished history is found in the Pension Records. In September, 1835, Examiner Vesical calculus formed about a ball. [From a was reduced in September, 1873. The concretion, contributed to the Museum by Dr. Randolph, is numbered 83 in the Surgical Section, and is well represented in Fig. 2 of Plate VII, the quadrilateral shell fragment. It weighs an ounce, six drachms, and twenty-four grains Troy; its original weight of two ounces five grains having been reduced by the crumbling ofthe investing phosphates. These consist almost wholly of the triple phosphate of ammonia and magnesia. Brevet Colonel Alexander K Dougherty, Commandant of the New Jersey Home for Disabled Soldiers at Newark, in 1868 successfully removed from the bladder of a soldier, wounded three years and four months previously, a round iron ball encrusted with ■An abstract ofthe case has been published by Professor J. C. HUGHES, M. D., in the Iowa Medical Journal, 18G9, Vol. V, p. 98. "RANDOLPH (J. V.), Case in which a Fragment of a Shell encrusted with Calculous Matter was extracted from the Bladder by Lithotomy in the Am. Jour. Med. S-i., 1S64, Vol. XLV111. p. 271 ; Gunshot Wounds of the Genitn-Urinary Organs, iu Circular No. (i, S. G. O., JSG'o, p. 20; Catalogue of the Surgical Section of the Army Medical Museum, 18oo\ p. 492 ; FltAXKr.I.Vs Science and Art of Surgery, 1867, Vol. I, p. TOG. \ * / M>d and Surg Hist of tkp War of the Rebellion Part II Vol.I. Plate VU opp page 272 Ward, phot J. Bien, Lith VESICAL CALCULI FORMED UPON PROJECTILES. Fi°.l. Med.Dir Dougherty's C ,Se < Spec 5520 ) Vvj. l.Frof. F.T. Miless fuse (Spec. 501!)) r'ip.-'.Suio.J.F Randolph's Case (Spec .881 tig 5. Dr. Cabot's Case IVjADr.G.M.M' Gills Case I Spec . l.'V.H ) Fi;J.G.Trof.H. Mr Gun es Cose (Spec. GlMWl Fi£.7.I>r.W.H.Forwoor' vireiuia Mediual ColIeee-in ,he Vir°inia 276 INJURIES OF THE PELVIS. [CHAP. VII. by Assistant Surgeon W. IT. Forwood, U. S. A., as already reported in Circular 3, Surgeon General's Office, 1871, page 2(30.* The principal points are here recapitulated: Oase 801.—In 1862. Sitamore, a Kiowa chief, aged 42 years, in a fight near Fort Larned, with Pawnees, was wounded, by an arrow, in the right buttock. The shaft was withdrawn, the iron head being left deeply embedded. He passed bloody urine immediately afterward, but the wound soon healed, and, for six years, he continued to engage in the chase without incon- venience. In August, 1869, he applied to Assistant Surgeon W. H. Forwood, U. S. A., at Fort Sill, with unmistakeable signs of calculus. On August 23, 1869, Dr. Forwood removed, by lateral lithotomy, the large concretion represented by Fig. 7 of Plate VII. The calculus was egg-shaped, and six hours after removal, before being sawn, weighed nineteen drachms avoirdupois, and was found to consist of a uniform deposit of triple phosphate about an iron arrow-head. The patient was almost convalescent on the eighth day, when his band carried him to his camp, sixty miles away, where an epidemic of fever was prevailing. He died nineteen days afterward. Cdculi having Nuclei of Bone, and Encrusted Bone-splinters.—It was observed by Hennen, that "depositions of calcareous matter are often formed in the bladder after its coats have been injured by a wound;" and, he adds, "a splinter of bone is, in most cases, found to be the nucleus of the deposition of calculous matter."2 Hennen figures a concretion of this sort (Fig. 227), and adverts to a case in Dease's practice. Sir Henry Thompson refers to a calculus in the Museum of the Royal College of Surgeons, having a nucleus of bone. It was presented by Sir William Blizard, as removed by dilatation from the female bladder by Mr. Allaway; but no further history of the specimen exists. A section of this concretion is represented in the wood-cut (Fig. 224). In a case in which Professor P. F. Eve removed by cystotomy, in 1846, from the bladder of a negro woman, a calculus having a nucleus of bone, there had been a fracture of the pubis by a fall from a stable-loft; the nucleus was a fragment of the pubis, and the concentric deposits are reported to have consisted mainly of uric acid. Although Hennen declares calculous formations about bones to be com- mon after shot wounds,3 published examples are not numerous, and the three instances resulting from the experience of the War are of unusual interest. Fig. 22-1.—Fusible calculus deposited on a piece of bone. [After Catalogue of Animal Concretions, in the Museum of the Roval College of Surgeons. Series VIII, H, a, 11. PLATE 11, FIG. 7. J |. 'In an interesting letter to the editor, January 14, 1873, Dr. W. II. FORWOOD corrects several errors in the report in Circular No. 3, 1871, p. 260; I. q.: " Litimore should be Sitamoue. Sit, in the Kiowa language, signifies Bear, and this chief was of the 'royal family' of Bears, of whom are famous: Sit-ank, Sitting Bear, Sit-axta, White Bear, Sit-amobe, Sleeping Bear, Sit-amgeak, Stumbling Bear." Secondly, the concretion weighed 1140 grains after removal, and its reduction to 815 grains, as recorded in the Circular, is explained by its division by a coarse saw, and subse- quent inspection and handling by a multitude of Indians. ■2 IlK.wi'.x (J.), Principles of Military Surgery, 3d ed., 1820, p. 433. 3 It is remarkable that such distinguished writers on military surgery as Dr. J. A. Lidell and Professor F. H. HAMILTON, and such an eminent lithologist as Sir Henry Thompson, should refer to instances in which bone formed the nucleus of a calculus as of almost unexampled rarity. Remarking, in a case of lithotomy at University College Hospital (The Lancet, 1872, Vol. I, p. 851), the great utility of a light flat-bladed lithotrite to measure and accurately diagnosticate vesical concretions, even when their removal by lithotrity was not contemplated, Sir HENRY THOMPSON described a case of a man of 40 years, whom, iu June, 18(i5, lie had sounded and found to have stone, and had then, as usual, introduced a lithotrite to ascertain the precise size of the calculus, and remarked that the mass did not feel like stone, and withdrew, for examination, a bit, which proved to be bone. The calculus was small, and on June 27th and 30th the phosphatic matter and bone were crushed together. The bony portions are represented in Figure 225, from a cut in The Lancet, drawn from the originals. The smaller pieces were removed by the lithotrite; the larger was impacted in the urethra, and was removed by tbrceps. Sir Henry Thompson also narrated the case of W. D------, a lad of 15 years, who had been crushed by a carriage FIG. 225.—Portions of bone removed from the bladder by a lithotrite from a man of 40 vears. (After Thompson.) -'-. FIG. 226.—Calculus formed about a nucleus of bone. (After THOMPSON.) 1 wheel passiug over his pelvis four years previously, and had suffered at first from hematuria and vesical inertia, and subsequently from the passage of grit and of a bit of bone, and, on March 6, 1871, had been successfully operated on by lithotomy. In this case, before performing the lateral operation, a fragment of bone was withdrawn by the lithotrite, and the form and dimensions of the concretion were accurately determined. The bone-fragment and calculus are represented of the size of SECT. II.] VESICAL CALCULI FORMED ABOUT BONE. 277 Dr. W. C. Livingston, in August, 1865, removed a large oval calculus having a bone splinter as its nucleus, and two encrusted bone fragments, from a soldier who had received a shot perforation of the bladder fifteen months previously: Case 805.—Sergeant George E. Shafford, Co. (), 83d New York, aged 21 years, was wounded at the Wilderness, May C, 1864, and made a prisoner. lie was admitted to the Annapolis General Hospital, September 26, 1864, from the flag of truce steamer New York. Surgeon B. A. Vanderkicft, U. S. V., records a "shot wound of the right groin, and diarrhoea." He suffered greatly with vesical irritation. lie was transferred to Co. B, 97th Now York, and discharged January 6, 18G5, and pensioned. He returned to his home in New York, and, on August (5, 1835, consulted Dr. W. C. Livingston, who learned from the sergeant that the missile, supposed to he a mini6 musket ball, had entered at tho right inguinal ring, passed through the bladder, and emerged at the middle of the sacrum. Urine dribbled constantly from the anterior wound. He lay under canvas until June 10th, when he was sent to hospital at Lynchburg, under the care of Assistant Surgeon II. C. Chalmers, P. A. C. S. About July 1st, mine began to pass by the urethra. By tho middle of September, both openings had closed. Soon afterward he began to experience symptoms of calculus. On August IStli, Dr. Livingston, assisted by Dr. Markoe and others, performed the median operation for lithotomy, and removed an oval calculus and two fragments of bone encrusted with calcareous matter. In the course of ten days the urine passed entirely by the urethra, and the patient made a rapid recovery. The fragments of bone were probably chipped off from the pubis, in which a notch could be felt. On sawing the oval calculus, the nucleus was found to consist of a fragment of bone.1 The Pension Examining Board of New York refer to a feature ofthe case unmentioned in the other reports, a stercoral fistula, from wound of the rectum. A report dated April 6, 1870, states: "Ball entered just below Poupart's ligament on the right side, passed through the bladder and rectum, and emerged three inches above the anus. In consequence of foreign material remaining in the bladder, vesical calculus formed, which has been removed by median operation. A complete faecal fistula remains. Disability total, third grade, and permanent. He also has a reducible indirect inguinal hernia, of which we are unable to state the origin." This pensioner was last paid June 6, 1873. nature in FIGURE 226, copied from a cut in The Lancet. The concretion consists of a bone nucleus largely encrusted by phosphates. After relating these cases. Sir Hknry Thompson refers to preparation II, a, 11, of Section VIII, in the Museum of the Royal College of Surgeons, a large phosphatic calculus removed by Allawat from the bladder of a woman, having a piece of bone in the centre, and to Specimen 5041 of the Army Medical Museum, at Washington, as the only additional recorded examples of vesical calculus with a nucleus cf bone. On the presentation to the New York Pathological Society, January 25, 1866, by Dr. Livingston, of the concretion from Sergeant Shafford's case, a phosphatic calculus with a nucleus of bone, it is reported (The Medical Record, 1866-67, Vol. I p. 186) that " Dr. Lidell remarked that the case, so far as his knowledge extended, was a unique one." And " Dr. Hamilton stated that a number of cases were reported in which balls found an entrance into the bladder and lodged; but he had never heard of an instance in which fragments of bone had been driven into the organ in the manner described by Dr. LIVINGSTON." It is FIG. 227. — Am- surprising that there did not occur to these teachers either the case of shot wound of the bladder moniaco-magnesian in which Staff-Surgeon Dease removed calculi having splinters of bone for nuclei (Hennen's formedat'about" "a Principles of Military Surgery, 1829, 3d ed., p. 432), and the concretion represented of the size pi(} splinter of bone, of nature in the fifth figure of Plate III, in the edition of 1820 of Hennen's work, and copied in calculus with porous bone [After Hknnen.1 -}-. the adjacent wood-cut (Fig. 227), cr the two more recent instances recorded by LEROr d'Etiolles, for a nucleus. Weight 434 or several others recorded in the annals of surgery. M. Leroy (V Union Midicale, 1853, T. VII, ffrs' lAfter Neudorfer.] -}-. p. 412) cites the cases: " De deux blesses de fevrier et de juin, 1848, dont le bassin fut traverse par des balles qui detaeherent et pousserent dans la vessie des esquilles d'os, lesquelles devinrent des noyaux de pierre. M. Lf.EOY ecrasa les concretions calculeuses et coupa les portions d os avec un instrument decrit page 251 de son Recueil demimoires." M. H. Larrey (Rapport sur les plaies de la vessie, in Mem. de la Soc. de Chir., 1851, T. I, p. 369) states that his illustrious father, after the siege of Acre, operated on an officer who had received a shot perforation ofthe bladder and rectum, and successfully removed a calculus formed about a fragment of the pubic bone. Professor P. F. Eve (Southern Med. and Surg. Journal, 1846, Vol. II, p. 587) records an operation for lithotomy on a negress, and the removal from the bladder of a piece of bone three-fourths of an inch square, coated with deposits of uric acid. Bertherand (Campagnes de Kabylie, 1862, p. Ill) relates the case of B------, 1st Zouaves, shot through the bladder, June IU, 1854, at Taourirt, by a ball, which entered the upper part of the left thigh near the crural arch, and made its exit through the right buttock. There was copious bleeding by the urethra and by the posterior wound. The patient was sent to the Dey Hospital at Algiers, and slowly convalesced, a urinary fistula persisting anteriorly. In November, 1854, a calculus was extracted through the fistula. It was bean-shaped, and consisted of a small splinter of bone encrusted with concentric layers of phosphate and carbonate of lime. After its passage the fistula closed, and the soldier recovered perfectly. A case recorded by Dr. NeudOefer (Handbuch der Kriegschirurgie, Leipzig, 1867, p. 811), the concretion being figured above (Fig. 228), was published since the remarks by Drs. Lidell and Hamilton on Dr. Livingston's operation. It is that of Franz Scharowetz, 21sl Infantry, wounded at Skalitz. The concretion, formed about a porous fragment of bone, was removed at a garrison hospital at Vienna, June 23, 1866, by Herr Neudorfer, by lateral lithotomy. This soldier made a rapid recovery. Dr. B. B. LEONARD (Cincinnati Lancet and Observer, 1871, Vol. XIV, p. 520) relates the ease of F. Hines, aged 8 years, who underwent snpra-pubic lithotomy in April, 1871. A calculus weighing three and a half ounces was removed from the bladder, with a piece of bone as a nucleus ; a speedy recovery ensued. Podrazki (Wiener Medizinische Wochenschrift, 1865, S. 1765-1780) records the case of an Austrian officer, Lieutenant P. A------, wounded at Solferino, June 24, 1859, by a ball, which entered through the left buttock and perforated the rectum and bladder. Urine escaped from the wound and the rectum. The ball could not be found. The wound healed in four weeks; but on March 20, 1862, the patient was admitted to Professor von Pith as clinic with symptoms of calculus. Allarton's operation was successfully performed with the expectation of finding a ball, but instead a heavily encrusted, rough-surfaced piece of bone about one inch in diameter was removed. Kotwithstanding an attack of pleuritis, the patient recovered completely in seven weeks. Professor Gross (Elements of Pathological Anatomy, 1845, p. 721) has in his cabinet a calculus presented by Dr. Jetton, of Summer County, Tennessee, containing three of the caudal vertebrae of a squirrel. The concretion was removed from the bladder of a man of thirty-five, addicted to nefarious practices. In the eighth and ninth examples in the antecedent note (p. 26S) on calculi formed about bullets, cases of operations by Cune and Larrey, portions of bone were included in the concretions. Specimen 2436, Section IV, in the Edinburgh Museum, is a vesical calculus having a nucleus of bone, from a case of shot wound of the pelvis (Cat, 1836). The concretion was presented by Dr. John Thomson. Tulpius (Obs. med., Leyden, 1716, p. 323) tells of a shot wound of the bladder that cicatrized; but difficulty of micturition ensued, which was accredited to a calculus. After death, a large fragmunt of the os pubis and three calculi were found in the bladder. Two other examples are noted further on. 1 The later history of this case is reported by Dr. W. C. Livingston in the Proceedings of tlie New York Pathological Society, January 25, 1866 ; in the Medical Record, 1867, Vol. I, p. 185. The case is referred to, also, in Dr. T. M. Markoe's article in the New York Med. Jour., 1867, Vol. V, p. 30, Obs. XVI,—in Er. F. H. Hamilton's Principles and Practice of Surgery, 1872, p. 118. liTS INJURIES OF THE PELVIS. [CllAlv VII. Dr. C. Terry, of Columbus, Georgia, lias recorded1 a case of successful lithotomy lor the removal of calculi formed about splinters of the sacrum, driven into the bladder of a soldier bv a shot perforation of the pelvis, seven months prior to the operation : Case 806.—[This abstract, is condensed from the detailed account printed by Dr. Terry.] Private J A. Miller, Co. E, 39th Alabama, was wounded near Atlanta, July 28, 1864. A conical musket ball perforated the sacrum near the left sacro- iliac junction, passed through the bladder, and made its exit through the horizontal ramus of the right pubis. He was treated at a hospital at Atlanta for a fortnight, and entered Walker Hospital, Columbus, September 5, 1864. The anterior wound had healed. The urine passed partially by the posterior wound. Abscesses formed on the right side of the scrotum, and there was sloughing, ascribed to injury of the spermatic vessels. Several small bits of bone and calcareous concretions passed by the urethra. The posterior wound remained open, and pieces of bone were discharged through it. There was much pain in the pelvis, and suffering during micturition. Three months after the reception of the injury, Dr. Terry was induced to explore the urinary canal with a sound. A grating sensation was felt, and an operation was determined on. March 3, 1865, a straight staff was passed down to the membranous portion of the urethra, when a piece of bone an inch and a half long, covered with calcareous matter, was found lying transversely embedded in the muscles. This fragment being removed, the canal, much deflected and adherent to the pelvis, was traced to the prostate, which was sufficiently incised to admit the passage of the finger into the bladder, and several more pieces of bone encrusted with calcareous matter were removed. A concretion the size of a filbert was found encysted, and this also was removed. The bladder was then thoroughly washed out. The calcareous matter was very soft, and much detritus was washed away. It was thought the fragments removed would fill the palm of the hand. The patient improved for a month, then calcareous matter and necrosed bits of bone were discharged by the urethra, and there was great vesical irritation. The hospital being broken up on the cessation of hostilities, the patient went to his home. On June 29, 1865, Dr. Terry visited him and performed lithotomy by the lateral method, and removed several small pieces of bone and three calculi. One was of the size of the egg of the guinea-fowl, the other two of the size of a hickory-nut.' Mr. W. J. Land, chemist, analyzed them, and found them to consist almost entirely of phosphate of lime, with slight traces of oxalate, deposited upon small nuclei of bone. The patient rapidly recovered, but a perineal fistula remained. This was treated by catheterization and cauterization, and after eighteen months it closed, without contraction of the canal ofthe urethra. On April 26, 1866, the patient had regained control of the bladder and was pronounced well. [Since the foregoing abstract was placed in print, Dr. C. Terry has had the great kindness to transmit the further history of this case, and to donate the only one ofthe four calculi remaining in his possession to the Army Medical Museum. A section of it is represented in the adjacent wood-cut (FlG. 229). It is an oval calculus, an inch in the largest, and nine and thirteen-sixteenths of an inch, respectively, in the transverse diameters, and consists of a uniform deposit of ammoniaco-magnesian phos- phates about a splinter of compact bone half an inch long. " I regret exceedingly," Dr. Terry writes, "that I am able to send you but a very small specimen of the calculi removed from Miller. After his complete recovery, he was in Columbus, and begged for the large calculus removed at the first operation, wishing to preserve it as a memento of his War history. I gave it to him, with a phial full of small pieces, and a splinter of bone on which a concretion fig 229.—Calculus formed about g deposited. The largest piece (FlG. 229) is the remains of the largest calculus extracted a miclens of bone. Spec. 032/. +. " o ■ r \ ^ / ^ ^ o ^ at that operation. It has stood for six or seven years in a phial on a shelf in my office, and has been inquired for so frequently, and shaken about in the bottle, that the outer soft layers have crumbled away. I now regret exceedingly that I did not preserve it more carefully, for it will hardly serve your purpose for adequate pictorial repre- sentation, though it may serve to show you the character ofthe deposit. The after-history ofthe case may interest you: Miller remained for about two years without virility, when this function rapidly returned, and he married, and informed me that he had no difficulty in his conjugal relations. He married a widow with two children; but, after two years, has had no issue. Eighteen months since I saw him in excellent health, weighing one hundred and eighty pounds."] Figure 2 of Plate VIII represents the large calculus formed about a splinter from the left pubis, successfully removed, by Dr. H. McGuire, from the bladder of a soldier three years and four months subsequent to a shot perforation of the organ. The details of the case have been already published ;2 the principal facts are as follows: Case 807.—Private M. C. H------, — Virginia, aged 23 years, was wounded at the engagement at McDowell, May 8, 1862. A musket ball, striking the horizontal ramus of the left pubis, perforated the bladder and rectum, and emerged through the right ischiatic notch. He was sent to Staunton, and remained in the general hospital there four months. Urine mixed with blood and pus passed through both entrance and exit wounds; faeces often escaped through the posterior wound. During the third week several bone fragments were discharged in defecation. In thirty-five days the exit wound closed, and urine was voided by the urethra. Urine continued to be partly discharged by the anterior wound, but this orifice gradually closed. In September, 1H32. he was able to get about on crutches. In September, 1865, he applied to Dr. H. McGuire with symptoms of stone in the bladder. A sound revealed the presence of a large calculus (Spec. .r;041). Lateral lithotomy was performed. The stone was found adherent to the cicatrix in the posterior wall of the bladder. After its removal the patient rapidly regained his usual health, without an untoward symptom. 1 TEURl* (C.), Remarkable Case of Gunshot Wound of the Bladder, requiring two Operations of Lithotomy, in the Richmond Medical Journal, 1866, Vol. II, p. 169. 'MCGUIRE (H.), Gunshot Wound of the Bladder and Rectum, and subsequent operation for Stone in the Bladder, in Proc. of Richmond Acad. of Med., in Richmond Med. Jour., 160?, Vol. V, p. 279. Compare also Circular No. 3, S. G. O., 1871, p. 258, Case DCCII. and London Lancet, 1672, Vol. I, p. 8ol, Clinical Remarks on Lithotomy, by Sir HENRY THOMTSON. SECT. II.] VESICAL CALCULI CONSEQUENT ON SHOT WOUNDS. 279 In some cases of cystitis following shot injury of the bladder, and complicated by the penetration of bone splinters into the cavity of the viscus, calculi are formed, but, singularly enough, not upon the bone fragments, but without any foreign substance that can be recognized as having afforded a nucleus about which the concretion has accumulated. batch an instance occurred to Surgeon D. W. Bliss, U. S. V., in the case of Mahay, who died at Armory Square Hospital, fourteen months after the reception of a shot perforation of the bladder, with fracture of the pubis. Bits of necrosed bone had been discharged through the urethra. At the autopsy, two large phosphatic calculi of homogeneous composition were found in the bladder. They are represented in the first figure of Plate VIII, and the particulars of the case will be found in the series of the fatal shot perforations of the bladder. Surgeon J. J. Chisolm, C. S. A., also had a case of this description, in which he successfully performed lithotomy, and had the kindness to present a section of the calculus1 to the Army Medical Museum. Dr. Chisolm has detailed the case in his excellent manual.2 Tlie concretion is shown in Fig. 3 of Plate VIII. Case 808.—Private II. S. Moore, Co. E, Palmetto Sharpshooters, was wounded at Frazer's Farm, June 29, 1862. The ball notched the crest ofthe right pubic bone and escaped through the right buttock. Urine escaped through both orifices, none by the urethra. The exit wound closed in a few weeks; the entrance wound was maintained as a urinary fistula until the date of operation, in May, 1863. During this period bits of bone and calculous matter were discharged through the urethra. In December, 1862, symptoms of stone. The communication of the fistula with the bladder was very direct. With some difficulty Dv. Chisolm removed an encysted calculus, formed about a pasty nucleus, with no trace of a foreign body (Spec. 4712). The abdominal sinus healed promptly after the operation, and the patient rapidly recovered. As there is no mention of a foreign nucleus in the following case, it may be inferred that none was observed: Case 809.—This case is fully reported3 by the operator, Dr. R. L. Madison, in the Richmond Medical Journal. The leading facts are as follows: "Sergeant S. F. P------, Co. C, 1st Virginia Cavalry, aged 25 years, was wounded at Front Royal, August 16, 1864. A ball entered above the left trochanter major, perforated the ischium and bladder, and lodged subcu- taueously on the anterior surface of the right thigh. It was removed through an incision by Surgeon Owen. Urine passed through the wound. At the expiration of a fortnight, Dr. Dorsey introduced and maintained a catheter in the bladder. In February. 1865, the patient was convalescent from his wound, but symptoms of calculous disorder had appeared. On May 19th, Surgeon R. L. Madison performed bilateral lithotomy and removed a soft calculus, which was crushed in extraction. The patient made a good recovery." The concretion is described as large and friable. The following instance of successful lithotomy, by Dr. Benjamin \V. Robinson, for the removal of calculi consequent on a shot wound of the bladder, belongs either to this category or to that embracing calculi with nuclei of bone. The concretions are stated to have been composed of phosphate of lime. The abstract is abridged from a report by Dr. Fessenden:4 Case 810.—Private John TV. Gardener, Co. F, 24th North Carolina, aged 25 years, was wounded at the battle of Freder- icksburg, December 13, 1862. A conoidal musket ball entered just above the pubis and passed out through the body of the ischium. He was sent to a hospital at Richmond, and, a week subsequently, was sent to his home in Cumberland County, North Carolina. He was admitted to the Fayetteville Hospital, November 1,1863. Urine passed through the orifices of entrance and exit; there were bed-sores, with extreme emaciation, debility, and pain. With careful treatment the general condition 1 The specimen is one-half of a nearly globular vesical calculus an inch in diameter. It weighs fifty grains Troy; the original weight of the entire calculus is unknown. Its exterior is of a slightly reddish gray, soft, porous, and granular. It is seen to be composed of a homogeneous struct- ureless mass, presenting to one side of the centre a comparatively large irregular cavity, which was originally filled with a soft pasty mass forming the nucleus of the calculus. It is of a muddy gray color, soft, granular, porous, and structureless throughout. A small quantity of the dust from the calculus heated on platinum blackened and cleared up with some loss, and dissolved in hydrochloric acid without effervescence ; the solution neutralized with ammonia and treated with oxalate of ammonia gave no precipitate. A fresh portion was soluble in boiling water to the extent of about one-third of the quantity used; the residue was insoluble in liquor ammonia?, but readily dissolved in acetic acid, from which it was precipitated by ammonia as a gelatinous deposit containing numerous crystals of triple phosphate. The solution in boiling water gave a deposit on cooling; boiled with liquor potassae it gave oif ammoniacal vapors ; treated with hydrochloric acid it gave a precipitate which, under the microscope, was found to consist of crystals of uric acid. It may be inferred that about two-thirds of the calculus consisted of triple phosphate, and one-third of urate of ammonia. 'Chisolm (J. J.), A Manual of Military Surgery, 3d ed., 1864, p. 35:2. 3 Report of a Case of Gunshot Wound of Bladder, with Recovery, followed by Calculus. Its successful Removal by Lithotomy. By It. L. Madison, JI. D., late Surgeon Virginia Military Institute,—in the Richmond Med. Jour., 1866, Vol. II, p. 487. 4 Fessenden (B. F.), Report of Surgical Cases in General Hospital, Fayetteville, North Carolina, in the Confederate States Medical and Surgical Journal, 1864, Vol. I, p. 115. . 280 INJURIES OF THE PELVIS. iCIIAP. VII. improved until, on November 10th, it was deemed prudent to explore the bladder, when the instrument came in contact with a calculus with a sharp, clear, wry audible sound. The urine gave a white deposit, which was found, on analysis, to consist of phosphate of lime. The patient was put on a course of tonics, with mineral acids and a moderate allowance of stimulants. On February 13. 18f>4. Dr. B. W. Robinson, in the presence of Drs. Haigh, McRae. and others, practised bilateral lithotomy, using Dupuytren's lithotome, and four calculi were successively and readily extracted. The largest weighed an ounce; the aggregate weight ofthe four was two and seven-sixteenths Troy ounces. The operation was followed by the happiest results. The wound of operation and the entrance wound soon healed. May 2, 1834, convalescence was so far established that the patient, greatly improved in health, was able to walk about. There was a slight fistula at the exit orifice, but no urine passed through it, and health and strength were in a great measure restored. [In a letter to the editor, dated Fayetteville, December 3, 1873, Dr. B. W. Robinson says: "I regret my inability to send you the calculi taken from Gardener. My office was sacked about the close of the War, and these and many other treasured objects were scattered and destroyed. The subject of the operation, who lives not very far from here, is a hale, hearty man. He has married since, and has several children."] Bits of clothing driven into the bladder were ordinarily eliminated by the urethra or by the wound-canal; but in one instance, occurring in the practice of Surgeon D. W. Bliss, U. S. V., a foreign body of this description became the nucleus of a calculus.1 This concretion is represented by Figure 4 of Plate VIII. The facts of the case, as compiled from the reports of nine surgeons,2 are as follows: Case 811.—Private Sherman C. Perry, Co. B, 16th New York, aged 27 years, was wounded near Salem Church, in General Sedgwick's advance at the battle of Chancellorsville, May 3, 1863, and made a prisoner. A conical ball penetrating his canteen, entered the groin, and, passing backward and to the right, made its exit at the right lesser sciatic notch, lodging under the skin. His body was inclined forward when he was struck, and he fell to the ground on receiving the wound, and believes that there was copious bleeding. He soon rose and walked forty rods to a small house. On May 7th, the ball was extracted by one of the medical officers of the 121st New York, who was also a prisoner, and who continued in attendance until May 12th, when Perry was taken with others to United States Ford, paroled, and delivered to the provost marshal, and placed under the care of Surgeon L. W. Oakley, 2d New Jersey, at the Sixth Corps hospital at Potomac Creek, who reported that no urine was passed by the urethra for eight days, but that blood and urine passed freely through the wound. Surgeon II. Janes, U. S. V., remarked that "the hall entered the left groin,3 passed through the bladder, and emerged through the right sciatic notch," and that " the urine passed through the anterior wound till May 29th, through a catheter kept in the bladder." At the end of May, Dr. Janes reports that "the wound is now healing." On June 13th, the patient was sent to Washington on a hospital transport steamer, and entered Armory Square Hospital the same day. Surgeon D. W. Bliss, U. S. V., reported that " the wound had nearly healed. A flexible catheter was constantly retained in the bladder for about four weeks previous to his admission, and continued for three or four days afterward, about which time, on withdrawing the catheter, a piece of blue cloth immediately followed, which was rolled upon itself, and was being very nicely encrusted with fine sand, serving as a nucleus for the formation of a stone. On June 21st, and after the introduction of a catheter, a small flat piece of bone passed through the urethra. It was well known that something yet remained in the bladder from the fact of his having pain and difhculrv in urinating, and at times the urine would suddenly cease to flow ; which condition of things continued until July 21st, wlief he experienced unusual pain in attempting to urinate, and the cause soon became apparent in the shape of a stone, measurinp about three-fourths of an inch long and half an inch in diameter, which resembled a peanut more than anything else in size; shape, and color. He suffered very severe pain during its passage to the fossa navicularis, from which place it was extracted with a small forceps." On September 9th, the evidence of further deposits in the bladder being conclusive, and giving the patieni trouble, Dr. D. W. Bliss, surgeon in charge, performed the lateral operation for stone, and removed a soft calculus of a flat oval shape, three-fourths of an inch long, one-half inch wide, and one-fourth inch thick, the nucleus of which seemed to be cloth.4 Weight, twenty-three grains. " September 19th: The patient has done well up to date." On October 28th, the patient was transferred to New York, and admitted to DeCamp Hospital. Assistant Surgeon J. Sim Smith, U. S. A., reports him conva- lescent from a shot wound of the bladder, and furloughed October 31st. Acting Assistant Surgeon Mason F. Cogswell reported Perry as admitted to the post hospital at Albany, November 3, 1863, with a "gunshot flesh wound of the abdomen," and aa 1 Examples of calculi formed about cloth or textile fabrics are extremely rare: 1. NICOLAS TULPIUS (06s. Med., 1716, Lib. Ill, Cap. IX, p. 195) relates the case of a West Indian youth, who had been gored by a buffalo in the hypogastric region, with lesion of the bladder. The wound healed, but calculous symptoms supervened and lithotomy was performed, and a stone removed having as a nucleus a piece of lint, a part of a tent used in dressing the lacerated wound. 2. HUTIN (Mim. sur la nicessiti d'extraire les corps etrangers, 1851, p. 16, Obs. IV) relates the case of Marsat, shot, in 1808, above the right pubis, the ball perforating the bladder and emerging at the left buttock. Urine passed at first through both wounds, which after- ward gradually closed. In 1827, Pasquier, aided by Yvan, practised lithotomy and removed three calculi, each with a piece of cloth as a nucleus. 2 Portions of the history of this case have been published by W. H. Butler, M. D. (Buffalo Med. and Surg. Jour., 18(i4, Vol. Ill, p. 459), and republished by H. A. Bobbins, M. D. (Am. Jour. Med. Sci., 1868, Vol. LV, p. 124). 3 Surgeon H. Janes, U. S. V., and Pension Examiners T. B. SMITH, C. C. Bates, and S. L. Paumelee state that the ball entered the left groin, which is, doubtless, true (see Cat Surg. Sect, A. M. M., 1866, p. 493). Acting Assistant Surgeons W. II. IHtlek and II. A. ROBBINS describe the entrance orifice as on the right side. Drs. Bliss, J. S. SMITH, and M. F. COGSWELL do not specify the point of entrance. 4 This specimen consists of a flattened ovoid vesical calculus measuring \% X ie X Ttf inches, and weighing 23 grains Troy. Its exterior is of a light reddish-gray color, compact, and smooth, but extremely soft and granular. It has been broken open and is seen to be composed of a nucleus and one coat. The nucleus comprises about one-half of the whole calculus, and is composed of matted cotton cloth mixed with crystals < f triple phosphate. (Mic. Spec. No. 161, S. S.) The coat of the nucleus is made up of numerous concentric laminae, and is very friable. It agrees with the description of the exterior in physical characters. A small quantity heated on platinum blackened but cleared up with little loss, and dissolved in hydrochloric acid without effervescence. The solution nearly neutralized by ammonia, and heated with oxalate of ammonia, gave no precipitate. Under the blowpipe it is infusible. A fresh portion was insoluble in boiling water and liquor ammonia, but was entirely soluble in acetic acid, from which it was precipitated by ammonia as a gelatinous deposit containing numerous ciystals of triple phosphate.—(Mic. Spec. 162, S. K.j (Spec. 1687, Surg. Sect.) ! ■ *<> W: '*; W ;>&■ ■•SM-. :"4' I." "'° *''• ''* ■■'"'*# *A ''■■■• •• . '•,:-%' !♦.• ■-. ' ■■•Vv. 8* ^■v: * Mm' & :;- PUp,^v "■/*■ 4.- :*.:•:. ■-.•. .*^:f. .1 REMOVtO AFTER SHOT * ri^:> Dr l< 1 Weirs <„,,-iS"..... . ,.;■■ ed i- i ■:.- "•.' rlViCC, lUl't 1 '<:' !•' • .>i:alp CO.IIjJ L'reatlv i It, mid [A. H r ;st'iii k•(■•!, :itm ' i:.'ii " ;d ,.f M:iv, Dr. Ki. t he ban;.; n- < .■ ii . ivi. i >"o ^ ■■■- l.'-CUig. H ■ , I ' rii< em of ihi . .'■:-.: •.; ..at i. o,ti '.;<• ( , Lht.ldoj ." A! :\,v ■ \\'a-iiii i^ton oi. a ^ >.»''' ■ .-(-.a ti..,t .■■ *:v .' of ;; i.io.v . .••ifapuniiu liin;-.' 't.:v "ii •,■■■• • e:se iii size ■■•in wh'-ih , ■! • ■ ; vi* t:xtra«w i -.mk losive. Li. i :' r:.: i\;:-. ;>-. ti'-ni ov.d a-olt -.-.: .......ll«i...... ml,;. J .-i nit i.'i.l • tlij- ■ li.- ••'.-■. , rit Med and Surg Hist ofthe War. of the Rebellion. Part H Vol.1. Plate VTJI.opp page 280 Ward, phot. J. Bien, Lith. VESICAL CALCULI REMOVED AFTER SHOT WOUNDS. FiS.l. SurgJD.WBliss's Case (Spec25G7) Fi£.3.Prof..7.J. CTusoWs Case (Spec 4713) Yi'2'1 Dr. H.M1' (mires Case (Spec.5041) Fig.4. Dr. D.W. Bliss's Case (Spec.1687 ) Fi£.5.Dr. R.F. Weirs Case (Spec 6211) SECT. II.] VESICAL CALCULI CONSEQUENT ON SHOT WOUNDS. 281 "discharged from service January 22, 1SJ4." This soldier was pensioned. Examiner T. B. Smith, of Washington, reported, April 2, 1804: "Ball entered above left pubis, perforated the bladder and pelvis, and passed out ofthe right buttock. Operation for stone in the bladder was done, and the nucleus found to be a portion of dress carried thither by the ball. He has now lameness of the right lower limb and incontinence of urine. General health good; disability two-thirds; will probably improve." Examiner C. C. Bates, of Potsdam, reported, September 12, 18.i,">: * * "There is lameness in the back, extending down the left thigh as far as the knee; the left thigh has a palsied feeling, lie has never been free from a burning pain extending from the scar in the left groin into the bladder; hips are very weak; the bodily health otherwise pretty good." The same examiner reported, November 21), 16'o'J, that this pensioner "suffers severe pains, every two or three weeks, in the abdomen, and excessively severe in the bladder and urethra, extending to other parts while passing water. There is always much trouble in urinating, and during these exacerbations he can neither lie, sit, nor stand still. He has used uva ursi infusion every day during the past year, consuming nearly five pounds of the leaves. His urine leaves always a wliitish sediment, and sometimes contains pure blood. All these symptoms have increased since his discharge. The disease is permanent. * * He works a little at the carpenter's trade. * * The paroxysms last several days." On September 10, 1872, the same examiner reports that this pensioner "has chronic cystitis, following gunshot wound of the bladder. Frequently the pain in making water becomes intense and burning. * * The kidneys are now diseased. * * The pensioner's habits are correct." On September 5, 1873, Examiner S. L. Parmelee, of Gouverneur, after describing the wound and operation, adds that this pensioner "still has symptoms of stone; occasionally passes blood; a good deal of sediment in the urine; also tenderness ofthe abdominal scar, and of the inside of the thigh. His disability continues total." In one instance, recorded1 by Dr. Thomas M. Markoe, in his important paper on Median Lithotomy, a tuft of curly hair, carried from the right pubic region into the bladder by a ball, formed a nucleus of a calculus, the ball itself passing through and emerging at the left sciatic notch. The following is Dr. Markoe's interesting narrative of the case: Case 812.—"Henry Smith, a German, aged 30 years, was admitted to the New York Hospital about the middle of August, 1863, with some symptoms on the part of the bladder, which had followed a wound of that organ, received August 9, 1862, at the battle of Cedar Mountain. The ball had entered in front, a little to the right of the median line, about an inch above the pubes, passing through the part of skin covered with hair. It passed nearly through the body, and was cut out behind over the left sciatic notch, through which it had probably taken its course. For a week, urine flowed out through both wounds, but, after a long course of tedious suffering, the opening gradually healed, and has since remained soundly cicatrized. Owing to some difficulty in passing water, which the patient cannot explain, the catheter was employed daily during ten months. The act of micturition continued to be painful, with great irritability of the bladder, and, in fact, all the symptoms of stone gradually developed themselves. On admission, his general condition was feeble and irritable, with great distress in the region of the bladder, urine dark colored and containing a good deal of pus. A sound immediately detected the presence of a calculus, apparently of large size. The median operation of lithotomy was performed on the 25th of August. The incision was carried well back and made quite free, under the conviction that the stone was of considerable size. The prostate was easily dilated and the forceps readily seized the stone, but, unfortunately, in attempting to extract it, it broke, and the numerous fragments required frequent introduction of the instrument for their complete removal. By care and patience, however, the bladder was entirely cleared, and well washed out by a stream of warm water. The haemorrhage was quite insignificant. August 25th, has been very comfortable, and has had some good sleep. His urine did not flow for about three hours after the operation, and then, by a voluntary effort, he passed several ounces through the wound. Since then it has dribbled away most of the time, though he has partial control of it. August 28th, can hold his water four hours without inconvenience. There is now no dribbling from the wound. When he wishes to pass water, a large portion of it comes through the urethra. From this time his progress was not interrupted by a single bad symptom. The water all passed by the urethra at the end of a week. The wound healed rapidly, aud he was discharged, cured, about the end of September. The stone was found to have for a nucleus a tuft of curly hair of the pubes, which had been carried into the bladder by the ball and there left, while the ball itself passed through." In the twenty-one foregoing lithotomy operations, seventeen were successful, three fatal, and, in one, the result has not transpired. Of thirteen cases in which missiles were removed, there were ten in which these were leaden bullets, three of the round, and seven of the conical variety; six of the ten balls were very slightly encrusted, while four formed the nuclei of large stones. In three cases the projectiles were of iron, a canister- shot, a grenade fragment, and an arrow-head, all coated with thick calcareous depositions. In eight cases, in which bone, cloth, hair, or soft organic matters had constituted the nuclei, the calculi were of medium or large dimensions, and commonly very friable. In six cases of this last series, of what may be termed traumatic calculi, there were no obvious contra-indications to lithotrity. In all of the encrustations and concretions the ammoniaco-magnesian phosphate prevailed, and several were almost exclusively composed of this triple salt; in others, phosphate of lime, urates, and organic matters were present ■Markoe (T. M.), Median Lithotomy, in New York Med. Jour., 1867, Vol. V, p. 23. 36 ■>vO INJURIES OF. THE PELVIS. |CIIAP. VII. in limited proportions. The remark of Marcct,1 that vesical concretions of this sort are uniformly of the fusible species—composed, that is, of nearly equal proportions of phosphate of lime and of the triple phosphate of ammonia and of magnesia—is not sustained by my observations, which rather tend to show that, in such concretions, the bone-phosphate is often altogether absent, and that the triple phosphate uniformly predominates. It may subserve the convenience of the reader to have the dates and principal circumstances of these operations in a tabular form. Table VIII. Descriptive Numerical Statement of Twenty-one Cases of Lithotomy for the Extraction of Projectiles or Traumatic Vesical Calculi. Datb OF— NO. Patient. Operator. Injury. Operation. Result. Authority. Injury. Operation. 1 Sept. 17,1862 Sept. 25,1862 Lieut.W. Palmer, E. 35th Mass. Dr. G. M. McGill, A. S. Shot wound over left pubis. Supra-pubic Died Oct. 13, 1862. S. G. O. Records. 2 Oct. 4, 1862 About Nov. 20, 1862 Unknown soldier. Dr. Felton....... Shot wound above right pubis. Supra-pubic. . Died24h'rs after op'n. WALLIs.in Nash.Med. Jour., 1867, II, p. 502. 3 July 2, 1863 April 12, 1866 Priv. T. Lindsay, F, 69th Penn. Dr. J.L.Forwood. Shot wound of pelvis.. Lateral...... Recovery.. Circ.3,8. G. O., 1871, p. 259. 4 Mar. 31,1865 April 16,1870 Priv. T. S. Mason, 198th Penn. Dr. J.L.Forwood. Shot wound through pubic arch. Lateral...... Recovery.. Ibid, p. 261. 5 In April, 1864 Feb. 22,1868 J. Mitchell....... Prof.J. C.Hughes. Shot wound of sacro-iliac junction. Bilateral..... Recovery.. Iowa Med. Jour., 1869, V, p. 98. 6 June 25, 1863 April 2, 1864 Priv. C. Lotes, A, Surg. J. F. Ran- Shot wound at end of Lateral...... Recovery.. Am. Jour. Med. Sci., 23d Indiana. dolph. coccyx. 1864. p. 271. 7 April 2, 1865 Aug. 31,1868 Priv. VV. Cockroft, D, 199th Penn. Dr. A. N. Dough-erty. Shot w'd over pubes... Lateral...... Recovery.. Circ.3, S. G.O., 1871, p. 259. 8 July 2, 1863 Nov. 25,1871 Priv. F. H. Mcin-tosh, A, 1st Mass. Dr.Samuel Cabot. Shot wound of pelvis.. Lateral...... Recovery.. Boston Med. and Surg. Jour., 1872, p. 169. 9 July ] 8,1863 .........1873 Col. A. C. Voris, Dr.J.W.Hamilton Shot w'd in left groin. ( ? ) ( ? ) Akron Beacon. 67th Ohio. 10 Aug. 30,1862 Aug. 3, 1867 Priv. G. L. Shrimp, Palmetto SS. Prof. F. T. Miles. Shot w'd left of spine.. Lateral...... Recovery.. Operator's report. 11 May 5, 1864 June 1, 1873 J. J. Canady..... Dr. J. F. King... Shot w'd thro' leftilium Lateral...... Recoverj'.. S. G. O. Records. 12 In 1867 Dec. 3, 1870 John Ely........ Prof. H. McGuire. Shot wound near right trochanter. Lateral...... Recovery.. Virg. Clin. Rec, 1871, p. 46. 13 Iu 1862 Aug. 23,1869 Sitamore,a Kiowa Dr. Wr. H. For-wood, A. S. Arrow w'd thro' right buttock. Lateral...... Died Sept. 19, 1869. Circ. 3, S. G. O., 1871, p. 260. 14 May 4, 1864 Aug. 18,1865 Sergt.G. F. Shaf-ford,G,83dN.Y. Dr. W. C. Living-ston. Shot wound of right groin. Median...... Recovery.. Mcd.Rec.,1861, p. 185. 15 July 28,1S64 June 29,1865 Priv. J. A. M---, F. 39th Ala. Dr. C. Terry Shot perf. of sacrum... Lateral...... Recovery.. Richmond Med. Jour., 1866, p. 169. 1G May 8, 1862 Sept., 1865 Priv. M. C H--- Prof. H. McGuire. Shot w'd of left pubis -. Lateral...... Recovery.. Richmond Med. Jour., 1868. p. 279. Chisolm, Man. of Mil. 17 J aue 29, 1862 Mav, 1863 Priv. It. S. Moore, Dr. J.J. Chisolm. Shot wound of crest of Supra-pubic. Recovery.. F, Palmetto SS. right pubis. Surg., p. 352. 18 Aug. 16,1864 May 19, 1865 Sevgt. S.F.P---, C, 1st Va. Cav. Dr. R.L.Madison. Shot perf. of ischium.. Bilateral..... Recovery.. Richmond Med. Jour., 1866, p. 487. 19 Dec. 13, 1862 Feb. 13,1864 Priv. J. W. Card- Dr.B.W.Robinson Shot w'd above pubis Bilateral..... Recovery.. Conf. States Med. and 1 en«r,F,24th N.C. Surg.J.AW4.v.llo. 20 May 3, 1863 Sept. 9, 1863 Priv. S. E. Perry, K, 16th N. Y. * Surg. D.W. Bliss. Shot penetration above left pubis. Lateral...... Recovery.. S. G. O. Records. 21 Aug. 9, 1862 Aug. 25,1863 Henry Smith..... Dr. T. M. Markoe. Shot penetration above right pubis. Median...... Recovery.. N. Y.Med. Jour., 1867, p. 23. Iu thirteen cases, the concretions are preserved in the Army Medical Museum, as follows: 1-4394; 3-6329; 4-6330; 6-88; 7-5220; 10-5019; 11-0292; 12-6203; 13-5931 ; 15-6327; 16-5041; 17-4712; 20-1687. The Museum preserves also photographs of the concretions in Cases 5 and 8. In seven instances, conical leaden balls were extracted, forming the nuclei of large phosphatic concretions in Cases 8, 9, and 12, and but slightly encrusted in Cases 1, 3, 4, and 11. In three instances, round leaden balls were extracted, with extensive deposits in Case 5, and a slight partial coating only in Casks 2 and 10. In three cases, the missiles were of iron, and were all largely encrusted (Cases 6, 7, and 13). In three concretions, formed about bone, Cases 14, 15, 16, the phosphatic depositions were large. In the five remaining cases, 17 to 21 inclusive, the concretions were of medium size, varying according to the duration ofthe calculous symptoms. Three were supra-pubic, twelve lateral, three bilateral, one unspecified, and two median operations. Lithotomy for ordinary Vesical Calculi.—To conclude what is to be said of lithotomy, a digression may be permitted to mention the operations that were reported of the removal of stones of spontaneous or non-traumatic origin. These were but three in number, and only two of them were performed on the persons of soldiers : Cask elli.—Private Michael Lannan, 5th New York Independent Battery, aged 33 years, was admitted to Summit House Hospital, Philadelphia, April 4. 1S05, with "calculus and incontinence of urine." Surgeon J. H. Taylor, U. S. V., reports that ''on April 24th, the patient was chloroformed and the lateral operation for lithotomy was performed by Acting Assistant Surgeon O. Shittler. A straight scalpel was used in dividing the several tissues and the prostate gland. Three calculi of phosphate of lime, about the size of filberts, were removed. At the time of operation the patient's constitutional condition was good. The after-treatment consisted of simple dressings, dilute nitric acid, extra diet, tonics and stimulants." The patient was mustered out on June 27. lSlw. Not a pensioner. 1 Maki'ET, An Essay on the Chemical History and Medical Treatment of Calculous Disorders, 1817, p. 75. SKCT. II. | SHOT WOUNDS OF THE BLADDER. 283 In a report on the diseases of the ."British army in the Spanish Peninsula, Sir James McGrigor remarks on the infrequency of calculous disorders in soldiers,1 and Hutchinson2 has treated of the rarity of such affections in seamen; but Yelloly3 has shown that the tendency of any particular class of persons to bo affected with such complaints is exceed- ingly small, especially during the period of active exertion in adult age.4 Cask 814.—Private Joseph Reisinger, Co. L, 8th New Vork Cavalry, aged 19 years, was admitted to Armory Square Hospital, April 22, 18(i3, and returned to duty October 21i, 181)3. In transmitting to the Museum the beautiful specimen of mulberry calculus represented in the woodcut (Fig. 230), Surgeon D. W. Bliss, U. S. V., gave the following history of the case: "Said Reisinger is a cooper by trade, born in the city of Rochester, New York, and has lived in Rochester and its vicinity until he enlisted in military service, August 30, 1S32. lie has had slight pain, on urinating, at intervals for the past five years. During these paroxysms he had constant desire to micturate, after which tliere was severe pain under the glans penis and along the track of the urethra. He was almost entirely free from the above symptoms from March, 1832, to October, 1802, when, on doing duty as a mounted man, he suffered extreme pain at every motion of the horse. Was not excused from duty at any time in consequence of his complaints of urinary trouble. He was taken ill with typhoid fever, January 1, 18(!3, and was sent to his regimental hospital at Belle Plain, and transferred to hospital at Hope Landing about February 1, 18153. On April 22, 18B3, he was trans- ferred to Armory Square Hospital. An examination was instituted on the 22d of June, and a stone detected hy means of the sound. On June 29th, lithotomy was performed by the lateral incision, the patient beini' perfectly anaesthetized by the inhalation of chloroform. No untoward symptoms j i u .j. rio *-,,.., i • • i , ,. , FlG- 230.—Mulberry eal- nave occurred to the present date, July 6, 181)3, the patient expressing himself as 'cured, but a little cuius successfully removed sore.' The wound rapidly aud kindly granulated." hi' "^"my- Spec. 1334. \ Case 815.—Surgeon Samuel D. Turney, U. S. V., reports that Peyton, a negro lad, aged 14 years, was admitted into the Murfreesboro' General Hospital, October 5, 1834, with symptoms of vesical calculus. On October 20th, Surgeon Turney performed the lateral operation, and extracted a concretion consisting of mixed phosphates, and weighing one ounce and three drachms. Urine passed by the urethra on November 1, 1864, and November 25, 1834, Peyton was discharged, cured. On November 25, 1873, Dr. Turney transmitted to the Museum a specimen purporting to be the calculus removed on this occasion; but, on examination, it was found to be a pyriform mass consisting of carbonate of lime and sand, possibly a cast of this calculus.5 Other Examples of Shot Wounds of the Bladder.—Akin to the examples of projectiles within the bladder encrusted with phosphatic deposits, is an instance of a ball, which, after perforating the bladder, lay in a fistulous track, exposed to encrustation by the urinous salts: Case 816.—Private T. Wrinans, Co. B, 28th Illinois, aged 22 years, was wounded at the battle of Shiloh, April 6, 1862. Surgeon R. Nicholls, U. S. V., reported that he was "admitted to the hospital at Quincy, May 7, 1833, with a gunshot fracture of the neck of the left femur. The ball entered three inches below and two inches behind the anterior superior spinous process of the left ilium, passed through the bladder, and lodged in the region of the sacrum. Treatment by Buck's method." This man was discharged from service December 6, 1832, with the accompanying remark over an illegible signature: "Hip anchylosed; general health good. About the fracture as above, I have my doubts." The patient receives a pension. On February G, 1872, Pension Examiner J. H. Ledlie reports, "several pieces of dead bone have been removed. Some months since a tumor presented itself near the anus. This suppurated, and upon opening it a large conical leaden ball was found, half of which was covered with what appeared to be the salts of the urine. Urine was freely discharged through the opening for several weeks. At present this is all healed. Tliere is anchylosis of the hip joint, shortening of the limb one inch and a half, atrophy of the whole limb, and constant pain along the sciatic nerve, which is much increased by walking." Disability is rated total and permanent. Extraneous Bodies Escaping by the Urethra.—It was remarked, on page 268, that several instances were recorded of the elimination of fragments of bone by the urethra, 'Compare BALLINGALL (Outlines of Mil. Surgery, 5th ed., 1855, p. 359), where Sir J. McGrigor's report is quoted; Smith (R.) (^1 Statistical Inquiry into the Frequency of Stone in the Bladder, in Great Britain and Ireland, in Med. Chir. Trans., 1831, Vol. XI, p. 1). 2HUTCHTKSON (A. C), On the Comparative Infrequency of Urinary Calculi among Seafaring People, in his Practical Observations on Surgery, 2d ed , London, 1826, p. 308. 5 YELLOLY (J.), Remarks on tlie Tendency to Calculous Diseases, in the Philosophical Transactions of the Royal Society, 1829, Part I, p. 55. 1 Medical Inspector A. L. GlHON, U. S. N., informs the editor that the records of the Naval Bureau of Medicine and Surgery show that calculus is almost unknown in the United States Navj'. COOLIDGE (R. H.) (Statistical Report on the Sickness and Mortality of the Army of the United States, 1860, p. 323) records 47 cases of calculus, in the twenty years, 1840-60, in an aggregate force of 187,144 men. WOODWARD (J. J.) (Med. and Surgical Hist of the War of the Rebellion, Part I, Vol. I, Table C, p. 641) records 2,643 cases of "stone and gravel" among the white troops in the period 1861-66, in an aggregate of 5,825,480 cases of disease, and (Table CXI, p. 712) 359 such cases in an aggregate of 629,354 cases of disease among the colored troops, in the period 1864-66. It is probable that not only instances of calculus and of sabulous urinary depositions were returned in this category, but many cases of dysuria of almost every variety. 5 Dr. Turkey was naturally deceived by the concretion forwarded to him from Murfreesboro', externally resembling the uric acid calculus he had removed. In a letter to the editor, this surgeon laments that he is "the victim of blunders," and refers to page 289 of the First Surgical Volume, in which, in a case of trephining, he is by implication made responsible for the statement "a silver plate was inserted." Dr. TUKNET assuredly made no reference to this absurd popular superstition, the statement appearing on a case-book of hospital No. 2, of Nashville, February 25, 1865, having apparently escaped the vigilance of the officer in charge, Surgeon J. E. Herbst, U. S. V. 281 INJURIES OF THE PELVIS. [CHAP. vir. though none were reported of the passage of small bullets by that canal. Two years after the War, Assistant Surgeon J. V. Lauderdale observed a case of the latter variety: Case A8.—Private John Rich, Co. M, 2d Artillery, aged 22 years, was admitted to the post hospital, Presidio of San Francisco, California, on August 4, 1867, suffering from the effects of a pistol ball fired by a barkeeper, who shot at him while his back was turned toward him and at a distance of ten feet. " The ball entered the pelvis at a point exactly midway between the posterior superior spine of the ilium aud the tuberosity of the right ischium. There was but little haemorrhage from the external wound. The patient was conveyed at once to the hospital, about half a mile away from the scene of the affray. An unavailing attempt was made to find the ball by probing the external wound. There being no unusual pain or other discomfort from the presence of the ball, its extraction was not again attempted. Hopes were entertained that the ball did not go deeper than the bone, and had probably rebounded. Soon the patient had an urgent desire to void urine, but without being able to do so. A catheter was introduced and a pint of bloody urine was brought away. A few hours later the desire to urinate recurred, and the same atony ofthe bladder existed. The catheter brought away a quantity of urine, but less tinged with blood than that first removed. The patient complained of a little pain in the region of the external wound, which was readily quieted by small doses of morphia. Cold-water dressings were applied, and the wound presented nothing more than a slight puncture of the integument. August 9th: The bowels were moved to-day with an ounce of castor oil; the wound has a healthy appearance, with but little discharge of healthy pus; the bladder has Fig 231.—Pistol recovered its normal tone, and the patient passes healthy looking urine; when the catheter was introduced the ball voided by last time yesterday, it came in contact with a foreign body, supposed to be about the size and weight of the the urethra. Spec. . . .,,,, „,, , „ ■, , . , , , i i • i i • •• • i * 0;>82. i missing pistol ball. August 10th: To-day the patient observes, when he would void his urine in an upright position, that some obstruction offers itself, but meets with no difficulty if he makes water while lying in a horizontal position. It was thought to be too soon for any operation for the removal ofthe foreign body by lithotomy, as injury might be done to the tissues recently penetrated by the ball. August 19th : This afternoon, while the patient was urinating, he felt a foreign body engaging itself in the lower portion of his urethra, and which caused the flow to cease; making a straining effort he drove this body so near the meatus that he could feel it on the under side of the penis with his fingers; by a little manipulation he succeeded in urging it along the urethral channel nearly to the meatus; here the canal proved to be too narrow for its further progress; a thin narrow-bladed bistoury was passed in the meatus and carried flatwise past the body, then its edge slightly turned upon the constricting fibres of the urethra; a little cutting sufficed, and a delicate pair of forceps being passed down and engaging the body, the missing pistol ball (FlG. 231) was extracted; weight of ball, eighty-four grains; patient recovered without a single unfavorable symptom, and, on the 2d of September, was doing duty in the light battery." As indicated on page 268, the escape of fragments of bone by the urethra was more common. It will be remembered that this took place in Oases 808 and 811, in which cystotomy was subsequently practised.1 In a fatal case, to be detailed hereafter, the case of Mahay, pieces of bone were discharged through the urethra; in another case, large bone fragments (Plate VIII, Fig. 5) occupied the cavity of an abscess connected with the urethra ; and in a third case, bone fragments impacted in the urethra were extracted, by Dr. Thomas Gr. Morton, by perineal section. In the following case, the escape of scales of bone persisted for a long period : Case 817.—Private A. Rennicker, Co. D, 209th Pennsylvania, was wounded at Petersburg, March 25, 1865. He was treated in a field hospital, where Assistant Surgeon Samuel Adams, U. S. A., reported as follows : " Gunshot penetrating wound of the bladder; the ball entered the left groin and passed out through the left buttock; urine came through the wound of entrance; no fever; tongue clean ; sleeps well; appetite good; no pain in the wound." Treated also in the Fairfax Seminary Hospital, and in the McClellan Hospital after May 21st. This soldier was discharged June 29, 1865, and pensioned. Examiner E. A. Smith reported on that date that " the ball entered the left iliac region and passed through the bladder, and out at the middle of the right buttock; he now passes calculi, and suffers great pain iu the left testicle." His disability ceased in September, 1887, but subsequently appears to have returned, as Examiner J. S. Suesserott, of Chambersburg, reported, September 4, 1873, that he was " still passing small pieces of bone through the urethra, and that the left testicle was subject to periodical swellings." The disability was rated as total. It has been already shown, on page 277, that the frequency of the presence of bone, as a foreign body in the bladder, has been underestimated.2 1 In Cases 785 and 800, bone fragments were removed with the projectiles; and in CASES 784, 783. and 789, fragments of bone were removed or escaped, but probably through wounds or fistulous tracks. See Note 2, p. 268, supra. 2 To the nineteen instances of bone fragments in the bladder adduced on pp. 277 et seq., the following may be added: 1. ASTIEll (Des corpi itrangcrs, qu'on a trouvi dans la vessie, servant de noyau a la pierre, These a Paris, 1839, p. 18) relates the case of a girl who had dysuria after a fall, with fracture of the ischium, and passed several bone fragments by the urethra. Eight years afterward she underwent lithotomy, and two calculi with nuclei of bone were extracted. 2. WARNER (Cases in Surgery, London, 1760, p. 221, Case XXXV) relates a case in which he removed from the bladder of a woman a calculus the size of a pigeon's egg, having a piece of bone as a nucleus. The concretion broke in removal, and the bone fragment was found to weigh sixteen grains. 3. Professor BUHL (Blasenstein mit einem Knochenfragment als Kern, in HEXLE und PFEUFFEU, Zeitschrift fur rationelle Medicin, lt".9, S. 82) records the case of a farmer of 29, stabbed in the right buttock, the knife penetrating the rectum and bladder. The wound healed in four weeks; but the man never recovered his health, and died after four years. In the bladder was found an adherent cicatrix and a calculus weigh- ing six and a half ounces, and having as a nucleus a piece of bone one by two centimetres. Near the cicatrix, the pelvis was carious. SECT. II.] SHOT WOUNDS OF THE BLADDER. 285 Iii two Confederate cases, recorded respectively by Dr. J. Theus Taylor1 and Dr. John D. Jackson,2 the passage of fragments of bone by the urethra in the course of convalescence is described. The original reports, from which the following brief abstracts are condensed, may be profitably consulted: Case SIS.—A Texan soldier was wounded at Mansfield, April 8, 1864. The ball notched the symphysis pubis and emerged at the left side of the coccyx. Neither the urethra nor rectum were injured, but urine escaped freely from both orifices. The constitutional symptoms were grave for some days. A gum-elastic catheter was maintained in the bladder, though frequently withdrawn and cleansed. The entrance wound healed in four, and exit wound in eight, weeks. After its closure there was cystitis from the presence of foreign bodies, and Dr. Taylor was repeatedly "on the point of cutting into the bladder to relieve it of the foreign bodies that were evidently the cause of the trouble, but concluded to wait and try systematic dilatation of the urethra. One morning, a large-sized bougie having been introduced, and the urine having been long retained, the patient was made to stand up and lean forward so as to enable him to exercise the greatest possible ejaculatory power. The bougie was then withdrawn, and was followed by a wad of foreign matters, consisting of portions of clothing3 and of bone, which was violently projected from the bladder with a torrent of urine. For several days smaller particles came away." The youth then rapidly recovered, and went home cured in July, 1861. Case 819.—Private Michael Tipps, Co. A, 17th Tennessee, aged '21 years, was wounded at Mill Spring, January 19,1862. Surgeon W. A. Gentry, of his regiment, stated that a ball traversed the pelvis, through the sacrum and horizontal ramus of one of the pubic bones, perforating the rectum and bladder. The patient was transported in an army wagon one hundred and sixty- five miles over a very rough mountainous road to Winchester. Urine and faeces and many bone fragments passed through both orifices for several weeks, and then the wounds gradually closed. Dr. John D. Jackson examined this man for discharge, November 26, 1863, and found the wound cicatrized. The patient stated that after the orifices closed he passed small pieces of bone through the urethra, and that even then, twenty-two months subsequent to the injury, bits of bone were occasionally passed by the canal, and he displayed several pieces of spongy bone corresponding with the cancellated tissues of the pubic bone. When it is remembered that, of thirteen cases in which projectiles were removed from the blad- der, there was probably direct complete penetration in six only, and that in seven cases the missiles entered by ulcerative absorption, and, in two in- stances, were extracted within the last year, and further, that the escape of small necrosed seques- trte has been observed many years subsequent to the primary injury of the pelvis and bladder, it may be inferred that instances of calculi formed on bone fragments or balls may still be looked for among the invalids surviving shot wounds in the pelvic region, of whom, according to the last report of the Pension Office, a considerable number remain on the rolls. The comparative frequency with which missiles, after 1 Tayloh (J. T.), Gunshot Wound of Bladder, Recovery, in the Southern Jour. Med. Sci., 1867, Vol. II, p. 28. 2 Jackson (J. D.), Gunshot Wound of Bladder and Rectum, in the Am. Jour. Med. Sci., 1869, Vol. LVII, p. 281. Jl. It will be remembered that in the elder CLINE's case of cystotomy for the removal of a ball (page 269 ante, Note, Obs. 8), a roll of shirting and cloth was discharged from the urethra prior to the operation. 2. Hennen (Princ. Mil. Surg., 3d ed., p. 426), remarking that "if extraneous matters carried into the bladder are of a soft and yielding nature, or of a small size, the natural flow of the urine often carries them out," adduces the instance of John Rowan, 50th Regiment, wounded at Vera in the Pyrenees, July 25, 1813, the ball passing through the skirt of his coat and entering the body above the tuberosity of the left ischium; the wound healed, and 138 days from the date of its infliction, after drinking to excess of the wine of the country, after straining for a half hour, he shot out from the urethra a substance coiled up in the shape of a fragment of bougie, nine lines in length and three in breadth, which proved to be a faded red piece of cloth with its lining; its texture was unaltered, and there was no calculous deposit on it. Guthrie (Comm., 5th ed., p. 605, and Lectures, Case 98) also adduces this case : "A soldier of the light division, etc." 3. Colles (Lectures on the Theory and Practice of Surgery, Am. ed., Phila., 1845, p. 133) records a case in which, "after a deal of effort, a piece, or rather two pieces, of cloth, which were rolled up into a ball and had lodged in his urethra, were shot out." This is the case of the Irish gentleman from whose bladder Colles removed a ball (Compare Case 13 in Note on p. 270 ante). Colles claimed the case in his sixteenth lecture, and exhibited the ball, which bore no marks of encrustation. 4. Quite recently, M. Pekmn (Gaz. Mid. de Paris, 1872, T. XXVII, p. 600) reported to the Surgical Society of Paris the case of a man of 40, impaled on the broken leg of a chair, which penetrated the base of the bladder through the rectum. Thirty days subsequently, the recto-vesical laceration was healed. A fortnight subsequently there was retention, relieved by the expulsion, after severe straining, of a roll of cloth, a fragment of this man's trousers. Henle (J.), Handbuch der Eingeweidelehre des Menschen, Braunschweig, 1866, B. I, S. 332. FlG. 232.—Median section of the lower part of the bladder. showing the outer and inner muscular and the mucous coats, the long muscles of the urethra and the orifice of the latter, the muscles of the trigonutn vesicae, the external and internal sphincters, the prostate gland with its sinus, the right vesicula seminalis, and beginning of the vas deferens. [After HENLE.]4 2S<3 INJURIES OF THE PELVIS. [CHAP. VII. traversing the pelvic parietes, are arrested in the wall or cavity of the bladder, is accounted for not only by the loss of momentum of the projectile, but by the sudden contraction of the bladder, and by the resistance of the urine it may contain. In the larger proportion of cases, the ball moves with sufficient velocity to surmount these obstacles and to produce a double perforation. If the perforation interests a part of the bladder covered by peri- toneum, there is no reason to anticipate other than a fatal termination; but if both orifices are below this, and free egress for the urine is provided, through a catheter or through the shot tracks, recovery may be looked for, under favorable conditions, in a considerable proportion of the cases. As was illustrated on page 267, the recoveries are for the most part incomplete. Here are two examples, however, of shot wounds of the bladder, in Confederate soldiers, where very perfect recovery is alleged :2 Case 820.—Dr. 11. Barkesdale relates1 that he saw a Confederate soldier of a North Carolina regiment, wounded at Fredericksburg, December 13,1862, who had walked a mile and a half to the rear of Marye's Heights after receiving an antero- posterior slrot perforation of the bladder, the ball entering the white line half an inch above the pubes, and emerging through the middle of the sacrum. Urine escaped from both orifices, and could be expelled also from the urethra. A gum-elastic catheter was introduced and retained in the bladder, and a quarter of a grain of morphia was given. No bad symptoms ensued. In four weeks both wounds were healed, and the man walked to Hamilton's Crossing on his way home, being allowed three weeks' furlough before resuming his military duties. The absence of particulars ofthe ulterior history of this unknown soldier, and the remote date at which the facts were chronicled, detract from the value of this otherwise interesting narration. Case 821.—Private John L. Fore, Co. H, 14th Virginia, aged 35 years, was wounded at Gettysburg, July 3, 1863. Acting Assistant Surgeon James A. Newcombe reported that " a ball entered the posterior and inner aspect of the right natis, and emerged through the scrotum on the left side." The motions and urine passed through both openings and also through the natural channels, the urine escaping in the alvine discharges. There was little haemorrhage. Surgeon Henry Janes, U. S. V., observed the case and reported it as a "wound of the perineum and bladder, with abnormal anus." Dr. Newcombe states that "profuse suppuration soon became established, but the wounds granulated healthily, and the urine had almost ceased to escape by the wound on the tenth day, the cessation being gradual; the faeces followed the same course, though more slowly. No inflammatory fever followed the injury, no catheter was introduced, and no medicine was exhibited except an occasional opiate. August 10th: At present the patient appears to be progressing rapidly toward complete recovery; the secretions pass through the natural channels. October 6th: He is fairly convalescent, and will be transferred to a general hospital." This man was sent to West's Buildings Hospital, whence Surgeon T. H. Bache, U. S. V., reports that he was paroled, November 12, 1863. 1 Barkesdale (R.), Gunshot Wound of the Bladder, remarkable Recovery, in Virginia Clinical Record, 1873, Vol. Ill, p. 367. 2 References to cases of recoveries from shot wounds of the bladder recorded in surgical annals, that have not been noticed in other connections, will be here briefly enumerated: 1. Cabrol (Alphabet, anat avec plus. obs.partie, Genevae, 1602, Obs. XXVI); a soldier shot through both walls of the bladder, at Pezenas ; CuorART alludes to the case (Mat des voies win., 1792, T. II, p. 88). 2. Riveluus (Op. med. univ., 1679, Obs. comm. No. V); soldier shot at Tarascon, through bladder and sacrum. 3. MANGETUS (Bibl. chir., 1721, T. Ill, p. 678); Reiche, a student; shot perforation of the bladder, in May, 1680. 4. Laeeey (D. J.) (Mim. de Chir. mil. et camp.); a mason at Lausanne, treated by MESLIX, for a shot wound of the bladder with injury of the epigastric artery ; there is a fuller account in Morand's Opuscules, T. II, p. 27. 5. DESPORT (Traiti des plaies d'armes a feu, 1749, p. 319); a soldier shot in the bladder, at Guastalla, September 19, 1734. 6. BORDENAVE (Pricis, etc., in Mim. de I'Acad. de chir., 1753, T. II, p. 523); a soldier treated by Poxeyes, at Charleroi, for shot wound of the bladder, August 2, 1746; PERCY refers to this case (op. cit, p. 246). 7. BOURIENXE (Jour, de Med.. T. XXXIX, p. 426); a grenadier, Lavigne, shot through the bladder, near Cassel, July 24, 1762. 8. GUERIN (MORAND, Opusc, T. II, p. 27) treated Lieutenant Corneillon, shot through the neck of the bladder, at St. Sebastian; there was much blood extravasated in the bladder; CHOPART (op. cit, p. 93) and Demarquay (op. cit, p. 308) relate this case. 9. Waltz (Graefe und Walther's Journal, about 1800), according to GUTHRIE (Lectures, p. 67), successfully treated a pistol-ball perforation of the bladder. 10. SOUTH (Notes to Chelius, Am. ed., Vol. I, p. 528) relates the case of Colonel A-----, wounded before Alexandria, a grape-shot passing through the rectum and bladder; the projectile is preserved in St. Thomas's Hospital Museum. 11. LARREY (D. J.) (Mim. de Chir. mil. et camp., 1812, T. II, p. 162); Chaumette, 22d mounted chasseurs, shot through the bladder and rectum, at Tabre, in 1799; and also 12. Case of Corporal Dacio, 9th line regiment, shot wounds of bladder and rectum, at Acre, in 1799. 13. Private Desjardines, 32d demi-brigade, shot perforation ofthe bladder, at Acre, in 1799, complicated by gangrene and fistula; and 14. (In Clin, chir., 1829, T. II, p. 520, citing from the Saltzburger Gazette); case of shot perforation of pubis and bladder. 15. (Ibid., p. 515); a grenadier, wounded in Austria, in 1809; and 16. A soldier ofthe same corps, wounded at Eslingen, a fearful shot laceration ofthe bladder. 17. HEXXEX (Princ. of Mil. Surg., 3d ed., 1829, p. 439) ; case of Labiche, 7th French dragoons, wounded at Waterloo, through the bladder; air escaped by the urethra. 18. GUTHRIE (Commentaries, 5th ed., p. 607); Captain Sleigh, 100th regiment, shot perforation of bladder, at Chippewa, July 5, 1814. 19-24. GUTHRIE (Lectures, etc., p. 66 et seq.); cases of French soldiers wounded at Almaraz, at Toulouse; of J. Sordis, wounded at Waterloo; BRUCF/s case of Thompson, 5th regiment; Boutflower's case of a cavalry soldier at Salamanca; and Captain M-----, wounded at Ciudad Rodrigo. 25. GaULTIER (in SliDILLOT's Journal, T. XL1I, p. 170); a soldier shot through the bladder, in the Valencia expedition, July, 1808; M. DEMARQUAY (p. 301) cites this case. 26. ChaMAISON (Consid. sur les plaies du Bas-ventre, Montpellier, 1815, Obs. IV, p. 13); corporal, 5th Miners, shot through the bladder, May 13, 1810. 27. l'i.EURY, cited by M. DEMARQUAY (p. 300); case of Found, a youth of 18, with a shot wound of the wall of the bladder, converted into a penetration by the separation of the eschar. 28-30. Baudexs (Clin, des plaies d'armes a feu, 1836, p. 367); A-----, 59th regiment, shot through the ilium and bladder, October 12, 1833, at Bougie; at page 384, of a soldier of the 3d regiment, shot, at Staoli, through the coccyx, rectum, and bladder; there was escape of gas and faeces through the urethra; and, at page 229, the case of Tonillier, in July, 1848. 31. PAOLI (Gaz. Med. de Paris, 1848, p. 108); case of Metti. aged 38, shot wound of the bladder, November 30, 1841. 32. M. DEMARQUAY (Mim. sur les plaies de la vessie par amies a feu, in Mim. de la Soc. de Chir., 1851, T. II, p. 324) reports an interesting case from his own practice: Oudin6, a national guard, shot through the pubis, the iliac artery, spermatic cord, and bladder and rectum, June 24, 1848; forty-one small fragments of bone, carried into tho bladder, were extracted by the forceps; after many grave complications, he recovered with a urinary fistula. DEMARQUAY reports tho same case in the L'Union Mid., 1851, p. 107. 33. B. BECK (Die Schusswunden, 1850, S. 227); a shot perforation of the bladder in an Austrian chasseur, in 1849. 34. MACLEOD (Notes on Surgery of the Crimean War, 1858, p. 274,; Private Griffith, 57th British Regiment, shot penetration of the bladder, before Sebastopol, in 1855. 35-37. CHENU (Rapport de SECT. II.] SHOT WOUNDS OF THE BLADDER. 287 The cases of recovery in the Union Army, of which precise details are accessible, with few exceptions were associated with serious disabilities; and several discharged and pensioned invalids succumbed finally to the remote effects of their injuries. Case 822.—Corporal S. D. Currier, Co. B, 4th Vermont, aged 2Q years, was wounded at Fredericksburg, December 13, 1862, and received treatment in Mount Pleasant Hospital, Washington, until March 24, 1833, and afterward in the general hospital at Brat tleboro', where he was discharged on May 11th on account of "gunshot wound ofthe bladder." Pension Examiner E. V. Wutkins, of Newbury, Vermont, reported, September 13, 1872, that " the wounds [meaning, probably, the cicatrized sinuses connected with them] were situated as follows: One immediately through the os pubis, and also through the bladder, coming out on the left side of the backbone ; one through the left testicle, and passing out also on the left side of the spine; one through the left groin, passing through the rectum ; and another in the right inner thigh. The disability consists in great irritability of the bladder, with pain in that region; an inability to retain the urine, in consequence of permanent contraction and a chronic inflammation of the neck of the bladder; also a weakness of the rectum or paralysis resulting from the passing through of the ball, very much impairing the functions of that portion of the bowels; and n loss of use of the right leg from the wound in the thigh. Finally, he has frequent calls to urinate, attended with very severe pain, especially after taking exercise or cold, and at such times is obliged to take to his boil. lie has defective circulation and symptoms of paralysis." Examiner J. T. Burns, of Brainerd, Minnesota, reported, September 1!>, 1*7:5, the injuries as described, and adds: " He cannot retain his urine, and has to use a bougie to keep the boivels open, and has partial paralysis of both legs; his disability is total." He was last paid to June 4. 1S73. Cask 823.—Private D. P. Grubh, Co. B, 48th Ohio, was wounded at the battle of Stone River, December 31,18G2. Surgeon W. P. Johnson, 18th Ohio, records his treatment for shot wound ofthe bladder, at Murfreesboro', till March, 1863, and Surgeon C. McDermont, U. S. V., reported his admission to Cumberland Hospital, Nashville, with a shot wound involving the pelvis, bladder, and rectum, and his discharge for '' recto-vesical fistula, consequent on shot wound," December 9, 18G3. Not a pensioner. Case 824.—Sergeant E. F. Yeaton, Co. D, 5th New Hampshire, aged 25 years, was wounded at Cold Harbor, June '.', 18ii4, and was admitted to the 2d Division Hospital, Alexandria, on the 12th, where Surgeon E. Bentley, U. S. V., in charge, recorded the case as a "gunshot perforating wound of the bladder, with injury of the pubic bone; ball lodged; simple dressings." He was discharged, on account of wounds and expiration of service, November 28, 1864, and pensioned. Examin- ing Surgeon J. N. Wheeler, of Dover, New Hampshire, reported, January 31, 1865: "Yeaton presents a wound of the bladder caused by a bullet. The ball entered just above the pubes in the median line and lodged, after penetrating the bladder. The wound is not yet fully healed, and he is still confined to his bed. Disability total, and uncertain as to duration." The records of the Pension Office show that this pensioner died on May 23, 1865. Camp, d'Orient, 1865, pp. 194, 195, and 205); cases of Guiol, Lallemand, and Morion, recoveries from shot wounds ofthe bladder. 38-40. CHEXU (Camp, d'ltalie, T. II, pp. 493, 494, 502); cases of Bournet, Dato, and of Grondeau, recoveries from shot wounds of the bladder; Dato had also a pene- tration of the rectum, and voided the ball at stool. 41. Lucre (Kriegschir. Aphorismen, in Laxgexijeck'S Archiv, 1866, B. VIII, S. 83) ; case at Sonderburg. treated by Dr. Volmer, tbe ball perforating the bladder and rectum, exciting but little inflammation. 42. OCHWADT (Kriegschir. Erf. wdhrend des Krieges gegen Danemark 18G4, Berlin, 1865, S. 346); case of Private G. I------, 64th Prussian regiment, shot through the rectum and bladder, June 29, 1864; pubis slightly injured, and fragments removed. 43. P. MUNDE, acting as a volunteer surgeon at WTurzburg, communicated to the Boston Med. and Surg. Jour., 1867, Vol. LXXV, p. 539, the case of John Graef, 8th Bavarian rifles, with shot perforation of the base of the bladder, received at Rossbrunn, July 22, 1866. 44, 45. F. II. LOVELL, in a communication to the Lancet (December 1, 1866, Vol. IT, p. 603), reports two cases of recovery from shot wounds of the bladder, in the Bohemian War of 1866, which are noted by H. Fischer in the Handbuch of VON PlTHA and BILLROTH, B. I, Abth. II, S. 252. 43, 47. K. Fischer (Militdrdrztliche Skizzen, 1867, S. 63) records two cases of recovery from shot wounds of the bladder in a soldier at Gitschin, and in a soldier treated in another Silesian hospital. 48. VOLKMAXX (Uber einige Fdlle von geheilten penetrirenden Bauchwunden, in Deutsche Klinik, 1868); case of Ratschinsky, 45th Prussian regiment, shot perforation of the bladder, at Trantenau. August 21, 18G6. 49, 50. Stromeyek (Uber Schusswunden im Jahre 1866, S. 43) records two cases of recovery from shot wounds of the bladder. 51, 52. B. Beck (Chir. der Schussverletzungen, 1872, S. 561); cases of F------, 1st Baden, shot through the bladder at Nuits, December 8, 1870; and of B------, 48th French infantry, who received a similar wound, at Worth, August 6, 1870. 53-56. MacCormac (.Votes and Recollections, etc., 1871, p. 74); case of Hautcfeuillei aged 22, shot through rectum and bladder, at Sedan, September 1, 1870, at the English hospital. Dr. MacCormac also saw two cases at a Belgian ambulance, and one at Bazeilles, under the care of Dr. Juxkeu, all with urinary fistulae, and likely to recover. 57. SOCIX (Kriegschir. Erf, 1872, S. 98); case of E. Arnold, shot perforation of bladder, at Gravelotte, August 18, 1870. 58, 59. Excel (Beitrage zur Statistik des Krieges von 1870 bis 1871) gives two cases of recovery from wounds of the bladder. 60-63. Stf.ixberg (Die Kriegslazarethe und Baracken von Berlin, nebst einem Vorschlage zur Reform des Hospitalwesens, Berlin. 1872) relates six cases of shot wounds of the bladder ; one died, and one was still under treatment. 64. Kirchxei; tArztlicher Bericht uber das Koniglich Preussische Feldlazareth im Palast zu Versailles wdhrend der Belagerung von Paris vom 19 Septembre bis 5 Miirz 1871, Erlangen, 1872) narrates one recovery and five fatal cases of shot wounds of the bladder. 65. REDAKD (Gazette des Hopitaux, 1872, p. 106) ; ease of E-----, aged 27, 90th line regiment, shot through the bladder and rectum, at Paris, September 30, 1870. In these sixty-five cases, the evidences of penetration of the bladder were incontestable, and convalescence was fairly established when they were reported as recoveries. In many instances, however, fistules or other distressing infirmities rendered the recoveries incomplete, what may be termed survivals rather than true recoveries. American oases of recovery from shot wounds ofthe bladder, other than those cited as observed during the War, arc few. 65. W. G. BllECK ( Virginia Med. Jour.. 1857, Vol. VIII, p. 461) records the case of C. Fairbanks, aged 20, shot in the pubic region, August 25, 1854, recovery after extensive exfoliation of bone; the case is interesting from the supposed regeneration of a portion of the pubis. 67. Grinstead (St. Louis Med. and Surg. Jour., Vol. XV, p. 489) i case of X. Long, aged 7, shot wound ot bladder. July 4, 1857. 68. J. S. ATHOX (Cincinnati Jour, of Med., 1866, p. 118); John B-----, aged 9, shot wound through bladder, in January, 1865. 69. Oat.max (I. J.) (Northwestern Med. and Surg. Jour., 1851, N. S., Vol. Ill, p. 301) records the case of J. H----, shot wound of left buttock ; a pint of blood passed by the urethra; bloody urine drawn by catheter for two days; no escape for urine by wound; sound detected a ball in the bladder; patient declined an operation, and recovered without bad symptoms; ulterior history not recorded. 70. KOEltrER (J. F.) (GKOSS, System, etc., 5th ed., Vol. II, p. 718) ; perforation from right buttock to left groin by a conical musket ball traversing the distended bladder of a young man; urine passed by posterior wound for six days; recovery, without fistula, in \ six weeks. 71. Jaxeway (E. G.) (Proceedings of the New York I'atlinlogieal Society, April 9, 1873, in the Medical Record, Vol. VIII, p. 344) presented to the society a round musket ball taken from the bladder of Joseph Ilasscnfratz, aged 51. who died of asthma, January 5, 1873, nineteen years after receiving an accidental shot wound in the buttock. Before death, a faint click revealed the presence of a metallic foreign body in the bladder. In the slightly hypertrophied wall of the bladder there were no signs of the point of penetration. There was a cicatrix in the hip. There were three small pouches in the posterior wall; Hie ball lodged in one of them, but was easily displaced, and fitted either of the others. The somewhat flattened ball was slightly encrusted at one small place. The deposit was believed to be composed of urates. 288 INJURIES OF THE PELVIS. [CiiAr. vu. In appreciating the partial recoveries from shot wounds of the bladder, the effects of the lesions of the pelvic bones and rectum, with which they were so frequently associated, must be allowed due weight. Cask 82.").—Private C. A. Warren, Co. H, 17th Maine, aged 36 years, was wounded at the Wilderness, May G, 1864, and was treated in the 3d division hospital of the Second Corps, by Surgeon 0. Everts, 20th Indiana, for a "gunshot penetrating wound of the abdomen." On May 28th, the patient Avas sent to Armory Square Hospital. Acting Assistant Surgeon E. P. Richards described that "the ball entered at the anterior superior spinous process of the right ilium, and injured the ascending colon and fundus of the bladder. He passed both fseces and urine through the upper wound until June 5th, when the faeces ceased to pass through the wound and he had natural alvine passages. On July 2d, a consultation was called, and a No. 5 catheter was passed by the urethra, through which the urine flowed freely; but, on July 3d, the catheter slipped out, and the parts were too much tumefied to allow of its being replaced. On July 8th, a flexible No. 5 catheter was passed, and the urine again flowed freely; but, on July 9th, this catheter came out, though tied tightly to both abdomen and thighs; the parts were very much tumefied." Surgeon D. W. Bliss, U. S. V., reported that this man was " discharged the service May 16, 1885, for urinary fistula; disability total." The Pension Records state that Dr. James G. Sturgis, late assistant surgeon 17th Maine, reports, on the application for widow's pension : " Wounded by a minie" ball, which entered the abdomen in front of the right hip, passing through the neck ofthe bladder, through the rectum, and through the sacrum. The wound never healed, but discharged from the time of injury until death. He was never able to leave his bed from the time of injury, being brought home on a couch. My knowledge of the above facts was derived from being with him and dressing his wounds at the battle of the Wilderness, and attending him after his arrival home until his death, which occurred March 1, 1857." Case 826.—Private David Tappen Sharp, Co. E; 40th New York, aged 20 years, was wounded at the Wilderness, May 6, 1864. There is no field memorandum in records ofthe 3d division, Second Corps, in which the regiment was brigaded. The wounded man was received at Armory Square Hospital, May 28th. Surgeon D. W. Bliss, U. S. V., reported that the " ball entered at the pubic region and made its exit at the sacrum," and that the soldier was " discharged from service, August 16, 1864, for paralysis of bladder from gunshot wound." He was pensioned. The New York Pension Board, Drs. Deming, Smith, Hogan, and Phelps, reported, April 3, 1872: " The ball entered the right groin and emerged through the left natis. The urine still passes through the opening in the groin. Extensive varicocele. There is constant inflammation of the groin where the ball entered, caused by the oozing of the urine. Disability total, third grade, and permanent." This invalid died August 4, 1873. In a letter to the Surgeon General, Dr. Elisha Harris, registrar, transmitted a memorandum of the case by Dr. J. Shrady, from which the following extracts are made : "The case of Mr. Sharp is one ofthe curiosities of surgery, and, so far as I know, unique. He was wounded through the right groin in the battle of the Wilderness, May, 1861, the ball passing through the bladder and some folds of the intestines, and emerging at the coccyx. He was seen by many surgeons, both civil and military, who have taken a deep interest in his case. Also the Surgeon General would be much pleased to know the result as a contri- bution to the surgical history of the last War. May I ask the favor of revising my diagnosis by an autopsy, or do I infringe upon the prerogatives of the coroner. If I do so infringe, please pass over the case to him, with the request that I be informed ^f the time of the inquest," * * . Ou November 24, 1873, Dr. Elisha Harris, registrar, transmitted Dr. John Shrady's aotos of the autopsy in this case, held thirty hours after death : " Present, Drs. Forbes, Cosine, Brockway, Reed, Ellison, and myself. Body only fairly nourished; thorax not opened, but no pulmonary symptoms evident during life. Liver and kidneys healthy. Surface of peritoneum coated with lymph, generally in form of flakes ; fluid inconsiderable. Bladder thickened and contracted to the capacity of only two ounces, with a perforation opening externally in the right groin. The adhesions surround- ing the orifice of the cicatrix were attached to the right ramus of the pubes. The course of the ball, which caused the wound, was not distinctly traced, owing to the decomposition, which was hastened by the high temperature of the season and the recumbent position of the body. There was also a reducible scrotal hernia of the right side, omental in character, and a thick- ened appendix vermiformis, but no perforation of substance or other solution of continuity." Case 827.—Private Wilson Robinson, Co. C, 7th New York Heavy Artillery, aged 27 years, was wounded at Tolopotomy Creek, May 29, 1864, and taken to the 1st division hospital, Second Corps, where Surgeon James E. Pomfret, of his regiment, reported a " penetrating shot wound in the right groin." Surgeon E. Bentley, U. S. V., records the case at Alexandria, from June 12th to October 11th, when the patient was sent to Ira Harris Hospital, Albany. Assistant Surgeon J. II. Armsby, U. S. V., reports that "he was discharged, June 19, 1865, on account of a gunshot fracture of the pelvis, the ball passing through the pelvis and bladder. There is caries of bone, and the trunk is flexed. The right leg is of little use. General health is impaired, and the man is unable to earn a subsistence." He was pensioned, and Examiners R. B. Bontecou and W. H. Craig, September 20, 1873, reported the case as " a gunshot wound of the right groin, the ball entering the ramus of the right pubis, fracturing that bone, and wounding the bladder. A fistulous opening still continues to discharge urine in the groin. The pensioner has been confined to his bed the past nine months, and requires the constant attention of another person. Disability total, first grade." This pensioner was paid to June 4, 1873. Case 828.—Private B. F. White, Co. C, 6th Kansas Cavalry, aged 22, probably wounded at Dry Wood, September 2, 1861, is reported by the regimental surgeon, Dr. J. B. Woodward, as "admitted to the general hospital at Fort Scott, January 1, 1862, with vulnus sclopeticum, and discharged July 10, 1882." The Department Register states that he was discharged by '• Medical Director J. E. Quidor, for wound of the bladder, causing the urine to pass by the rectum." In applying for a pension, the applicant alleged that a "ball had passed through the small of the back, ranging forward, and that another ball had passed through the left thigh." The application was rejected ou the ground of insufficient evidence. Examiner A. Fuller, of Lawrence. then reported, March 24, 1870: " Gunshot entering at the right of the point of the sacrum, passing through the neck of the bladder, and still lodged beneath the integuments of the abdomen below the umbilicus, disabling him from active exercise or labor; disability total and permanent.-' Some time after this, and prior to April 5, 1871, this invalid soldier died. The precise date and cause of death have not been ascertained. sect, ii.] SHOT WOUNDS OF THE BLADDER. 289 It will be sufficient to enumerate briefly the larger proportion of the remaining cases reported as recoveries from shot Avounds of the bladder: Cases 829-833.—Private K. S. Davis, Co. I, 104th Ohio, aged 21 years, was wounded near Atlanta, August G, 18G4. Surgeon E. Shippen, U. S. V., reported a penetrating shot wound of the pelvis. Surgeon F. Meacham, U. S. V., and Surgeon J. H. Ranch, U. S. V., reported the case as a shot wound ofthe bladder. This soldier was returned to duty January 17,1865; discharged June 17, 1865, and pensioned. Examiners Z. E. Bliss, Wooster, and Boise, of Grand Rapids, reported, September 16, 1873, that "the ball entered tho left groin just anterior to tho anterior superior process of the ilium, passed downward and inward, remaining lodged in the body, disabling him by weakening the thigh, and causing rheumatic pains."— Private W. Ford, Co. II, 12;*)th Ohio, aged 31 years, was wounded at Winchester, September 19, 1864. Surgeons R. Sharpe, 15th Now Jersey, and W. A. Barry, 98th Pennsylvania, reported the injury as a gunshot flesh wound of the groin or thigh. At Jarvis Hospital, Assistant Surgeon D. C. Peters, U. S. A., reported "a gunshot wound of the bladder," and the man's transfer to the Veteran Reserves, January 20. 18i5, and discharge and pension June 29, 1865. Examiner W. D. McGregor, of Steubenville, reported that " he was wounded first in the left arm, * * * ; the wound docs not trouble him much at present, * * . A second shot struck in front of the left leg three inches below the hip joint, and, passing inward, it came out in the left groin; striking again, it passed through the upper part of the scrotum, and was taken out of the right groin. The wounds are painful during exercise and changes of weather, in consequence of the injury to the nerves; disability one-third and probably permanent." Pensioner paid to June 3, 1873.—Private F. Gonzalalo, Co. K, 9th New Hampshire, aged 23 years, was wounded at Poplar Grove, September 30, 1864. Surgeon J. Harris, 7th Rhode Island, reported a shot wound ofthe scrotum. Surgeon E. Bentley, U. S. V.. adds that the urethra was injured. The patient was discharged September 8, 1865, and pensioned. Examiner J. Phillips, of Washington, reported, July 23, 1858: "The ball entered the right thigh, passed through the scrotum, injuring the urethra and right testicle. Tliere are several openings in the scrotum, through which, he says, the urine flows." Examiner T. F. Smith, of N5w York, reported, September 6, 1873, that a "ball passed through the right testis and left hip, making its exit through the posterior aspect of the hip joint; the bladder must have been perforated, as the only discharge of urine is through the wound ofthe testicle; the wound in the hip joint interferes with locomotion; there is thickening and induration of the scrotum."—Sergeant J. Scott, Co. D, 94th New York, was wounded at Bull Run, August 29, 1832. Assistant Surgeon C. A. McCall, U. S. A., regarded the injury as a flesh wound of the back. Acting Assistant Surgeon M. F. Cogswell reported it as a "gunshot wound through the pelvis, penetrating the bladder and rectum." This man was discharged February 26, 1863. Examiner E. S. Lansing, of Watertown, reported, March 23, 1833: "Ball passed into the pelvis on the left side, injured the bladder, and passed out on the right side near the trochanter major, doing extensive injury; disability total." The pensioner was paid to June 4,1873; there is no later account of his condition.—Private J. H. Springstead, Co. D, 10th New York, was wounded at Spottsylvania, May 12, 1854. Seven surgeons report this case, with sundry discrepancies in details, but the injury appears to have been regarded by most as a shot penetration of the pelvis without visceral injury. This man was discharged and pensioned July 18, 1855. Examiner T. F. Smith, of New York, reported, September 16, 1373, that "the ball entered the left gluteal region and made exit at the outer aspect of the right thigh, wounding the bladder in its passage. He is troubled with incon- tinence of urine; power of locomotion in right leg is impaired; disability one-half." Cases 834-845.—Private A. Keller, Co. A, 203d Pennsylvania, was wounded at Fort Fisher, January 15,1865. Surgeon N. S. Barnes, U. S. V., reported a shot wound of sacrum, Assistant Surgeon D. Bache, U. S. A., a shot wound of the bladder, from McDougal Hospital, where the patient remained longest, and whence he was discharged, July 6, 1865.—Corporal G. S. Harger, Co. I, 10th Massachusetts, aged 24 years, was wounded at Spottsylvania, May 18, 1864, and made prisoner, and paroled to Annapolis, where Surgeon B. A. Vanderkieft reported that the "ball entered the right buttock and passed forward, wounding the rectum, urethra, and bladder, and emerged through the upper third of the left thigh." This soldier was sent to Boston, well, April 15, 1855, for muster out.—Private J. Gorman, Co. K, 82d Pennsylvania, aged 20 years, was wounded at Cold Harbor, June 3, 1864. Surgeon E. B. P. Kelly, 95th Pennsylvania, reported the case as a shot wound ofthe abdomen, and Assistant Surgeon S. A. Storrow, U. S. A., reported, from Filbert Street, Philadelphia, that the ball " penetrated the bladder." This soldier was returned to duty August 16, 1864.—Captain T. S. Beall, 51st Georgia, was wounded near Knoxville, November 29, 1863. Surgeon A. M. Wilder, U. S. V., reported that "a ball passed through the bladder."—Private E. Estep, Co. F, 4th Ohio, aged 22 years, was wounded at Chancellorsville, May 3, 1833. Surgeon Justin Dwindle, 106th Pennsylvania, reported, "gunshot wound through back and bladder;" Surgeon A. Heger, U. S. A., at Point Lookout Hospital, reported "wound of left hip and bladder."—Lieutenant E. Thompson, 2d Massachusetts Cavalry, aged 22 years, was wounded at Winchester, September 19, 1834. Surgeon A. P. Clark, 6th New York Cavalry, reported a "severe bullet wound of the bladder." This officer was mustered out July 20, 1865.—Private G. B. Akerman, Co. B, 67th Pennsylvania, aged 20 years, wounded in attempted desertion, October 20, 1854, is reported by Surgeon Z. E. Bliss as having received "a gunshot wound of the right hip, the ball passing internally, wounding the bladder." He was returned to duty May 20, 1865.—Private D. Sulch, Co. K, 8th Pennsyl- vania Reserves, wounded and captured before Richmond, June, 1362, was reported by the Confederate officials as having received "a gunshot wound of the bladder."—Private A. Winne, Co. C, 33d Ohio, was wounded at Perryville, October 8,1862. Surgeon J. G. Hatchitt, U. S. V., reported that he received "a gunshot wound of the bladder." He was discharged on certificate of total disability, February 15, 1863.—Corporal J. McKee, Co. I, 85th Indiana, was wounded, March 5, 1863; reported on the field casualty list as "shot through the hip and bladder."—Private T. D. Strickland, Co. A, 11th Georgia, is reported, by Surgeon A. M. Wilder, U. S. V., as having received a "gunshot wound through the neck of the bladder," at Knoxville, November 29, 1863.—Private D. W. Davis, Co. L, 1st Massachusetts Heavy Artillery, aged 24 years, was wounded at Spott- sylvania, May 19, 1854. Assistant Surgeon J. C. McKee, U. S. A., reported "a gunshot wound of left ilium, ball penetrating neck of bladder." Acting Assistant Surgeon Stephen Smith also reports the case as a "gunshot wound through bladder," without comments. None of the above twelve are pensioned. 37 290 INJURIES OF THE PELVIS. [CHAP. VII. M. Demarquay holds that there may be shot contusions and lacerations of the outer tunics of the bladder, with secondary penetration of the cavity upon the separation of the eschars, and adduces an observation by Fleury in support of this view, which MM. H. Larrey, Chassaignac, and Giraldes1 hesitatingly admit. Facts appear to sanction the belief that such lesions of the external coats occasionally result from shot injury, and that secondary penetration of the vesical cavity, upon the separation of the eschars, may or may not result. The following are possibly instances of this sort, though the evidence of vesical lesions is inconclusive: Case 846.—Private R. Hussey, Co. A, 6th Maine, aged 24 years, was wounded at Chancellorsville, May 3, 1883. He was sent on a hospital steamer to Douglas Hospital on May 8th, and Acting Assistant Surgeon II. L. W. Burritt reported that "the ball entered just inside of the anterior inferior spinous process of the right ilium, passed directly across the pelvis, apparently just outside of the deep fascia and very near the bladder, and came out nearly in the same position opposite its entrance; the bowels moved freely; there was some pain with a little blood in the urine, which was drawn once by the catheter; castor oil and whiskey were given, with full diet. May 15th : The abdominal tenderness and urinary difficulty subsided; no fever at any time; some injury to the bladder. 21st: Remains the same; no irritation or fever; wound suppurates healthily and is healing rapidly; pulse 78; skin moist and bowels regular; some pain and passage of blood with the urine; an anodyne diuretic was given. 25th: Improving; no irritation of the bladder or bowels; no fever, pain, or swelling; the discharge has nearly stopped, and the wounds are closed except at one small point. June 3d: Wound healed; no pain in bladder, which was evidently contused by the passage of the ball; appetite and general health good." He was transferred, on June 16th, to West's Buildings Hospital, Baltimore, and subsequently to Point Lookout, whence he was sent to duty November 15, 1863. He served in the Veteran Reserve Corps, and was discharged January 31, 1836. Pension Examiner B. Johnson, of Dover, Maine, reported, April 16, 1866, that in consequence of the wound he was unable to perform any labor which required lifting or much exertion, and rated his disability as three-fourths and permanent. He was pensioned from the date of his discharge, and was last paid to June 4, 1871, and since then has not been heard from. Case 847.—Private Philip Matties, Co. H, 26th Wisconsin, aged 28 years, was wounded at Resaca, May 15, 1864. The injury is described as a shot wound of the abdomen at a field hospital of the Twentieth Corps, and at Chattanooga, Nashville, and Jefferson Barracks, in similar terms, with the addition that the missile entered the left groin, passed downward and lodged; but at the Swift Hospital at Prairie-du-Chien, where the patient was admitted April 29, 1885, Acting Assistant Surgeon F. W. Kelley states that the "ball passed into the pelvic cavity, injuring the bladder, and has never been found." This soldier was discharged, June 30, 1865, without pension. Fatal Shot Wounds of the Bladder.—M. Demarquay complained that materials for the treatment of the pathological anatomy of shot wounds of the bladder were absolutely lacking. The experience of late wars would be expected to contribute toward supplying this deficiency. In our War, in cases of this group, a certain number of autopsies were made, and some interesting pathological preparations were preserved for the Army Medical Museum. The descriptions of the appearances observed were commonly very brief, but several of the preparations speak for themselves. Of cases described in detail, oblique perforations were the most numer- ous, the missile entering a groin and pass- ing out at the buttock of the opposite side, or, in about equal proportion, traversing this track in the reverse direction. Many illustrations have been given already of cases in which balls pursued this general course, sometimes passing through the notches or foramina, sometimes penetrating the bony walls. In other cases, the perforations were antero-posterior, or the reverse, implicating FIG. ~!:i3.—SLn>t perforation of the Madder and rectum. 1 Mimoires de la Sociiti de Cliirurgie, 18ol, T. II, pp. 300 and 335. SECT. II.] SHOT WOUNDS OF THE BLADDER. 291 commonly the pubes or sacrum, or both. The simplest shot perforation is that through the obturator foramen and sciatic notch, where the ball can hardly avoid the great vessels in some part of its track. The single instance of this sort recorded was promptly fatal: Case 848.—Captain Richard II. Kimball, Co. K, 12th Massachusetts, was wounded, August 30, 1862, by a ball, which entered the right obturator foramen, passed through the bladder, and emerged through the left greater ischiatic notch, cutting the pyriformis. He survived the injury only a short time. The missile (FlG. 234) was cut from the gluteal muscles previous to embalming the body, aud was placed in the Museum, with the foregoing memorandum, by Acting Assistant Surgeon F. Schafhirt. Fig. 234.—Missile from a fatal case of perforation of the bladder. Spec. 4C0G. Case 849.—Private C. Wolver, Co. H, 24th New York, aged 20 years, was wounded at Centre- ville on August 30,1862. Acting Assistant Surgeon W. II. Butler1 reports that " a musket ball entered above the pubis one inch to the right of the median line, passed obliquely to the left and downward, and escaped four inches above the coccyx and three inches to the left of the spinous process." The patient wa« admitted into the Union Chapel Hospital September 1st. The posterior wound had closed, but from tho anterior there was an almost constant flow of urine, notwith- standing the retention, from the first, of a catheter in tho urethra. The pulse was 125. A difficulty in passing the catheter was finally overcome by withdrawing the stylet gradually after the catheter passed under the pubis, and giving it an upward tilt on the inner end. Cleanliness was enforced; a nutritious diet was given, with opium in full doses. Tbe bowels were confined till Sep- tember 9th, when the tongue became thickened and coated, and the patient complained of oppression in the bowels. An enema of warm water was followed by a normal evacuation. A marked jaundice ensuing on the 10th, a mercurial cathartic, followed in six hours by castor oil, was administered, with the effect of producing a free and painless evacuation. On the 11th, sherry wine in the yelk of an egg was given every four hours; at bed-time, ipecac with quinia and blue pill. The patient was quiet till the latter part of the night, when he became restless and delirious. Stimulants and opiates were continued on the 12th; clots of blood were expectorated during the day and at night; respiration was accelerated, and the pulse 140; failure occurred gradually, and the patient died on the morning of September 13,1862. Three hours afterward, the cadaver was yellow and emaciated, rigor mortis was well marked, the bowels tympanitic, and the eyes sunken. There was well-marked suggillation on the back, neck, and thighs, and the pupils were remarkably dilated. The external appearance of the superior wound was very dark and dry. On cutting through the abdominal walls a slight fracture of the superior part of the pubis was discovered, some small pieces of bone being detached; ulceration had taken place to a considerable extent beneath the parietes of the abdomen and to the right of the bladder. A small piece of bone was driven into the bladder from the os pubis. The walls of the bladder were thickened at least one inch, and its capacity lessened about one-half. The ball was found to have passed through the left side of the bladder and through the upper part of the ischiatic notch. The outer wound was com- pletely closed, and could not be forced open. The lungs were normal anteriorly; on the left the lobes were covered with plastic lymph, and the cavity of the chest and the peri- cardium were filled with serum of a dull yellow color. The liver was much enlarged; the kidneys normal; the spleen congested. Externally the heart presented a normal appear- ance, but its cavities were filled with thick and tenacious fibrinous bands. This was partic- ularly marked in the right auricle, the mass on being removed taking casts of the veins well up into the head. The stomach and intestines were healthy." The specimen, con- tributed to the Museum by Dr. Butler, is represented in the adjoining wood-cut (FlG. 233). The perforation is completely cicatrized, its site being indicated by a large depressed scar. Case 850.—Private Fleming P------, Co. K, 6th Georgia, aged 23 years, was wounded at Antietam, September.17,1862, and was sent to a field hospital. Surgeon H. S. Hewit, U. S. V., records that he was admitted to Frederick Hospital No. 5, on October 4th. Acting Assistant Surgeon A. V. Cherbonnier gives the following particulars of the case, which first came under his notice on October 18th: "The patient had been struck by a round bullet, which entered a little above the tuberosity of the right ischium, passed through the bladder near its neck, and made its exit near the inferior anterior spinous process of the right ilium. He suffered great pain; the abdomen was tense, and sensitive to the lightest touch; there was severe pain in the perineum, constant unavailing desire to void the urine, and an abscess was forming over the pubis. Urine mixed with pus dribbled from both orifices With some difficulty a catheter was introduced, and offensive matter was drawn off to the amount of a few ounces, mingled with a slight quantity of urine. Fomentations were applied to the abdomen; then compound cathartic pills were given, and the wounds were carefully cleansed. On October 19th, the patient had passed a more comfortable night; the abdomen was less tense and painful; pain in the perineum not complained of. Urine with pus passed through the catheter, which he introduced himself. He complained very much of the abscess forming over the pubis. The wound was thoroughly washed, and dressed with simple cerate; fomentations were continued over the abdomen, a flaxseed-meal poultice was applied over the forming abscess, and a grain of morphia was ordered if the bowels should be open. October 20th: The patient had passed a sleepless though npt a restless night, and had two copious stools; the pubic abscess pointing, was opened with a lancet and discharged copiously, affording great relief; all unpleasant sensations about the abdomen were much, if not entirely, relieved. The urine was much clearer, but still mixed with pus. The patient looks more cheerful and feels much better, with appetite returning; he ate some chicken-broth with a little chicken. Treatment the same. October 23d: His condition is improving; he thinks himself able to go home; the urine is voided almost entirely through the catheter; the wounds 1 Butleb (W. H.), Three Cases of Gunshot Wounds of the Bladder, in the Buffalo Med. Jour., 18G4, Vol. HI, p. 456. FlG. 235.—Shot perforation of the urin- ary bladder. Spec. 510. 29l2 INJURIES OF THE PELVIS. [CHAP VIT. are looking healthy. October 25th: He complains of much pain in the right groin along the track ofthe spermatic cord; another abscess is forming, and the opening over the pubis is suppurating; a small piece of bone was removed therefrom; his general health is improving. October 27th: I opened the abscess in the right groin; lm had complained incessantly of it, and much pus was discharged therefrom, and also pieces of clothing; fiaxseed-meal poultices'to all the wounds were ordered; much less pus passed through the urethra; a full dose of castor-oil was ordered. October 23th: The patient is much better and dots not complain of pain, but is unable to sleep; two grains of opium were ordered. November 1st: The patient is better; he has rested well, and his appetite is good. November 12th: He is slowly but surely improving, and the wounds are closing. November ICth: The bladder is resuming its power; the wound in the groin is closed. November 13th: The posterior wound or point of exit is closed; the patient is quite cheerful and contented, though the two remaining wounds are suppurating and he still uses his catheter. December 7th : He has had a good night's rest, which was procured through the aid of a half grain of sulphate of morphia, and he feels comparatively well. December 8th: He litis slept well without morphia; passed urine by the catheter; some of the urine again escapes from the lower wound, which troubles his mind; an explanation cheered his spirits, and he sank into an easy slumber. December 11th: He is occasionally fretful, but is easily reconciled to his condition; the wounds have closed up again; patient cheerful and improving. December ICth: He is improving, but still draws his urine by the catheter. December 19th: He has left off the use of the catheter and passes his urine without any trouble; the urine is still mixed with some pus, and some of it, though little, escapes through the wound again; his general health is good. December 22d: He is improving, and walked and sat up awhile to-day; to-night he complains very much about his bed-sore, and an air pillow and poultice were applied. December 23th: He is still improving, and gets up awhile every day. December 28th: lie complains of diarrhoea; ordered pills of quinine, Dover's powder, rhubarb, and carbonate of iron." On the 29th, the man was transferred to hospital No. 1, where Assistant Surgeon 11. F. Weir, U. S. A., continued the report as follows: "January 10th: The patient is evidently slowly failing; he continues very irritable; the pulse is 115 and very weak, and the tongue furred, brown, and rather dry; much difficulty is experienced in getting him to take his medicine, and, at times, it seems almost impossible for him to swallow; fears are entertained that tetanus will super- vene; the mucous membrane of the mouth is covered with aphthous ulcers; he has constant pain over the course of the urethra, and the passage of calculi is suspected; on introducing the catheter it was found to grate over some hard substance near the neck of the bladder; this was thought to be a piece of bone (Fig. 5, Plate VIII) which had been forced into the bladder from some point of the urethra previous to his admission. A con- sultation was held, but, owing to the patient's prostrate condition, it was thought advisable not to remove the foreign body; enemata of beef-tea with brandy were ordered. January 16th: _ The patient is very feeble; his pulse is slow and weak, and the tongue red at the edges and coated in the centre; bowels regular; skin dry and hot; he has a great desire for water, and great difficulty in swallowing medicine and nourishment; the wounds are not in good condition, and the urine escapes from the openings; there is considerable trouble experienced in introducing the catheter. January 24th: The patient is slowly improving and the pulse is somewhat better; the tongue is cleaning up and the bowels are regular. January 27th: The patient seems more comfortable this morning; he rested well last night; the wound was dressed with simple cerate and the bed-sores dressed with a poultice; he is improving. January 28th: The patient has considerable cough, and I ordered an anodyne; the pulse is quite weak; he has not so much trouble in swallowing; the tongue is coated'and the breath fetid; the bowels are becoming more regular. January 29th: The patient is very weak this morning, and I ordered a blister to his chest, as he complained-of severe pain there, and coughs very much; he continued to gradually sink until about three o'clock P. M., when he died. Examination ten hours after death, showed the body much emaciated. The track of the ball is as follows: The point of entrance is found to be half-way between the trochanter major and the tuberosity of the ischium of the right side; the exit is just above the root ofthe penis, on the abdomen. In the track of the wound, commencing at the ramus of the right side, the tuberosity of the ischium was splintered at its lower aspect. A portion of necrosed bone was found in this place. BeloAV the border of the symphysis pubi3 on the left side, the descending ramus of that side was also found much comminuted; it had not been completely fractured transversely; the ball had apparently been deflected near the median line. The superior, lower, and anterior parts of the pubis to one and a half inches from the median line was found in a state of necrosis, with destruction of cartilage; this formed the posterior wall of an abscess, in the cavity of which was found necrosed bone and fragments of bone, three of which, about the size ofthe thumb-nail, were located in a passage communicating with the upper floor of the urethra, just posterior to the triangular ligament; these wrere obstructions to the urethra, and were noticed during life on all passages of the catheter; this explains the injury to the catheters during life. The abscess above was ofthe capacity of from four to six ounces; all the urinary tracts opened to it. The second opening was on the upper portion of the right thigh near the scrotum; the third and fourth on the left thigh a short distance below Poupart's ligament. The other portions of the urethra were not found involved. The bladder was slightly diminished in size, and the walls were but little thickened; the mucous membrane, however, was very much congested near the base and was almost in a sloughing condition; embedded in it were numerous flattened roughened deposits of phosphate, and one smooth particle about the size of a pea. The kidneys presented similar deposits, and were mottled, and presented in places the appearances of fatty degeneration, but there Pio. 236.—Drawing of a wet preparation of the pelvic viscera, show- ing1 the wound in the bladder made by a ball which entered through the right ischium and escaped above the left pubis. Also the bone fragments near the neck ofthe bladder. Spec. 3975. SECT. 11.1 SHOT WOUNDS OF THE BLADDER. 293 was no material difference in size and color. The lower lobe of the left lung was inflamed, and the inferior mesentery engorged and enlarged." A wet preparation of the pelvic viscera from this case, forwarded to the Museum by Dr. Weir, is imperfectly delineated in the foregoing drawing (Fig. 23!!). The artist has not succeeded in representing the abscess and false passages between the pubis and prostate, or tlie form of the bone fragments. The latter are accurately drawn, of the size of nature, in Fig. 5 of Plate VIII. Case 851.—Sergeant H. B------, Co. K, 5th Minnesota, aged 21 years, was admitted into hospital at Nashville, December lii, 1854, for a wound received at Franklin the previous day. Assistant Surgeon C. ('. Byrne reports that "a conoidal ball passed through the rectum an inch above the verge of the anus, through tbe bladder, and then fractured the right os pubis, escaping upward without opening the peritoneal cavity." The fractured pubis is represented by Fig. 182, p. 237, and a cursory examination would suggest that the course of the ball was the rev< of I'm. 237.—Preparation of a shot perforation of the bladder and rectum. Spec. \'/l~>2. that described, the loss of substance being much greater on the inner surface of the horizontal ramus. But a closer inspection indicates the correctness of Dr. Byrne's hypothesis, the greater loss of substance ofthe inner table being obviously due to the oblique impact and deflection of the projectile. The clinical report continues : "The wounds were dressed simply, and opium was administered. F.ctes and urine escaped from the wound of entrance. The patient sank slowly, and died from exhaustion and peritonitis, December 29, 1864." A preparation of the pelvic viscera (Fig. 237), exhibiting the track of the ball, was contributed to the Museum by Acting Assistant Surgeon H. C. May. The integument from the groin is tilted upward, at right angles to its proper plane, so as to exhibit in the drawing, at A, the exit orifice made by the ball. Case 852.—Corporal L. T. Eel yea, Co. A, 9th New York, aged 28 years, was wounded near Petersburg, June 18, 1864, and sent to a field hospital of the Fifth Corps, and was recorded by Surgeons Reed and Faxon as a case of flesh wound of the hip. On June 19th, he was transferred to City Point, and sent thence to Washington, and admitted into Stanton Hospital on July 1st. Surgeon John A. Lidell, U. S. V., reported the case as a "gunshot, wound ofthe bladder and rectum." Ice dressings were applied, and stimulants administered, with tonics. Death, July 2, 1854, from peritonitis. Case 853.—Lieutenant F. A. Morrell, Co. K, 10th New York, was wounded at Fredericksburg, December 13, 1862. Assistant Surgeon A. E. VanDuser, 10th New York, reports that "a rifle ball had entered upon the left hip, passed through the bladder, and lodged. At the same time he received this wound a spent shell struck him in the right subclavian region." This officer was sent to the Seminary Hospital, Georgetown, on December 17th. Surgeon J. II. Brinton, U. S. V., entered on his note-book: "When admitted, had dulness, subcrepitant rale, occasionally a dry sibilant rale ; pulse 120, weak and feeble; sleeps badly. January 9, 1863: Catheter; much better; pulse 98; appetite tolerable. January 14th: Pulse 96; bowels good; had a slight chill; urine passed through the posterior opening made by the ball. After January 9th, a catheter was kept iu the bladder; his condition improved; pulse 96; appetite tolerable." Acting Assistant Surgeon II. W. Ducachet reported that after the middle of January this officer's condition gradually deteriorated, and that he died February 4, 1853. It must not be overlooked that patients may recover from the vesical injury and perish from intercurrent disease : Case 854.—Private M. Jones, Co. F, 25th Wisconsin, was wounded, July 22, 1864, near Atlanta, and was taken to hospital No. 3, at Rome, Georgia. Surgeon (J. F. French, U. S. V., states that "a ball from a sporting rifle perforated the bladder and lodged in the right inguinal region, where its presence caused the formation of an abscess. The missile gradually worked its way to the surface, and was extracted September 11,1834." The ball represented iu the wood-cut (FlG. 2:58) was sent to the Museum by Surgeon French. The patient suffered from chronic diarrhoea, and Surgeon J. II. Grove, U. S. V., reports that he died of this-malady September 23, 1864. Case 855.—Private W. B. Wait, Co. K, 103th New York, aged 28 years, was wounded at Monocacy, July 9, 1861. Acting Assistant Surgeon G. M. Paullin reports that "a conoidal ball entered the left buttock about two inches above tbe tuberosity of the ischium, passed upward and forward, perforated the rectum, severed the prostatic portion of the urethra, fractured the ramus of the pubis of the same side, and emerged at a point about an inch and a half to the right of the penis. He was admitted from the field into hospital at Frederick on July 11th. His general condition was good, and he complained of but little pain; the appetite was good. On introducing the catheter by the urethra, an obstruction was found near its prostatic portion which interrupted the further progress of the instrument, and upon introducing the finger into the rectum it came into immediate contact with the catheter. The male catheter being withdrawn, a female catheter was introduced by the rectum through the wound in the urethra into the bladder, where it was retained by means of a T-bandage; but proving of little or no advantage it was removed, as the urine emptying from the urethra into the rectum was discharged with the faeces. On July 12th, symptoms of peritonitis supervened; the pulse increasing from 75 to 100, with extensive tympanitis. Wet cups were applied to the abdomen, subsequently a cantharidal plaster. On the following day the patient was much more comfortable, all the symptoms of peritonitis having abated. The symptoms having increased on the 17th, a poultice of hops and flaxseed was applied to the abdomen. On the 18th the patient was somewhat better; the tympanitis had subsided. There was little change by the 30th; he complained of no pain; his appetite for light articles of food was quite good, yet the patient failed gradually; delirium and subsultus came on, and he died on August 14, 1854. The bladder, rectum, pubis, and ramus of the ischium were dissected out en masse at the post-mortem, but were so disorganized and lacerated as to be scarcely recognizable. The ramus of thev pubis of the right side was somewhat comminuted." Fig. 238.—Battered round rifle ball that penetrated the pel- vis, lodged, aud was discharged from an abscess. Spec. ;S;293. 294 INJURIES OF THE PELVIS. ICIIAP. VII FlG. 239.—Entrance •wound of a shot perforation of the pubis. Fig. 240. in the same case Exit wound The next case furnished the calculi represented in Figure I of Plate VIII, and presents several other features of great interest, such as the passage of bone fragments by the urethra, the persistent fistulous orifice in the right wall of the bladder, the ligamentous union of the fractured pubis, and the concentric hypertrophy of the muscular tunic. Case 856.—Private John M------, Co. H, 101st New York, aged 19 years, was wounded at the second battle of Bull Run, August 29, 1862. He was taken to Armory Square Hospital. Surgeon J. H. Brinton, U. S. V., made a memorandum ofthe case in his note-book, with diagrams indicating the position of the entrance and exit wounds. Reduced copies of these drawings are represented in Figs. 239 and 240. The missile, probably a conical musket ball, entered over the horizontal ramus of the right pubis an inch from the symphysis, and, passing downward and a little outward, emerged through the right buttock. Surgeon D. W. Bliss, U. S. V., forwarded a report of the case. After giving the military description and seat of injury, the report continues: "Several pieces of bone, at different periods, passed through the urethra, and although he has never been perfectly free frohi pain, sometimes of the most severe character, his appetite and strength long continued good. The wounds made by the entrance and exit of the ball would close up for a longer or shorter period, and again open and discharge urine, pus, and blood; and, when urinating, the contents of the bladder would pass quite as freely through these fistules as through the urethra. He generally urinated freely, but never without pain, referred to at times as very severe; the urine always albuminous, muco-purulent, or bloody, and in considerable quantities. During the earlier part of the treatment a catheter was retained in the bladder, and attempts have been made, at different later periods, to reintroduce it, but were attended with unendurable suffering. The catheter never seemed to be of much benefit. The patient has suffered much pain, referred to the kidneys, at different periods, which was allayed by cupping, warm fomentations, and opiates. About six weeks ago (September 15, 1863) he was placed under the influence of ether, and the anterior wound was dilated and an irregularly shaped piece of bone was extracted, and, at the same time, a stone was distinctly felt, but it was not deemed prudent to operate for its removal at that time. Since then, he has been gradually failing, and he died on the evening of October 24, 1863.' At the autopsy, on the following day, it was discovered that the course of the ball varied but little from the foregoing description. The bladder Avas greatly contracted, and the walls or coats were three-eighths of an inch in thickness, and the cavity was nearly filled by two stones, one weighing two drachms ten grains, the other three drachms fifty-seven grains, or, conjointly, six drachms seven grains. Several pieces of necrosed bone were removed from the point of exit of the ball." The two calculi here referred to were sent to the Museum, and were numbered 2567 of the Surgical Section. They are represented of the size of nature in Fig. I, Plate VIII. The bladder and injured portion of the right os innoininatum were also forwarded, and constitute the highly interesting specimen represented in the wood-cut (Fig. 241). There is ligamentous union of the fracture of the horizontal ramus of the pubis. The fractured ischium is united by callus and so much deformed as to be a puzzling study. The thickened bladder adheres to the pubis and ischium, and its wall appears to have been perforated at one point only, the opening remaining widely pervious. The missile *-**, probably struck the viscera while distended, and produced a single Ktj laceration on its right lateral wall. In Dr. J. PL Brinton's note-book fkr there is a memorandum of a visit to the patient, January 3, 1863: |^ "Patient is nearly well, tie complains of pain at the anterior wound when he draws a long breath, and of constant pain in the glans penis, and frequently pulls at the prepuce. Appetite good. Pieces of bone were discharged some five or six days since through the posterior opening, and some little pieces came through the urethra, the size of a •'rain of rice, and ragged. One piece was expelled which was larger, about half an inch in length and nearly a quarter of an inch in width (FlG. 242). There was great pain in micturition. The catheter has, at various times, been introduced." Casio 857.—Private H. C. Hotchkiss, Co. H, 90th New York, aged 18 years, was wounded at Cedar Creek on October 19,1864. Assistant Surgeon J. Homans, jr., U. S. A., reported that a musket ball fractured the ilium and ischium, and penetrated the bladder and lodged in the muscles of the opposite side. The patient was sent to the Sheridan field hospital, and thence to Baltimore. On October 26th he entered Newton University Idospital, where Surgeon R. W. Pease, U. S. V., reported, there ensued " peritonitis, cystitis, and sloughing of the sciatic artery, and death, October 30, 1864." As in the foregoing cases, in a majority of the ninety-six fatal cases of shot wounds of the bladder likewise, the complication of fracture of one or more of the pelvic bones 1 A duplicate cf this report is found on a case-book of Armory Square, without signature. The substance of it has been published, more or less literally, by Dr. W. H. Bltleu (Buffalo Med. and Surg. Journal, 1864, Vol. Ill, p. 458}, and by Dr. II. A. ROBMNS (Am. Jour. Med. Sci., 1868, Vol. LV, p. 125), both formerly employed at Armory Square as acting assistant surgeons. Fig. 241.—Fistule from shot perfora- tion ofthe bladder, with fracture of the right pubis and ischium. Spec. 17jS. FIG. 242.—Fragment of necrosed bone expelled through the urethra. [From a drawing by Dr. J. H. Brinton.) |, SECT. II.] SHOT WOUNDS OF THE BLADDER. 295 FIG. 243.—Ball embedded in the inner part of the right ischium. Spec. 819. Fig. 'J44.—Partly consoli- dated shot fracture below tho trochanters of the left femur. Spec. 798. was present. This statement must be submitted, in place of an exact determination of the frequency of this complication, the fractures being specified in twenty-eight cases only. A number of the cases, five at least, of fatal shot wounds of the bladder were complicated by the graver injury of fracture of tlie neck of the femur with destruction of the hip joint. The following may be particularly noticed here as explaining a mistaken reference,1 of a Museum specimen: Case 838.—Private J. P. Caranagh, Co F, 17th South Carolina, was wounded at Antietam, September 17, 1862. He was treated with other wounded prisoners on the field until October 9th, when he was sent to hospital No. 1, at Fivilcrick, and placed under the care of Dr. Redfern Davies, who made the following note of the injury and autopsy : "Tbe external wound was beneath the left trochanter major, which, with the adjacent shaft of the femur, was much comminuted. The joint was apparently injured. A probe passed freely into the bladder. The urine escaped partly by tbe wound and partly by the natural channel. The general condition was pretty good. October 14th, since a careful examination, three days ago, the patient lias rapidly grown worse, lie died on October 15. 1862. Scctio cadatrris: Trochanter major pulverized; trochanter minor extensively comminuted; shaft of femur at its junction-with trochanter and neck comminuted, the fragments held together by periosteum. The ball passed through the thyroid foramen. A finger passed readily into the bladder from tbe wound. Beneath the periosteum, in the pelvic cavity, there was extensive sloughing and destruction of the soft parts. Tbe peritoneum covering the intestines was injected. The bladder was perforated in two places. The bullet was found fixed in the tuberosity of the right ischium, its base only visible. The ischium was comminuted." [There can be no doubt that the specimen 819 referred to, and figured (FlG. 191) on page 242 ante, Case 703, of William Laws, really belongs to this case, which also furnished the specimen No. 798 (FlG. 244) of partly consolidated shot fracture of the left femur below the trochanter. On referring to the abstract of case 70:>, it will be observed that the ball perforated the ischium, making its exit near the tuberosity of the ischium. In the case of Caranagh, the ball, after fracturing the left femur (FlG. 244), embedded itself in the body of the right ischium, and a careful review of the reports of Dr. Redfern Davies and of Acting Assistant Surgeon W. W. Keen, jr., leaves no room for doubt that specimens 798 and 819 were both obtained from the case of Cavanacjh.~\ The following is also an instance of fracture of the neck of the femur conjoined with injury of the bladder, and is interesting from the vesical lesions having been apparently secondary, as in the cases adverted to on page 290, the penetration of the bladder resulting from consecutive sloughing: Case 859.—Sergeant W. Spendlove, Co. E, 1st New York Cavalry, aged 25 years, was wounded at Piedmont, June 5, 1864, and was taken prisoner, and a few days afterward admitted to a Confederate hospital at Staunton. Assistant Surgeon W. Grurnbein, 20th Pennsylvania Cavalry, made the following special report of the case: "He was wounded in the left hip by a piece of shell; the wound in the soft parts was extensive, and the trochanter and neck of the femur comminuted; by probing the wound the lower end of the upper portion could be distinctly felt, having the appearance of a direct fracture; the lower portion was more oblique. A great number of pieces of bone were taken out and suppuration removed others. It was decided to wait until the suppurating stage was fully established and then resect the bone. At the time when the operation should have been performed, however, pulmonary symptoms had made themselves manifest, of a very ambiguous nature, precluding all hopes of a successful termination of the case. Tbe patient sank daily, and phthisis pulmonalis was fully established. By enquiring into his previous history, I ascertained that he has had a dry hacking cough for some time, and also has had haemor- rhage from the lungs. For the last three weeks of his sickness his urine was bloody and contained some pus. He died Julj' 16, 1864. Post-mortem appearances: The external wound looked red and healthy, not at all indicating the degree of injury existing within. On laying open the joint there was no sign of reparation, the tissues forming a dark sloughing mass. Notwith- standing the small quantity of matter that escaped through the opening the cavity was filled with coagulated blood, and communicated, with the bladder by a fistulous opening through the obturator foramen. The piece of shell was not extracted. It was supposed that it had not lodged in the wound, but that a splinter of bone penetrated toward the bladder, injuring its coats, which afterward sloughed tlu-ough. Tbe right lung seemed healthy, but the left lay in a pool of matter and was very much disorganized." 1 The two specimens arrived together from Frederick. The ischium appears to have been forwarded by Dr. Redfkkn Davies, the femur by Dr. W. W. Keen, jr., and the two were numbered 798. (See Catalogue of A. M. M., 18C3, p. 41.) The ischium was then transferred to No 819 (ibid., p. 42). In the quarto Catalogue of 1866, p. i!81, Specimen 798, not conforming to the history to which it was referred, is classified as of unknown origin, and No. 819 is referred to the "case of William Laws. The memoranda accompanying the specimens are well calculated to deceive; but a careful com- parison of numbers and letters proves, beyond question, that there was no pathological preparation forwarded in the case of William Laws, and that the two preparations 798 and 819 belong to the case of Cavanagh. 296 INJURIES OF THE PELVIS. [CIIAP. VII. Like Case 859, and those adduced on page 290, the following is an instance of secondary penetration of the bladder by ulceration, the progress of the lesions having been explained by an autopsy: Case 860.—Private D. Smith, Co. I, 57th New York, aged 30 years, was Avounded at Gettysburg, July 2, 136:?, and treated at the Seminary and Camp Letterman hospitals. Assistant Surgeon S. B. Sturdevant, 139th Pennsylvania, reported: "He was admitted August 8, 1883, having been wounded by a minie ball entering the body on the left side of the spine near its junction with the sacrum, touching, in its passage, the last lumbar vertebra, passing into the cavity of the pelvis in a line downward and forward, and between the lower end of the middle of the rectum and the base of the bladder; the ball was not extracted. The patient had been doing well since the injury, aside from the emaciation which gradually took place, until the morning of September 4th, when prostration suddenly ensued, and simultaneously with it a considerable quantity of urine and pus was discharged from the rectum. Death resulted on September 8,1863, from exhaustion, consequent ou the injury. Simple dressings, tonics, stimulants, and nourishing diet were prescribed from the time of his entrance into the hospital until his death. A post-mortem examination was made in this case, when it was discovered that at the point where the ball had touched the anterior portion of the rectum and the posterior wall of the bladder in its passage between them, ulceration had taken place involving all the coats of the bladder, and that part of the rectum lying contiguously to the bladder, making a communication which had allowed a free passage of urine into the rectum. Only a small amount of pus was seen, and there was no disorgan- ization of the pelvic viscera beyond the ulceration as above described." Urinary infiltration was the cause of death in a large proportion of cases of shot wounds of the bladder.1 If the urine gained access to the serous sac, fatal peritonitis resulted; if it permeated the pelvic fascia, sloughing or diffuse suppuration was less promptly, but almost as surely, mortal. Case 861.—Private F. Smith, Co. I. 10th New York, was wounded at Bull Run, August 28, 1862, was sent to Ryland Chapel Hospital, at Washington, in September. Assistant Surgeon V. B. Hubbard, U. S. A., reported that "a minie ball pene- trated the bladder through the right ilium and lodged. Urine was extensively infiltrated into the surrounding tissues, and escaped with pus from the wound, especially during paroxysms of coughing and during defecation. A catheter was introduced into the bladder and maintained in position till death. There was a scanty flow of urine through the catheter, and during the last few days it was intimately mixed with pus. The surrounding tissues were much discolored, and would have sloughed extensively had the patient survived a violent irritative fever, of which he died September 14, 1862." Case 862.—Private J. Smith, Co. A, 10th New York, wounded at Bull Run on August 28, 1862, was sent to Washington, and admitted into hospital on September 2d. Assistant Surgeon V. B Hubbard, U. S. A., reported that a ball entered the pelvis at the left sacro-iliac synchondrosis and lodged. There ensued complete paralysis of the bladder, and no urine was voided save by the use of the catheter, which was retained in the bladder and gave issue to an intimate mixture of blood and urine in about equal proportions. The genitals were oedematous; the tissues of the pelvis were infiltrated with urine, and escaped from the wound with the pus. The patient died on September 19, 1862. The symptoms and termination of this case were very similar to those of Private Frank Smith, who died five days previously from a similar wound. The coincidence of shot perforations of the bladder and rectum,1 already repeatedly exemplified, is further illustrated by the three following cases, two of which have been alluded to on page 252. The subject will be more fully considered in the following subsection, on wounds of the rectum: Case Sd'A.—Private R. Baggs, Co. F, 1st West Virginia, was wounded on November 27, 1863. Surgeon D. Baguley, of his regiment, reports that "a pistol ball entered the right groin, penetrated the bladder, and passed through the rectum, establishing a communication between them, which caused the greater part ofthe urine to be voided by the rectum. A catheter was introduced and retained in the bladder for some days. At length inflammation was manifested, and the patient rapidly sank, and died on December 17, 1863, twenty days from the time he was wounded. The post-mortem revealed a gangrenous condition of the bowels, with extravasation of urine. The ball had entered the fundus of the bladder and passed thrtmgh on the opposite side into the rectum, and was embedded in the coccyx." Case 864.—Private A. Tweedy, Co. I, 79th New York, aged 26 years, was wounded at Blue Springs, Tennessee, on October 11, 1863. Surgeon C. W. McMillin, 1st Tennessee Mounted Infantry, reports that "a ball entered half an inch to the right of the symphysis pubis, crushing the ramus, tearing the bladder and rectum, and making its exit through the eoccyx." The patient was sent to the Asylum Hospital at Knoxville, October 12th, and died October 15, 1863. The autopsy revealed "extensive inflammation from infiltration of urine; the intestines adhered to each other and to the abdominal peritoneum." Case 865.—Private H. F. Potter, Co. M, 1st Pennsylvania Cavalry, was wounded at Brandy Station, June 9, 1-63, and was sent to Annapolis, on the steamer Platonic, June 22d. Surgeon B. A. Vanderkieft, U. S. V., reported that " a ball entered the right buttock, passed forward through the ilium, rectum, and bladder, and lodged." Death, July 15,1863, from urinary infiltration. 'JARVIS (X. S.) (Surgical Cases at Monterey, In New York Jour, of Med., 1847, Vol. VIII, p. 15G) records a fatal example of shot fracture of tlie ischium, in the case of Private Capers, Baltimore Battalion, with urinary fistula at the pubes and urino-stercoral fistula in the buttock, terminating fatally on the sixteenth day. The same author records the case of Private Young, 1st Tennessee, wounded at Monterey, September 21. 184!i, who died, on the twenty-third day, from a diagonal shot perforation ofthe bladder and rectum without pelvic fracture. SECT. II.] WOUNDS OF THE BLADDER. 297 Nearly all of tlie fatal cases of shot wounds of the bladder in which accounts of the morbid appearances were reported are detailed in the preceding pages, though a few instances relating to the subject will be found in succeeding subsections on wounds of the prostate gland and on wounds of the urethra. Surgeon J. A. Lidell, U. S. V., has pub- lished1 the history of a case of transverse double shot perforation of the bladder, fatal at the end of the third week, and described the agglutination of the intestines and other viscera "by grayish-white or ash-colored, soft, plastic exudation, the product of recent diffuse peritoneal inflammation." Dr. E. G. Jane way has printed2 a very interesting account of dissection of a bladder, in the hypertrophied walls of which a round leaden ball had been sacculated for nineteen years. In a letter to the Surgeon General, Surgeon J. G. F. Holston, U. S. V., referring to an autopsy3 of a soldier shot in the pelvis, remarks that "post-obit examination proved the existence of a perforation of the blad- der, though not a drop of urine had escaped externally, neither had he suffered that excruciating anguish generally the accom- paniment of the extravasation of urine into the peritoneal cavity." Dr. B. B. Miles, in his reports of autopsies at Jarvis Hospital, describes4 the appearances observed in a case p -i ■ lii. I" l' Cj.1 III! FlG. 245.—Section showing the pelvic viscera near the anterior wall of 01 diagonal SU0t perlOratlOn OI tne bladder the pelvis, the rectum turned back: a a, ureters, b b, vasa deferentia. 1 . 1 . \. . ~ The relations of the fasciae, muscles, and iliac vessels and nerves are terminating fatally On the thirty-third day. also well shown. [After HENLE, Handbuch der Eingeweidelehre, B. I, Examples of the effects of shot wounds of the bladder complicated with lesions of the viscera of the abdomen proper, have been adduced under previous headings, as, for instance, Case 533, on page 169, Case 637, on page 219, Case 645, on page 221, Case 690, on page 238; Cases 690 and 697 may also be compared. An analysis of the observations of shot wounds of the bladder observed during the War, teaches that when such lesions are limited to the portions of the bladder uninvested by peritoneum, they will heal readily, provided no foreign sources of irritation are present, and a ready exit for the urine5 is afforded by natural or artificial channels, so that the organ may remain in that state of rest the healing process requires. The wrinkled 'LipELL (J. A.), On Rupture ofthe Abdominal and Pelvic Organs, especially the Bladder, including those occasioned by Fire-arms, in Am. Jour. Med. Sci., 1867, Vol. LIII, p. 3G7, Case X, of Private W. Hesling, Co. I. 9th Cavalry, wounded May 30th, died at Stanton Hospital, June 23, 1854. 2 JANEWAY (E. G.), Proceedings of tlie New York Pathological Society, April 9, 1873, in The Medical Record, Vol. VIII, p. 344. The chief points are stated at the end of the note on page 287, supra. 'Case of Private J. Ingold, Co. A, 68th New York (Cameron Rifles), wounded on picket, October 12, 1861, died at Alexandria, October 14, 1831. * Case of Sergeant H. J. Tucker, 1st New York- Independent Battery, wounded at Cedar Creek, October 19, 181)4, died November 21, 1864: " The ball fractured the left pubis near the symphysis, passed through the bladder, and fractured the spine of the right ischium. Near the ball track, the peritoneum was discolored and in a gangrenous condition; there was slight effusion of blood in the peritoneal cavity. The coats of the bladder were _ indurated and the mucous coat was ulcerated at some points, and the muscular tunic was disorganized in spots. The scrotum was infiltrated with effused blood. The kidneys were congested, the liver and spleen were normal." sColles (Lectures on the Theory and Practice of Surgery, Am. ed., Phila., 1813, p. 133) remarks: "In gunshot wounds of the bladder urine is never effused." BECK (Chirurgie der Schussverletzungen, 1872, S. 562) cites four fatal cases of shot wounds of the bladder. At the autopsy, in the case of B-----, 2d Baden Grenadiers, after opening the peritoneum, a reservoir filled with urine, ichor, and gas was found; ichorous exudations were found in the pelvic'cavities of the other cases. Stbometek (Maximen, u. s. w-, S. 630) recites at length a case of shot wound of the bladder. Urine in very small quantities continued to ooze slowly into the cavity of the abdomen, as indicated by continued vomiting and cold extremities, while there were hardly any signs of peritonitis. A "spitzkugel" had opened the bladder, the point remaining in the bladder. The ball had beeu pushed back by a catheter just enough to allow the urine to escape into the peritoneal cavity, as was demonstrated by the autopsy. NEUDORFER. (Handbuch der Kriegs- chir.. 18.17. S. 814) relates the case of Wischnai, 9th Hussars, shot in the abdomen in February, 1834; death, March 10, 1834. At the autopsy, the missile was found to have grazed the external coat of the bladder, and, passing between the bladder and rectum, to have catered Douglas's space, escaping to the right ofthe gluteus; secondary opening of tho bladder; the peritoneum above the bladder and the adjacent connective tissue were thickened and infiltrated with urine and pus, and covered with phosphates; beyond this space no peritonitis. 38 298 INJURIES OF THE PELVIS. [CHAP. VIL form of cicatrix usually remaining is represented by Figure 245; but, after the lapse of time, all marks of perforation by a small projectile maybe obliterated, as in Dr. Jane way's observation. The viscus usually contracts adhesions to the adjacent tissues at the seat of injury, and, when there is pelvic fracture, is often united to the bone by adventitious fibrous tissue, as in Case 856. Such adhesions involve unpleasant dragging sensations when the bladder is distended. When large fistules are established, communicating with the cutaneous surface of the groin or perineum, or with the cavity of the rectum, their walls acquire an epithelial lining continuous with the mucous coat of the bladder. It is alleged that persistent fistulous communications with the small intestine have been observed.1 I have never seen an anatomical demonstration of this, and have looked in vain for a satisfactory description of such a condition. Mere or less hypertrophy of the muscular tunic is observed when patients survive mechanical lesions of the bladder for any considerable length of time. If the injury is near the neck, and its effects seriously impede micturition, the consequent muscular hypertrophy is proportionally exaggerated. The cases in which extravasation of urine into the peritoneal cavity was clearly estab- lished proved speedily fatal. The observations of Syme, Chaldecott, and Walters2 indicate, however, that the undecomposed urine does not necessarily act as a mortal irritant to the serous sac, and suggest a therapeutic expedient, to be considered hereafter. Diffuse infiltration of urine between the deep pelvic fasciae had consequences varying with the extent and direction of the infiltration; generally, more or less sloughing of connective tissue was induced, and abscesses, and pysemic or septicemic infection often followed.3 Projectiles lodging in the cavity of the bladder are apt to induce chronic cystitis, with ammoniacal urine and phosphatic deposits, which usually encrusted the foreign body. It was noticeable that iron missiles were more quickly coated than those of lead, and that silver catheters maintained in the bladder were very soon encrusted, phenomena suggestive of an explanation partly chemical, partly mechanical. Projectiles lodged more frequently in the walls of the bladder than in the cavity, and, in some instances, induced no functional disturbance, until, by ulcerative absorption, they intruded into the cavity. If the tissues were tolerant of the presence of these metallic foreign bodies in some situations, it was otherwise with detached fragments of bone. These, if driven into the cavity of the bladder, sometimes became the nuclei of calculi; if lodged in the walls or surrounding tissues, they invariably induced abscesses and fistulous communications with the exterior. Coagulated blood and mucus, and hair likewise, served as nuclei for phosphatic concretions in the bladder. MM. H. Larrey, Ohassaignac, and Girald^s assert (I. c, p. 336) that coins 'Compare Dr. PETEES's observation, Case 790, and the cases recorded by KEItAUDREN (P. F.) (Causes des Mai. des Marins, 1817) and by FLEUKY (DEMARQUAYS Mim., p. 300). 2 CHALDECOTT (ProvincialMedical Journal, London, 18J6, p. 333); case of John Philps, wine-merchant in Dorking, aged 50; the distended bladder ruptured by violent contact with a post. Si'ME (Contributions to the Pathology and Practice of Surgery, 1818, p. 303, reprinted from the Edinburgh Monthly Jour, of Med. Sci., 1848, Vol. VIII, p. 503); a youth of 17, in Benjamin Bell's practice; bladder lacerated by a fall on a sharp paling; recovery after free extra-peritoneal incisions. WALTERS (A. G.) (Case of Rupture of the Bladder, treated by Abdominal Section, in the Med. and Surg. Reporter, 1862, Vol. VII, p. 153); case of John Bohland, aged 22, rupture of the bladder from a kick, a case largely reprinted at home and abroad. 3 ATCHLEY (Extravasation of Urine in a Child, following Rupture of the Urethra from a Blow, in Lancet, 1871, Vol. II, p. 677); BlRKETT (Case of Extravasation from Urine from Ruptured Urethra, in Lancet, 1856, Vol. I, p 230); WlCHJIANX (J. E.) (Idee.n zur Diagnostik, Hannover, 1703-1802, B. Ill, S. 44); OsiANDER (F. B.) (Neue Denkwiirdigkeiten, u. s w., Gottingen, 1797, B. I, St. 2, S. 302); CAGNION (Infiltration d'urine a la suite d'un contusion au pirinie, in DESAULT, Journal de Chir., Paris, 1792, T. I, p. 373); Sabatier, (Mid. opiratoire, Paris, 18:22, T. II, p. 156); Wallace (Extravasation of Urine from Rupture of the Urethra by a Fall, Lancet, 1856, Vol. I, p. 230); BOXETUS (Sepulchretum, Genevae, 1700, Lib. Ill, Sect. XXIV, Obs. XII, p. 631); MONTAGU (C) (A Case of a Rupture of the Bladder from a Fall, in Med. Communications, London, 1790, p. 284); OLLEX- ROTH (Jll.) (Von einer bey starker Quetschung des Beckens zerplatzten Urinblase, in THEDEN, Neue Bemerkungen und Erfahrungen, Berlin, 1795, B. Ill, Beob. 3, S. 138); CHOPART (Traiti des maladies des voies urinaires, 1792, T. II, pp. 80, 94); GuYON (Article Abdomen, in Diet encyclop. des Sci. Mid., 1869, T. I, p. 174),- LAUGIER (Article Vessie, in Diet de Mid., en 30, Paris, 1846, T. XXX, p. 741); HOLT (Lancet, 1866, Vol. I, p. 457) cites two ciises of extravasation of urine, one from retention, the other from external injury; DlTTEL (Harninfiltration, in vox Pitha und BILLROTH, Handbuch der Allgemcinen und Speciellen Chirurgie, 1872, B. Ill, Abth. II, S. 187); PETIT (Des ipanchemens dans le Bas-ventre, in Mini, de I'Acad. Roy. de Chir., 1753. T. II, p. 101); Clejiext (De lipanchemeut d'un liquide ou d'un gaz comme accident des plaies du bas-ventre, These a Paris, 1839, p. 20). SECT. II.1 WOUNDS OF THE BLADDER. 299 Fin. 216 —Vpsienl calculus having a deformed conical ball as a nucleus. Spec. 6329. J. and buttons, as well as bone fragments, may be driven into tho bladder by shot. The possibility is obvious, but, as there is no evidence that such foreign bodies ever have boon thus introduced, the remark is hardly in conformity with that scientific precision to be anticipated from such a source, that exactness which surgical investigators should ever esteem a sacred obligation.1 In connection with considerations on the pathological anatomy of shot wounds of the bladder, may be inserted representations of the encrusted projectiles already referred to on page 271, in detailing the cases of Mason and Lindsay, Cases 796 and 797. These interesting specimens were kindly transmitted by Dr. J. L. Forwood, but, it will be remembered, not in season to admit of the insertion, in the proper place, of engravings to illustrate them. Figure 246 represents the concretion removed from the bladder of Lindsay (Case 796), a flattened conoidal ball, largely encrusted with triple phosphate,2 successfully extracted by lateral lithotomy two years and nine months subsequent to the reception of a shot wound of the pelvis. In December, 1873, seven years and eight months subsequent to the operation, Lindsay enjoyed fair health, and was employed as a weaver in a factory at Upland, Delaware County, Pennsylvania. Figure 247 represents the encrusted conoidal ball with limited deposits of triple phosphate, successfully removed from the bladder of Mason (Case 797, p. 271) five years after the reception of a shot wound of tbe pelvis.3 Mason was also well in December, 1873, pursuing his avocation as a fisher- man on the Delaware. Dr. J. L. Forwood is 'mrmly of the opinion that the ball was not in Mason's bladder until six weeks prior to the operation." "I knew him very well," Dr. Forwood continues, "and for years after his return from the army I saw him every few days. There was a puckered cicatrix in the centre of the pubic arch. There were no symptoms of calculus whatever. Six weeks prior to the operation, while he was fishing for sturgeon in Delaware Bay, he suddenly felt a stinging sensation in the hypogastrium and a desire to urinate, and passed a little blood with his urine. Calculous symptoms supervened immediately afterward. Mason left his boat and came home to Chester and consulted me, and, on sounding him, I detected what I believed to be a ball. The operation followed as soon as his consent was obtained. There was no chronic inflam- mation in this case, an evidence, in my estimation, of the correctness of my hypothesis that the ball had a brief residence in the cavity of the bladder. Mason had a quick recovery, and subsequently enjoyed uninterrupted good health."4 'Professor Longmore (Holmes's System, 1861, T. II, p. 68) directly, and GUTHRIE (Lectures, p. 70) by implication, state that: "Percy removed a ball and a portion of shirt from the bladder." Percy simply recounts such an operation by Duvkrge (p. 269, supra). " The greatest length of the rounded encrustation and ball together, a* they probably were placed in the bladder, was about 38 millimetres. The weight of the ball and investing matter is 631 grains Troy. The encrustation consists almost entirely of ammoniaco-magnesian phosphate; there is, however, a trace of phosphate of lime. 3 The encrusted missile weighs 4S6 grains Troy. The encrustation is of unmixed ammoniaco-magnesian phosphate. 4 In addition to the thirty-two examples of balls extracted from the bladder already noticed, I find a thirty-third instance in Wierrf.r (Neueste Vortrage der Professoren der Chirurgie und Vorstdnde der Kranlcenhaiiser zu Paris uber Schusswunden, Sulzbach, 1849, S. 76, note): Major G------, of WUrzburg, was shot in the groin in the Russian campaign of 1812, and the wound healed without serious derangements. Fifteen years subsequently, this officer began to suffer from calculous symptoms. Iu the latter years of his life he could micturate only by strongly flexing the thigh and leaning [he trunk to the opposite side. lie died of an affection ofthe heart, in 1836. At the autopsy, a ball was found in the coats of the bladder near the neck; half of the missile, projecting into the cavity of the bladder, was covered with calcareous deposit an inch long by half an inch in width, the concre- tion acting as a valve over the urethral orifice. The encrusted ball was presented by Dr. WlERUER to the Anatomical Museum in WUrzburg. Fio. 247.—Conoidal mus- ket ball removed from the bladder. Spec. 6330. J . 300 injuries of the pelvis. [chap. VII. FlG. 248.—Cystic oxide calculus removed from a discharged soldier. Spec. 6334. \. Dr. J. L. Forwood more than compensated for the delay in forwarding the specimens from the cases of Lindsay and Mason, by transmitting the specimen and history of a third ease, an instance of shot contusion of the bladder, followed by the formation of a cystic oxide calculus, which was successfully extracted by lithotomy: Cask 866.—Sergeant William McMonegle, Co. A, 12th New Jersey, received an injury at the battle of Chancellorsville, Mnv 3, 1863. Dr. J. L. Forwood, of Chester, reports that the sergeant's statement was that, while in the act of firing, a piece of shell struck the butt of his musket, and that he was knocked down and remained insensible for half an hour, when he rallied and rejoined his regiment. After the battle, he reported to the regimental surgeon and was off duty for three weeks. The monthly report of Surgeon A. Satterthwaite, 12th New Jersey, for May, 1863, mentions by name only those ofthe command who were killed at Chancellorsville, and this case is not reported on the Corps casualty lists; but these omissions by no means invalidate the soldier's personal narrative, which proceeded to recount that, on recovering from his swoon, he felt a severe pain in his back, and one week afterward a stinging pain in the bladder, accompanied by partial retention of urine. He was not placed under medical treatment, and a month subsequently his urine was voided with difficulty and pain, and sometimes dribbled away involuntarily. These symptoms never abated; but rather increased steadily up to the period at which, years afterward, he underwent lithotomy. At the battle of Gettysburg, July 3, 1863, Sergeant McMonegle was wounded in the forearm and was sent to West's Buildings Hospital, where Surgeon George Rex, U. S. V., recorded his admission without indication of the nature of the injury, and added that this soldier was sent to modified duty as a guard at the Park, July 24,1863, 'and to duty October 21, 1863. The sergeant stated that after rejoining his regiment he suffered so much with pain in urinating that he was off duty half the time. The urine would dribble away uncontrollably, and he would be mortified at dress parade by the stains on his trousers. He was discharged on the expiration of his term of service, in August, 1865, and returned to his home in Woodbury, unable to work, and suffering with such painful vesical symptoms as to be deprived of rest at night. He was treated by Drs. Clark and Howell, of Woodbury, but did not improve, and, in 1867, removed to Chester. Drs. C. J. Morton and Roland explored the bladder with sounds without detecting the presence of a calculus. Then, for a year, the patient was under the care of Dr. Del worth, of Chester, and his symptoms were not alleviated. Then he applied for treatment at the clinic of the University of Pennsylvania, but when Professor II. H. Smith was about to explore the bladder with a sound, the sergeant's courage forsook him and he escaped from the table. He came under Dr. J. L. Forwood's observation in this wise: As the Doctor was pursuing a country drive, he saw a man on the road with a wheelbarrow, who presently set down his barrow, and lying down in the pathway on his side, endeavored to void his urine, apparently with extreme distress, so that when the Doctor stopped and enquired the cause of his suffering, he said: "I wish the ground would open and let me in!" He readily accepted Dr. Forwood's advice, and, on exploration, a sound at once detected a calculus of medium size. On November 20, 1869, the ordinary operation of lateral lithotomy was performed; the concretion (FlG. 24S) was easily grasped and extracted. The after-treatment presented no unusual incidents; convalescence was uninterrupted and rapid. In December, 1873, McMonegle was enjoying good health and was employed in a foundry at Chester. The calculus, weighing, after drying, two hun- dred and fifty-eight grains Troy, is a remarkable and beautiful example of a cystic oxide concretion, capped at the extremities of the long axis by deposits of triple phosphate. The exterior (Fig. 248) and the appearances on section (FlG. 249) are accurately represented in the accompauyiiig wood-cuts. The calculus and the principal memoranda from which the foregoing abstract was compiled were contributed by the operator, Dr. J. L. Forwood, to the Army Medical Museum. In this case, cystitis and possibly consequent calculous deposition is referred to a blow upon the hypogastrium, which, beyond cavil, appears to have temporarily paralyzed the contractile power of the bladder. The case, in the latter point of view, confirms the obser- vation of Dr. F. H. Hamilton (Case 780) on this effect of contusions in the hypogastrium. M. Legouest and Mr. Blenkins agree with Professor Hamilton1 as to the frequency of this 1 HAMILTON (F. II.) (Princ. Mil. Surg., 1865, p. 324). LEGOUEST (L.) (Traiti de Chirurgie d'Armie, 2me 6d., 1872, p. 423), who also teaches that, '"L<> gros projectiles * * lorsqu'ils frappent obliquement sur l'abdomen ou le bassin, peuvent rompre la vessie." Blenkixs (Additions to Article Gunshot Wounds, in the eighth edition of COOPER'S Dictionary, 1861, p. 835): "Paralysis of the bladder is not an uncommon result of blows fioin shot or large pieces of shell, and rupture of the bladder when in a state of distention may occur, without being accompanied by corresponding injury to the external parts." Williamson (Mil. Surg., 1863, p. 118) notes a case of incontinence of urine from a contusion by a spent round shot. FIG 6334. 24i).—Section showing the internal structure of Spec. sect, n.] WOUNDS OF THE BLADDER. 301 FlG. 250.—Side view of the viscera cf the male pelvis. WILSON.] [After result, of which I find no evidence, and sustain also the supposition that shell contusions produce ruptures of the bladder, of which the experience of our own and other late wars has afforded no instance, the nearest analogous example being the case reported by Air. Presoott Hewett,1 of rupture of the bladder by a blow of a bar of iron on the hypogastrium. The only pathognomonic sign of wound of the bladder is the escape of urine by the artificial opening. Pain, frequent micturition, and bloody urine are uncertain signs; indeed, the source of hsematuria, in abdominal injuries, is often very obscure. The diagnosis rarely presents difficulties, save in regard to the extent and nature of the complications. A glance at Quain's familiar plate (Fig. 250) suggests that these must of necessity be frequent and varied; shot wounds of the bladder unat- tended by injuries either of the pelvic bones, the rectum, the blood-vessels, or genital organs, being rarely observed. Restlessness, anxiety of counte- nance, lumbar pain, tenesmus, haematuria, a rapid pulse, and low temperature are usual, but not invariable, accompaniments of wounds of the bladder.2 Contrary to general opinion, M. Demarquay (I. c, p. 293) has established, by repeated actual measurements, that distention of the bladder does not elevate the recto-vesical duplicature of the peritoneum, the distance from the extremity of the cul-de-sac to the perineum remaining at 7 or 8 centi- metres, whether the bladder is full or empty. Accepting these measurements, there is difficulty in believing that this peritoneal fold escaped perforation in some of the cases of recovery. Among the fatal cases were several of men shot in prone or stooping postures, the missiles entering the nates or perineum (Fig. 251) and passing through the fundus of the bladder into the abdominal viscera, causing extravasa- tions and mortal peritonitis. In the treatment of wounds of the bladder, our surgeons had no confidence in the preven- tion or cutting short of inflammatory accidents by depletion, and directed their efforts to the mitigation of the complica- tions caused by urinary infiltration.3 To restore the passage of the urine by the natural channel, to prevent consecutive distention of the organ, to evacuate blood accumulated in its# cavity, and to diminish as much as possible the escape of urine through the tissues, were the objects held in view, and mainly sought by the aid of the catheter. Cystoraphy, though recommended by M. Legouest, was not practised. 1 Hewett (P. G.), Ten Cases of Ruptured Bladder, in Transactions of the Pathological Society of London, 1850-52, Vol. HI, p. 229. 2 Compare M. Le Gros Clark's discriminating observations on the diagnosis, Lect on the Principles of Surg. Diag., 1870, p. 335. 'FISCHER (H.) (Schussverletzungen der Bauchhohle, in vox Pitiia and Billroth, Handbuch der Allgemeinen und Spec. Chir., B. I, Abth. II, S. 252,) remarks: '"Shot wounds of the bladder are more frequent and dangerous, when the organ is distended and the ball enters from behind. Generallj-, diffuse peritonitis, copious infiltration of urine, and gangrenous inflammation soon develop themselves. But adhesions and closing of shot wounds of the bladder with double perforation even have been observed. * * Shot wounds of the anterior wall of the bladder need not open the peritoneum.'' FIG. 251.—Drawing to show the direction of a shot penetration of the bladder nearly in a line with the long axis of the body. [Aitered from BOUItG&ItY.] 302 INJURIES OF THE PELVIS. [CHAP. VII. No instance of protrusion of the bladder after shot wounds was reported; indeed, Samuel Cooper's observation of three cases of traumatic cystocele, after the battle of Waterloo, remains unparalleled in- modern warfare. As the bladder rarely protrudes and its shot perforations are seldom simultaneously single and communicating with the exterior by short and direct canals, the cases admitting of the easy application of sutures must be very infrequent. Some of the many survivors with vesical fistula might, perhaps, hope for relief by cystoraphy. Early incisions were rejected, as facilitating rather than obviating urinary infiltration; but, after this had taken place, incisions for evacuation of urine and pus and gangrenous connective tissue were often practised with the most beneficial results. PoneyeVs practice1 having suggested, and Chopart's writings2 inculcated, the advan- tages of catheterization in shot wounds of the bladder, the elder Larrey attached great importance to this feature in the treatment. In accordance with Larrey's precepts, the introduction and maintenance of a catheter throughout the progress of treatment was regarded as of imperious and uniform necessity in wounds of the bladder; but, as many lithotomists came to doubt the utility of maintaining a tube in the prostatic wound after cystotomy, and then to discard this expedient as superfluous and occasionally hurtful, so, as experience in the management of wounds of the fundus of the bladder has- augmented, some surgeons have become skeptical regard- ing the necessity or advantage of keeping an instrument in the bladder. Baudens appears to have first suggested3 that the presence of a catheter might prove a hindrance to the healing process. In a case reported by , 252.—Squire s catheter a demeure. Spec. 4088. £. ox x j Professor Van Buren,4 already alluded to on page 264, he advantageously refrained from the employment of a catheter; and Herr Beck's later experience5 inclines him to the view that catheterization should not form a routine part of the treatment. On the other hand, the judicious use of the catheter constitutes, in many instances, the most essential therapeutic resource. Surgeon T. H. Squire, 89th New York, who has paid special attention to the subject, attaches great importance to the continuous maintenance of a catheter, and, in a case that will be described with Wounds of the Urethra, devised an instrument with a special curve (Fig. 252), adapted to the pendulous portion of the urethra. A French elastic catheter is, I think, preferable. 1 In BORDENAVE's Observations sur les Playes par Armes Afeu, in the Mim. de I'Acad. de Chir., 1753, T. II, p. 523. In the case of a soldier shot in the bladder at Charleroi, " M. Poney6s voyant que les urines ne sortaient point par le voie urinaire, eut recours a la sonde, qui devient trfis-utile pour debarasser la vessie des urines, et procure Tissue de quelques petits caillots et de portions membraneuses." 2 CHOrART (Traiti des Mai. des voies urinaires, 1792, T. H, p. 93): "II faut souvent, et mime dSs le premier temps introduire par l'urfitre une sonde dans la vessie, soit pour procurer Tissue de Turine ou quelques caillots de sang qui y sont retenus, soit pour detourner ce liquide de ces plaies." 3 BAUDEXS (Clin, des plaies d'armes a feu, 183G, p. 368): "Cette fistule, comme on le voit, s'est etablie et guSrie par les seules forces de la nature, dont les efforts salutaircs ont 6t6 un instant arretes par Tintroduction de la sonde. Ce qui prouve qu'il est des cas ou il faut savoir s'abstenir de Tintro- duction de la sonde dans la vessie, et que la presence de celle-ci n'est pas indispensable pour la gu6rison des fistules urinaires.'" 4 VAX BUREX (W. H.) (New York Medical Journal, 18G5, Vol. I, p. 105): " The continuous presence of a catheter in the urethra and bladder of a man, already suffering from a most serious wound, is no trifling addition to the burden he has to bear, and although, in deference to all high authorities, from Chopart and the Larreys to Legouest and Hamilton, the use of the instrument is properly regarded as the rule in gunshot wounds of the bladder, the result of this case demonstrates that the rule may be occasionally disregarded to the advantage of the patient." In this case, Professor Van BUREN states that: " The temperature, during the first two weeks of his confinement, was never below 80°, varying from this to 92°." An astonishing observa- tion, about which there must have been some mistake ! 6 BECK (B.) (Chirurgie der Schussverletzungen, 1872, S. 559) advises the use of the catheter'only where there is retention. An elastic catheter, or, better still, one made of tin, may be introduced, perineal section being practised, if catheterization is otherwise impracticable. He describes hia change of view as follows: "Icli liabe in friihester Zeit der Ansicht gehuldigt," der Katheter miisse augenblicklich nach der Verwundung eingef iilirt sverden, ich bin aber seit vielen Jabren davon zurUckgekommen." SECT. II.] WOUNDS OF THE PROSTATE. 303 It is important to leave the orifice free, and to renew the instrument every two days, until the cure is complete. Opium, by the stomach and by enema, and frequent warm baths, greatly mitigate vesical irritation, and, if the extent and direction of the wounds admit of it, washing out the bladder by tepid injections is very serviceable. After the first few days the bowels should be kept soluble, by diet if practicable, by laxatives if necessary.1 Wounds of the Prostate.—While so much has been written on enlargements and other diseases of the prostate,2 Velpeau and Vidal3 are among the few authors who have treated of its injuries in a systematic man- ner, although in all treatises on the pathology of the urinary organs, or on operations on the urethra or bladder, considerations respecting the physical lesions of the prostate necessarily hold an important place. From the point of view of the military surgeon, the general custom of omitting any special mention of wounds of the prostate might well be followed, for incised wounds are considered in treating of cystotomy; and such is the complexity of shot wounds of the pelvis, that there are few that interest the pros- tate without, at the same time, implicating parts less tolerant of injury. Still, in a work of the magnitude of this history, it is convenient to multiply subdivisions, and as one case was reported in which a ball lodged in the prostate, and others in which this organ was the principal seat of injury, it is not amiss to form a separate grnnn trinilO-h ftlP Pnaaa inrlndprl in if mi crYi f tin VP Fin. 253.— Prostate, seminal vesicles, and bulb of the urethra seen ioup, uiougn Lue caseb mciuueu in it, migni nave from behind and showinff alS() Cowpers glandSi the ischi„.lir()S. l 1 i •.] ,1 i c • f il tatic ligaments, and middle perineal fascia, sections of the corpora been placed Wltil tlie aCCOUnt OI injuries Ot the cavernosa, and the internal obturator muscles. [After Axgek.] $. bladder or of the urethra. Of the pathology of the seminal vesicles and Cowper's glands (Fig. 253) little is known. Civiale, Lallemand, and Faye4 have collected a few examples of calculus, of suppurative inflammation, and of tubercle in these organs. In a case of shot wound involving these parts,5 there was persistent priapism. The direction of the wound-track, ischuria, excessive pain in defeca- 1 Few, if any, pathological preparations cf shot wounds of the bladder are preserved outside the Army Medical Museum ; at least I have not found such in the collections I have examined or the catalogues to which I have access. In many museums, there are numerous specimens illustrating wounds or cicatrices after cystotomy or vesical puncture; and examples of ruptured bladder, in which the Army Medical Museum is deficient, are not uncommon elsewhere. Preparations exhibiting stabs or lacerations of the bladder are uncommon. At the Warren Museum, No. 2482 is the bladder of a child transfixed by a hay-hook (J. B. S. Jackson's Cat, p. 524). At 0 uy's, 2104 93 is a bladder pierced by a catheter, and 2104 rs shows a stab in the posterior wall. At St. George's Museum, No. 35, in Series IX, shows a laceration of the rectum and bladder by the broken leg of a chair (Cat, p. 412); No. 4, of Series XII, shows a stab wound of the bladder, and No. G, same series, shows a puncture ofthe bladder by a catheter (Cat, p. 549). 2 Prostate,—npo, before, uttij.ui, to stand ; Lat., Glandula prostata ,- Ger., Vorsteherdriise. 3VELPEAU (A. L. M.) (Plaies de la prostate, in Diet de mid. en 30, 1842, T. XXVI, p. 134), a lucid, exhaustive essay of ten pages, in the best style of the master. VlDAL (AUG.) (Traiti depath. ext et de mid. opirat, 5we ed., 18G1, T. IV, p. 707) devotes a chapter of his classical work to this subject, reproducing in the main his valuable paper from the Annates de Cliirurgie Franc, et itrang., 1841, T. II, pp. 31 et 20G. Emmert (C.) (Lehrbuch der speciellen Chirurgie, 1862, B. Ill, S. 708) has one short paragraph on Wunden der Prostata. COSTELLO has a short article on Wounds of the Prostate, in the third volume of the Cyclopedia of Practical Surgery. Systematic writers generally refer only incidentally to one group of wounds of the prostate, those from within outward, in treating of the contusions and false routes made in catheterization, the punctures and incision; rur;-osely made in operations. In the journals, an occasional observation of physical lesions of the prostate is found; thus: MONOD (Blessure de la pr/state dans laponction visicale sus-pubienne, in Gazette des HOpitaux, 1855, No. 121, p. <.84). 4Civiale (Traiti pratique sur les maladies des organes ginito-urinaires, 3">e 6d., 18o8, T. II, p. 503); Lallemand (Des maladies des organes genito-urinaires, Paris, 1825); Lamperiioff (Diss, de vesicularum natura et usu, Berlin, 1835). The chief observers were Ameiis, Cruvkiliiier, Dalmas, and Mitchell. Fayk (Diss. de. vesiculis seminalibus, Christiania, 1841). " Case of Private M. Perkins, Co. K, 6th Maine, wounded near Fredericksburg, May 3, 1863. The ball chipped the left acetabulum and ischium, and passed through the thyroid foramen, between the rectum and prostate ; he lived thirty-eight days; there was persistent priapism for many days. 301 injuries of the pelvis. [CHAP. VII. tion, and sio-ns detected on catheterization and exploration by the rectum, may sometimes suffice to establish the diagnosis of a lesion of the prostate; there is no pathognomonic sign. Abstracts are given of two fatal cases, and of one which had a favorable termination : Case S.J7.—Sergeant 11. Ford, Co. F, G7th Xew York, was wounded at Fair Oaks, May 31, 1862, and was admitted to Douglas Hospital on June 4th. Assistant Surgeon Warren AVebster, U. S. A., reported that " a ball entered on the posterior part of the thigh two inches below the lower portion of the sacrum and three inches to the right of the median line, passed forward and inward, apparently through the lesser ischiatic notch, and lay embedded in the neck of the bladder or the prostate portion of the urethra. A sound introduced into the bladder comes in contact with the ball near the neck of the bladder. AVater injected into the bladder passed out through the wound. The urine, having a fetid smell, and being mixed with pus, was disciiarged by means of a catheter. June 12th, haemorrhage from the urethra, apparently venous in character, occurred this afternoon, and one quart of blood was lost; ice was applied to the perineum until the haemorrhage ceased. A pill, contain- ing half a grain of opium and three grains of sugar of lead, was given every two hours. June 14th, the haemorrhage has not returned, and the patient now passes his water without difficulty; there is still a fetid discharge of pus and urine from tbe wound. On June ICth, haemorrhage from the wound occurred again to the amount of one quart. June 17th, the patient has bled several times since the 15th, always from the wound, and had much trouble about passing bis urine. He died at eleven o'clock P. M. Examination, ten hours after death, showed that the ball had passed inward, fracturing the spine of the ischium, detaching the lesser sacro-sciatic ligament, wounding the internal pudic artery, and was embedded in the prostate gland." Cask 80S.—Private Charles C------, Co. A. 30th Iowa, aged 24 years, was wounded at Vicksburg, May 22, 1863. He was placed on a hospital transport and taken to Memphis, and admitted to Jackson Hospital on May 27th. Acting Assistant Surgeon S. H. D. Garretson made the following report of the case: "The ball entered midway between the trochanter major of the left femur and the apex of the os coccygis, and made its exit in the right femoral region one inch below Poupart's ligament. Patient stated that very profuse haemorrhage occurred immediately after the reception of the wound. Urine escaped from both entrance and exit wounds, but none from the urethra. At every considerable motion of the patient blood escaped from the femoral opening of the wound despite the pressure of compresses. Slight diarrhoea, accompanied by deep jaundice, occurred on the 30th. On June 4, 1863, the patient expired. Post-mortem revealed that the prostate gland above the floor ofthe urethra and at its junction with the bladder was cut away; that the right ramus of the os pubis was shattered to fragments; and that the femoral vein was either originally cut or had afterward sloughed from the effects ofthe injury. There was not much infiltration of urine among the pelvic tissues. At the request of Surgeon E. M. Powers, 7th Missouri, in charge of the hospital, the bladder, prostate gland, and femoral vein were dissected out, and accompany this condensed history of the case." The pathological preparations were transmitted to the Museum by Surgeon W. AA7atson, U. S. V.. and one is represented in the accompanying wood-cut. In the preparation of the urinary bladder (FlG. 254) there is a large loss of substance at the fundus, which appears to have been made in removing the viscus. The destruction of tissue in the prostate is greater than represented by the wood-cut. The prep- aration of the femoral vein will be represented in the subsection on wounds of the blood- vessels. The orifice in the vessel is very large. Case 869.—Private E. Holloway, Co. E, 1st Delaware, aged 18 years, was wounded at Morton's Ford, February 6,1864, and was admitted to the field hospital ofthe Second Corps, where Surgeon F. A. Dudley, 14th Connecticut, reported: "Gunshot wound, lacerating the prostatic portion of the urethra. March 4th, the ball was extracted through the left natis. March 15th, the urine now flows from the anterior wound." On March 24th, the patient was transferred to the 2d division hospital, Alexandria, and the injury was recorded as a penetrating wound ofthe bladder. The patient was transferred to Tilton Hospital on August 20th, and thence transferred to the Veteran Reserve Corps, January 28, 1865, and discharged without pension. Cases 791 and 855 are also instances of shot lesions of the prostate ; * another example, Case 899, will be found on page 313, and still another with Wounds of the Urethra. 1 Special works on the diseases of the prostate, where the effects of mechanical lesions are sometimes incidentally adverted to, are those by HOME (E.) (Pract. Obs. on the Treatment of the Diseases of the Prostate Gland, London, 1811); his paper, on the Middle Lobe, is in the Philosophicul Transac- tions, 1806; Wilson (J.) (On the Male Urinary Organs, London, 1821); Amussat (Lecons sur les ritentions d'urine et les mat de la prostate, Paris, 1832); DL'GA (Frag.pour servir & lliist des mat de la prostate, These de Montpel., 1833); VERDIER (G. E.) (06*. et Reflex, sur les phlegmas. de la prostate, Paris, 1838); MERCIER (L. A.) (Essai sur un nouv. moyen de diagnos. des diverses diformat. de la prostate, in the Arch, gen., 3e serie, 1839, T. V, p. 209); Lerot (d'Etiolles) (Considerat anat. et chir. sur la prostate, Paris, 1840); Stafford (On the Prostate, 2d ed., London, 1845); Cacdemont (Des engorgements de la prostate, 1847, ThSse de Paris, 198); Adams (J.) (Anat and Dis. of the Prostate Gland, London, 1853); Gellik (De Vhypertrophic de la prostate, etc., These id., 1854, No. 149); Beraud (Des mat de la Prostate, the. d'agg., Paris, 1856); COULSON (On the Diseases of the Bladder and Prostate Gland, 5th ed., London, 1856); HODGSON (The Prostate Gland, London, 1856); Ledwich (Inflammation of the Prostate, in the Dublin Quart. Jour., 1857, Vol. XLVII); JAPLN (De Vhypertrophie de laprostate, Th. de Paris, 1857, No. 155); TAGAXD (De laprostatite aigue, 1858, id., Xo. 131): Daussure (De Vhypertroph. de la prostate, id., No. 136); DELII0MME (De la prostatite aigue, id., 1859, No. 87); GUERLAIN (De la prostatorrhie, I860, id., No. 237); THOMSON (II.) (Diseases of the Prostate, Jacksonian prize-essay for 1860, 4th ed., Phila., 1873); MALSANG (Prostatite, Th. de Paris, 1865, No. 141); Descubes (Sur les abcls de laprostate, 1866, id., No. 185); Dodeuil (Sur les alt. senile de laprostate, 1866, id., No. 8); Llschka (Das vordere Mittelstuck der Prostata und die Aberration derselben, in ViRCHOW : *lrc7i. d. path. Anat, 1865, S. 592); Verneuil (Ectopie congen. part, de la prostate, in Arch, gen., 6° s6rie, 1866, T. VII, p. 660); GOULEY (J. W. S.) (Diseases of the Prostate, Chapter XI of his work on Dis. ofthe Urinary Organs, 1873, p. 259); GUTGUES (Quelfpies considerations sur laprostate, Paris, 18C8). FlG. 254.—The prostate channelled and disintegrated by a musket ball. Spec. 2093. £. sr.rr. ii.j WOUNDS OF THE RF,(TUM. 305 Wounds of the Ivkctum.—Of the traumatic affections of this region described by systematic writers, those made by pointed or cutting instruments are commonly produced by the surgeon, and will he noticed under the head of operations. The rectum' may be lacerated in defecation, or by the penetration of sharp fragments of bone into the intes- tine A\Tith the feces; such accidents usually induce fi-tules of the anus, which will be examined further on. Pieffenbaclr and others have known the clumsy introduction of a clyster-syringe to produce perforation of the rectum, and the injection of the liquid of the enema into the cellular tissue, a very dangerous accident. Serious lesions are sometimes consequent upon the introduction oi' bulky or irritating foreign bodies into the rectum with a therapeutic or criminal purpose; such cases will be considered under the head of foreign bodies. Shot wounds of the rectum are not infrequent, tliough rarelv uncomplicated; they are scarcely mentioned by Mayo and others, who have treated specially of the injuries and diseases of the rectum; but claim the serious attention of the military surgeon, for the safety and the comfort of the patient largely depend upon the judgment and skill with which their treatment is conducted. This subdivision will, accordingly, be mainly occupied with the examination of the cases of this group reported during the War; but recorded operations for fistules, hemorrhoids, foreign bodies, etc., will also be chronicled. One hundred and three cases of shot wounds of the rectum were reported, of which fortv-four, or 42.7 per cent., resulted fatally. In forty-six cases concomitant fractures of the pelvic bones are distinctly noticed, the osseous lesion being specifically re- ferred to the pubis in eleven cases, to the sacrum in nine, to the ischium in four, to the coccyx in four. Bv implication, however, the reports indicate the existence of pelvic frac- tures in a much larger proportion than forty-six of one hundred and three cases; indeed, there is nothing in the observations to contradict the theoretical Considerations from Which Fio. 255.—Section of the pelvis, according to Desormeaux, showing a portion of the 1 • r 1 ir1 re°tum> a portion of the bladder at the neck, the pelvic aponeuroses, etc. From the extreme rarity ot shot wounds ot bouvier's inaugural thesis. [After anger.] *. the rectum without pelvic fracture might be deduced. Pelvic cellulitis, and septicaemia3 from fsecal infiltration, diffuse suppurations and other consequences of osseous lesions, and secondary bleedings from injury of the branches of the iliac arteries, were the complications that most commonly preceded a fatal termination in this group of cases. The wood-cut (Fig. 255) indicates 1 Rectum, a Latin word, preserved in the English, French, Spanish, and Italian languages, notwithstanding its unfitness, to designate the third and last portion of the great intestine: Gr. Aoyyavoi', Gn. Mastdurm. * DlEFFESBACH, in Journal fiir Chirurgie und Augenheilkunde, B. IX, S. 14?. 3Beck (B.) (Chirurgie der Schussverletzungen, 1870, S. iJ'A) regards shot wounds of the rectum as not dangerous in themselves, though often attended by mortal complications. lie adduces four cases having a favorable issue and live fatal eases, and remarks of the latter that "death ensued in consequence of extensive csseous lesions involving the head cf the femur, the acetabulum, etc., or else from injuries of the vessels, particularly of branches of the internal iliac ; or, finally, from septicaemia consequent on the infiltration cf faeces.'' Further on (S. 555) the same author advises "not to search in blind channels for the missile, as it frequently passes spontaneously with the fa?ces." ^9 306 INJURIES OF THE PELVIS. [CHAP. VII. the relations of the rectum to the pelvic fasciae, and explains .the liability of the faeces, retained by the contractions of the sphincters, to be widely diffused along the aponeurotic planes when the gut is perforated. Thirty-four of the cases, of which fourteen were fatal, are known to have been complicated with wounds of the bladder. Many of these cases have been detailed in the subsection on wounds of the bladder.1 Some examples of comparatively satisfactory recovery2 after shot wounds of the rectum will first be examined: Case 870.—Private TV. A. Colton, Co. F, 42d Mississippi, was wounded and captured at Gettysburg, July 3, 1863. Surgeon A. J. Ward, 2d Wisconsin, reported a gunshot wound of the pelvis. The patient was transferred to De Camp Hospital. Surgeon J. Simons, U. S. A., reported that "a ball entered the left ilium about three inches posteriorly to the anterior superior spinous process, and emerged about an inch to the left of the anus." Acting Assistant Surgeon A. N. Brockway stated that "faecal matter came from each orifice; the man was in a very weak condition on admission; pulse small, at 110 and very weak, and he was much reduced in flesh. He had moderate diarrhoea, and the discharge from the wounds was copious. He was put upon stimulants and beef-tea, with opium; the diarrhoea was soon relieved. The wounds were dressed with oakum alone, and kept well washed; he soon began to mend, and the wound of exit closed in three weeks; the wound of entrance healed in the middle of September. Two or three small fragments of necrosed bone had come away. The general health of the patient rapidly improved, and he was sent to Fortress Monroe about the 1st of October, 1863, to be exchanged; he was then in apparently perfect health." Case 871.—Corporal J. W. Alexander, Co. B, 10th West Virginia, aged 22 years, was wounded at Cedar Creek, October 19, 1864, and, on the 23d, was admitted into the Patterson Park Hospital, Baltimore, where Acting Assistant Surgeon M. Kempster reported that "the ball entered about two and a half inches to the right of the anus, and, passing obliquely upward, had penetrated the rectum at a point three and a half to four inches above the anus. The patient had a profuse diarrhoea, and was considerably debilitated; faecal matter passed through the artificial anus continually, making the man a loathsome object. An astringent was administered, good diet given, and the wounds were dressed with dry oakum. October 26th: The patient complained yesterday of pain and swelling an inch anterior to the anus, and this morning there is an opening there, which also discharges faecal matter; none is discharged by the anus. Stimulants were given, and also anodynes to relieve the acute pain. October -28th: The patient is somewhat improved; the last opening carries off all the faecal discharges, thus relieving the original opening made by the ball. The diarrhoea is somewhat better; the discharges are less frequent, but thin. November 1st: The diarrhoea is nearly well, and the opening made by the ball is healing, and, since the discharge has been checked, the opening anterior to the anus is closing and the faecal discharge passes naturally. The opening anterior to the anus is syringed with cold water at each dressing, and the man appears clean and healthy. The diet throughout has been low, and no solids whatever have been given. November 10th: The wound made by the ball is nearly healed; the other is closing fast; no faecal matter has been discharged from it for five or six days; the diarrhoea is entirely checked. The object has been to keep the bowels somewhat constipated, and the result thus far has been satisfactory; his general condition is very good. The wounds have entirely healed, but the parts are yet a little tender. There has been no further treatment beyond limiting the diet and dressing tlie wounds with dry oakum." This soldier was returned to duty January 17, 1855. He is not a pensioner. Case 872.—Private G. W. Parks, Co. A, 16th Pennsylvania Cavalry, aged 30 years, was wounded at Po River, May 9, 1864, was treated in the Cavalry Corps Hospital, and subsequently transferred to the Second Division Hospital at Alexandria, where Surgeon E. Bentley, U. S. V., reported: "Admitted, May 24th, with a gunshot wound ofthe upper third ofthe left thigh and right natis, the ball passing through the rectum. Simple dressings were used, the wound healed, and he was furloughed on November 7th. He was readmitted on November 30th, and was discharged the service on May 30, 1885, on certificate, with complete disability, the consequence of gunshot wounds of both thighs, bladder, and rectum." Examiner C. H. Dana, of Tunkhannock, reported, March 15, 1872, that the " ball entered the upper and inner portion of the left thigh, passed under the pubic arch, and made its exit just under the ischium of the right side, passing through the rectum and neck of the bladder. The wounds of the rectum and bladder soon healed, but the wounds at the points of entrance and exit of the ball would heal for a time and then open. They now remain constantly open, and continually discharging pus, and sometimes blood, submitting him to great inconvenience, producing weakness and considerable pain on exercising. Disability three-fourths and probably permanent." This pensioner was paid to June 4. 1873. Case 873.—Sergeant J. F. McGill, Co. D, 25th New York Cavalry, aged 21 years, was wounded at Woodstock, October H, 18(54. On the 11th, he was transferred to the depot hospital at Winchester, and on December 5th, to Frederick. Acting Assistant Surgeon T. E. Mitchell reported that " a small conical ball passed through the fleshy part of the thigh at the upper third, through the perineum and lower part of the l-ectum, and came out near the left sacro-iliac articulation. When he was admitted at Frederick, the wound of exit was discharging but little; his bowels moved once or twice a day, with but little pain; ten grains of tartrate of iron thrice daily, with milk-punch, constituted the general treatment. He continued to improve until the 20th, when a discharge of faecal matter occurred from the wound of exit, accompanied with loss of appetite, and smarting pain in the track of the wound. It lasted but three days, when the fever subsided, his appetite rjturned, and the condition of his bowels became quite regular, being moved but twice in twenty-four hours." He was transferred to New York, January 7, 1865, and was discharged from service, at McDougal Hospital, June 13, 1865. He is not a pensioner. 'Compare Cases 786, Wesson; 788, Janisch; 789, Blake; 790, Estee; 791, Mooney; 805, Shafford; 807, M. C. H,---; 810, Gardener; 821, Fore; 822, Currier; 823, Grubb; 825, Warren; 832, Scott; 835, Harger; 851, H. B---; 852, Relyea; 855, Wait; 8G0, D. Smith; 863, Baggs ; 864, Tweedy; 865, Potter. * S ir< jmeter (L.) i Maximen, etc., 1855, p. 6C8) asserts that: '• Injuries of the rectum occur generally in shot wounds of the lower portions of the MiiTiim. and, of themselves, are not dangerous.'' SECT. II. 1 WOUNDS OF THE RECTUM. 307 The relative proportion of cases of complete perforation of the pelvis by balls, and of cases of penetration with lodgement, has been only approximately ascertained. If instances of subcutaneous lodgement are included, the latter group would have a consid- erable numerical predominance. The following are some instances of lodgement, with extraction of the projectiles through incisions : Case 874.—Sergeant A. G. Buchanan, Co. I, 139th Pennsylvania, aged '-il» years, was wounded at Chancellorsville. He was sent from a Sixth Corps hospital to Stanton Hospital. Surgeon J. A. Lidell, U. S. V., records a shot wound of the right buttock, and the patient's transfer to Satterlee Hospital, June 17, 18(33. Acting Assistant Surgeon L. K. Baldwin reported that "a conoidal ball entered the right natis nearly on a level with the anus, penetrated to the depth of seven inches, and lodged. When admitted, he was suffering a grout deal of pain in and around the wound, from which there was a profuse discharge of unhealthy pus. Several shreds of clothing came away with the discharge, much to the relief of the patient. On July 10th, an examination revealed the lodgement of the ball between the tuberosity of the ischium and the anus. It had gravitated to this point and become so painful as to render its extraction necessary. An incision made between the tuberosity of the ischium and the anus failing to reach the ball, another was made through the rectum, at the verge of the anus, when the ball was easily reached and extracted with the forceps. The bowels were then locked up for a week, and the wound was dressed with cold water. At the end of this time it was found that the opening made through the rectum had entirely healed, and no faecal matter passed through it when his bowels were moved. By August 8th, the opening made in the fossa and the wound of entrance were almost entirely healed. The patient, having suffered severely from the pain attendant on the wound and long confinement to which he was subjected, now began to slowly regain his health Fio. 256.—Compressed i i t. i i ■■> -, .. * j /.i i it -r. / < ancl mutilated musket and strength." He was returned to duty on March 2b, l&b4, transferred to the Veteran heserve Corps ball extracted through January 28, lSoo, and was mustered out June 29, 18(1", and pensioned. The Examining Board at the rectum. Spec. 4429. Pittsburg, Drs. McCook, McCandless, and Wishart, reported, June 7, 1871, that this pensioner was permanently disabled by the injury received from "a ball, which entered the middle of the right gluteus muscle and passed toward the median liue, cutting the rectum and injuring the sphincter ani." The missile (FlG. 256) was presented to the Museum by Dr. L. K. Baldwin. Case 875.—Private I. M. D. Crane, Co. G, 3d Michigan, aged 2(5 years, was wounded at Chancellorsville, May 3, 1863. Surgeon E. L. Welling, 11th New Jersey, reported his admission to a Third Corps field hospital with a shot wound of the left hip. He was sent to Armory Square Hospital, and acting Assistant Surgeon R. S. L. Walsh reported that the ball entered four inches posterior to the anterior superior spinous process of the left ilium and lodged. It evidently passed through the rectum, as, in giving an injection, part of this would pass out of the wound. He was very much exhausted from the discharge and the formation over the right ischium of a large abscess, which was opened on June 4th, to his. great relief. There was a great discharge of pus, but the ball was not found as was expected. June 24th: Patient doing well with the exception of a bed-sor e. September 12th: A spherical case-shot was removed from the right natis by the surgeon in charge. September 24th : Patient doing well. He received a furlough in January, and was readmitted in March, and, on July 2, 1864, was discharged the service. The missile, represented in the wood-cut (Fig. 257), is a round iron ball from spherical case, and was transmitted to the Museum, with the foregoing memorandum, by Surgeon D. W. Bliss, U. S. V. Examiner H. O. Hitchcock, of Kalamazoo, reported, October 17, 18d4, that "there is loss of power in the left leg, and constant pain in the left leg and back, with severe constipation." He rates the disability at th^ee-fourths and temporary. Kig. 257. — Iron case- Examiner E. Arasden, of Allegan, reported, September 4, 1873: "The ball was extracted from near the buttock, after perforata" tuberosity of the right ischium, causing considerable injury to the gluteal muscles. Disability three- the rectum.—Spec. 4489. fourths, not permanent." Case 876.—Private F. Gleaser, Co. G, 8th New York Heavy Artillery, aged 25 years, was wounded at Petersburg, June 22, 1854. Surgeon J. F. Dyer, 19th Massachusetts, and Surgeon F. F. Burmeister, 69th Pennsylvania, reported from a Fifth Corps hospital that "he had received shot wounds of the right or of both hips.'' The patient was sent to Judiciary Square, when Assistant Surgeon A. Ingrain, U. S. A., recorded, July 1, 1864, that "the ball, passing through the right hip, perforated the rectum." Transferred to Rochester, November 26, 1864, the patient was reported, by Acting Assistant Surgeon A. Backus, as "having a fistulous opening communicating with the rectum, caused by a minid ball, which entered the right buttock, and was extracted from the perineum at the field hospital before Petersburg." This soldier was discharged from service July 25, 1865, for total disability. He appears not to have been pensioned. Cask 877.—Sergeant D. K. Brinson, Co. H, 13th Georgia, aged 21 years, was wounded at Gettysburg, July 1,1863. He was treated in the Seminary Hospital until July 30th, and then transferred to Camp Letterman, where Acting Assistant Surgeon J. A. Newcombe reported: "The ball entered the left groin and was excised from near the point of the right buttock. There was considerable haemorrhage from the anterior or wound of entrance, but scarcely any from behind, though the ball was almost immediately removed. The rectum, however, was wounded, and its contents escaped through the posterior wound; this ceased altogether after the lapse of a week. The bladder escaped unhurt. August 7th : The wounds are now nearly healed and give no inconvenience, and the patient walks out daily; he is quite convalescent. Tonics and full diet were given and the wound dressed. Ou August 20th he was suffering from diarrhoea, which was relieved in a few days by the use of astringents and opiates. September 15th: The patient is quite well as regards general health, but has not recovered the perfect use of his limb; he experiences some difficulty in flexing the thigh upon the abdomen.'' On September 10th he was transferred to West's Buildings Hospital, whence he was paroled September 25. 1863. 308 INJURIES OF THK PELVIS. [chap. vu. Stercoral Fistuloz after Shot Wounds of the Rectum.—The occurrence of abnormal anus after shot perforation of the rectum was not infrequent, and there was, perhaps, a greater persistency in ilecal fistula? in this region than in those communicating with the colon through the fleshy parietes. The frequently attendant osseous lesions satisfactorily account for this, the discharges from carious bone and the occasional escape of sequestra keeping open sinuses that might otherwise contract and close : Case 878.—Private E. Machenbach, Co. E, 4th Missouri Cavalry, aged 25 years, was wounded at Mine Creek, Kansas, October 25, 1864. Surgeon F. V. Dayton, 2d New Jersey Cavalry, reported a slight shot wound of the left hip. The patient was treated at Mound City, by Surgeon E. Twiss, 15th Kansas Cavalry, until January 15, 1865. and then transferred to Fort Leavenworth, where Surgeon G. W. Hogeboom, U. S. V., recorded a "wound of the left hip and thigh by a conoidal ball, which penetrated the abdomen." On April 24, 1865. this soldier was discharged and pensioned for "gunshot wound through the left ilium;" disability rated as total. Examiner J. Bates, of St. Louis, reported, on May 1, 1865, that the wound of exit was still suppurating and there was lameness, which would probably improve. This invalid never drew his pension, but subsequently enlisted in the 29th Infantry. On March 30, 1868, Surgeon G. E. Cooper, U. S. A., reported that he had been in hospital at Fort Monroe suffering from the effects of a wound through the sacrum, implicating the rectum, and causing a fistulous sinus, through which the fasces passed when the bowels were at all soluble. He was returned to duty with his company at Alexandria, March, 1868. Case 879.—Private W. H. Aucker, Co. B, 1st Minnesota, aged 22 years, was wounded at Gettysburg, July 2, 1863, by a minie" ball, which entered the right thigh two inches above and one inch posterior to the right trochanter major, penetrated the right ilium, passed across the body, wounded the rectum, and emerged two inches external to the left sacro-iliac synchondrosis, having penetrated the left ilium from the inner surface. He was received into the field hospital on the 3d, and, on July 26th, was transferred to Camp Letterman Hospital. Assistant Surgeon H. C. May, 145th New York, reported that, "on admission, the wound of entrance was healed; that of exit still open, and discharging faecal matter. He had lain upon his face almost the whole time since the reception of the injury. His appetite was good; he slept well, and suffered very little pain." On November 7th, he was transferred to Newton University Hospital, Baltimore, on April 25, 1864, to De Camp Hospital, New York, and discharged from service June 4, 1854. Dr. A. L. Lowell, of the Pension Office, has furnished the following memoranda in the case: "Certificate of discharge states: Gunshot wound of the right hip and abdomen, the ball passing through the intestines. Certificate of examining surgeon, September 15, 1864: The wound is not healed; subject very feeble. July 24, 1866: Partial artificial anus where the ball passed out. The use of the legs is much impaired. Ingtsta and small seeds pass out at times through the wound of exit of the ball. April 12, 1869: An artificial anus still exists, and at times the contents of the bowels pass out through the opening; he cannot endure hard labor, espec-ally in walking, as both legs are affected. December 6, 1871: When the wound is open, wind passes through the opening on the left side; when closed, air infiltrates the surrounding parts; he has frequent discharges of blood and pus from the rectum; the parts are very sensitive to pressure; the left leg is somewhat atrophied, with lessened nervous sensibility; all efforts at manual labor are painful." Case 880.—Corporal E. H. Shermcr, Co. H, 74th Ohic, was wounded at Stone River, December 31, 1862. Three slugs entered the left buttock, passed through to the right, lodged there superficially, and were removed by the surgeon ofthe field hospital [Surgeon George D. Beebe, U. S. V.], where he remained two days, and was thence transferred to hospital No. 9, Nashville, and was about five weeks under the care of Assistant Surgeon Stegman, 2d Missouri; he was then sent to New Albany, and, five months later, to Madison, where his wounds healed, and on November 27,1863, he was transferred, by Surgeon Gabriel Grant, U. S. V., to the Veteran Reserve Corps. He was discharged the service, April 12,1864, from Cliff burne Barracks, Washington. Dr. Adams Jewett, Pension Examiner at Dayton, reports : "Exactly how long he was under treatment, my notes do not record; he says that faecal matter was discharged from both wounds for about four and a half months, and that a piece of bone came out about ten months after he was Avounded, and that his faeces sometimes passed involuntarily. On April 16, 1864, I examined him for pension. In the left gluteal region, six inches in front of the median line of the sacrum and seven inches below the crest of the ilium, is a cicatrix as large as a dollar, and in the right gluteal region a smaller scar also, about six inches in front of the median line of the sacrum and eight inches below the crest of the ilium. In sitting, he rests upon the edge of the chair, bearing his weight on one tuberosity of the ischium; he says that sitting square causes pain at the end of the backbone; he says he has not full power to retain the contents of the bowels, especially if there is any tendency to diarrhoea; he is considerably lamed, and looks of infirm health. He was examined September 30, 1865, when his general health seemed improved, and he was less lame, but found much difficulty in walking over uneven ground; he complained of pain in the lower part of the back, hips, and thighs; the control of the alvine evacuations is improved but not perfect; he still sits upon the edge of tho chair, though he can sit squarely for a time by help of a cushion." This .pensioner was paid to June 4, 1873. Case 881.—Private H. Shafer, Co. A, 116th Ohio, aged 21 years, was wounded at Winchester, June 13, 1863. He was transferred from the field hospital to Jarvis Hospital, Baltimore; on April 26, 1854, to De Camp Hospital, New York; and on June 9th, to the Seminary Hospital at Columbus, Ohio. Assistant Surgeon G. Saal, U. S. V., reported: "Gunshot wound; ball entered right hip; exit at pelvic region; faecal fistula in the left groin; simple dressing and compresses." Transferred, August 27. 1864. to Camp Dennison, and afterward treated in Tripler Hospital. Discharged February 4,1855; disability three-fourths. Pension Examiner W. Walter, of Woodsfield, reported, May 13, 1867: "At Winchester, June 13, 185.'., he received a gunshot wound in the rear of the left hip, entering within one inch of the spine, passing through the pelvis, and making its exit in the left groin near the scrotum, causing weakness of the left leg and back. In my opinion he is for the greater part incapable of obtaining subsistence by manual labor; disability three-fourths, probably permanent," This pensioner was paid to March 4.1873. SECT, u.l WOUNDS OF THE RECTUM. 309 In the next case, it appears quite likely that tlie sigmoid flexure, rather than the rectum, was implicated, and, from the scanty indications in the report, it may be inferred that eversion and prolapsus of the intestine at the entrance orifice had supervened: Case 882.—Private II. P. Stoddard, Co. F, 2d Vermont, aged 24 years, was wounded at Savage Station, June 29,1862. Transferred to Broad and Cherry Streets Hospital, thence to Marine Hospital, Burlington. The first detailed account of the injury is given by Acting Assistant Surgeon S. W. Thayer, who reports that "the ball entered to the left of the penis, passed through the pubis, rectum, and ilium, and came out a little to the left of the anus. lie passed fa-cos through both openings for several weeks." This soldier was discharged July 30, 18(13, and pensioned. Examiner C. M. Chandler, of Montpelier, reported, September 4, 1873: "A discharge from the wound over the pubic bone is now uncomfortable and disagreeable. There is quite a growth at the entrance wound. The ball entered through the left pubis and made its exit through the buttock ofthe same side. There is an artificial anus, and the disability continues total." In the following eases, the patients succumbed to the constitutional drain involved by the irritation maintained by persistent stercoral fistules: Case 883.—Private B. H. Clark, Co. A, 32d Massachusetts, aged 18 years, was/ wounded at Spottsylvania, May 12, 18(54, by a conoidal ball, which entered the pelvis and perforated the rectum; he also received a wound of the head. He was treated in a field hospital, and on the 18th was transferred to Stanton Hospital, Washington; was furloughed on June 30th, and admitted into Dale Hospital, Worcester, July 5th. At each of the above hospitals a shot injury of the rectum was recorded. On November 14th, the patient was transferred to the Soldiers' lvest, Boston, where Acting Assistant Surgeon W. E. Townsend reported that "two fistulous openings were left by the wounds, through which fares passed." He was discharged the service December 8. 1865, and applied for a pension, stating in his declaration "that he was unable to leave his bed or help himself in any way." He died April 17, 1866, at the Home for Discharged Soldiers, in Boston. Cask 884.—Private E. D------, Co. F, 120th New York, aged 36 years, was wounded at Spottsylvania, May 10, 1864. and admitted to Harewood Hospital on the 13th, the injury being noted as a wound of the left groin by canister shot. He was discharged, April 25, 1865, for total disability from a gunshot wound of the left groin, by Surgeon 11. B. Bontecou, U. S. V., who transmitted to the Museum the photograph copied in the wood-cut (FlG. 23S). Pension Examiner J. H. Clark, of Newark, reported, July 31, 1867: "The ball entered the left side of the abdomen opposite the crest of the ilium. It seems to have found its way outside the small iiitestiues and to have penetrated the rectum. The ball was removed from this situation. Before its removal, however, the fsrcal matter seems to have found its way out. Now the wound presents the appearance of an artificial anus; indeed, faecal matter was manifest to the sight and smell when I visited him to-day. He says that he defecated by the anus every week or two, but that the contents of the bowels continually find exit by this abnormal orifice. His general health is good. He has been in the hands of good surgeons, who see no chance of his recovery. It would seem impossible that surgical interference should avail to close the orifice in the rectum. Eight pieces of bone have been discharged; the ulcer looks as if more might appear. Were not the rectum penetrated, I should suppose recovery possible. He is now, of course, very helpless, and requires constant attendance and the performance of disgusting services; blood frequently passes from the anus. Disability total and permanent." The records show that this pensioner died on June is, 1869. Case 885.—Sergeant Kufus G. Hayward, Co. B, 4th Vermont, aged 10 years, was wounded at Fredericksburg, December 13, 1862, and was treated in field hospital until the 18th, when he was admitted to Mount Pleasant Hospital, and thence furloughed on May 12, 1863. On August 5th, he entered the Brattleboro' Hospital. Surgeon E. E. Phelps. U. S. V., reported a "gunshot wound; ball perforating abdomen, but not lodging, with lesion of intestines.'' This patient was discharged the service October 30, 1863. Pension Examiner S. Newell, of St. Johnsbury, Vermont, reported, November 4. 1864. * * : "Gunshot wound, ball entering the left side, wounding the intestines and bladder; urinary fistula and artificial anus resulted. He is failing in health ; will probably terminate fatally in a few months;'' and on November 23. 1869, Examiner C. (' Cahoon reported: "I attended Rufus G. Hayward occasionally after his discharge up to the time of his death, which occurred on August 10, 1869, so that I was familiar with his disease up to his death. He had two abscesses on his left side, which broke out and became running sores; and, by a breaking of the colon or huge intestine, there was a constant discharge of faecal matter up to the time of his death, rendering him helpless; he had also three abscesses in his back constantly discharging; an entire loss of use of left arm and leg, so that he was wholly unable to dress and undress himself, all occasioned by gunshot wounds received in action." Case SS6.—Corporal A. Young, Co. C, stb Ohio, aged 35 years, was wounded at Mine Run, November 27, 1853, sent to Alexandria, and discharged May 7, 1864, by Surgeon T. R. Spencer, U. S. V., for "gunshot wound ofthe abdomen, perforating the cavity and wounding the bladder and rectum, and chronic cystitis resulting therefrom." This soldier applied for pension, September, 1864, Examiner G. K. Thompson certifying that a ball had passed from the left groin through the bladder and rectum, and that a rectal fistula persisted; and, subsequently, that the patient died December 5, 1864. Dr. Meyer, of Bucyrus, certified, in support ofthe application ofthe heirs for pension, that the shot wound ofthe bladder and rectum was the sole cause of his death. -.—Stercoral fistula of the [1'ioin a photograph.] 310 INJURIES OF THE PELVIS. [CHAP. VII. In the two preceding cases and in the following case, there were vesicointestinal fistules. and the details reported'do not clearly indicate how far the communications with tbe bladder contributed to the fatal results, or whether the vesical or the rectal injuries should be considered the dominant lesions: Case sv?.—Lieutenant G. Robinson, Co. H, 70th New York, was wounded at Gettysburg, July 2, 1863, and was treated in a field hospital for some days, and the case noted as a gunshot wound of the bowels and lumbar region. The records of the Pension Office state that "this officer received a minie" ball through the lower part of his head, fracturing his jaw, in the Penin- sular campaign; he recovered, and was wounded in the back at Gettysburg, and was treated in Baltimore, at the house of Mayor J. L. Chapman. He was discharged the service March 5, 1864, for disability." Dr. J. E. Culver, of Hudson County, New Jersey, reports that "Lieutenant Robinson died August 3, 1864, from a gunshot wound received at the battle of Gettysburg; the ball having passed through the bladder and rectum, producing injuries which made recovery impossible." A review of cases of pensions after shot wounds of the rectum indicates that paralysis with incontinence of the faeces, or obstinate constipation, stricture, muscular contractions and atrophy, sinuses leading to carious parts of the pelvis, and recurrent abscesses were among the remote disabilities resulting from injuries of this group: Case 888.—Private J. W. Huntoon, Co. D, 4th Vermont, was wounded at Chancellorsville, May 3, 1863. He was admitted to afield hospital ofthe Sixth Army Corps at Potomac Creek, as a paroled prisoner, on May 13th, and, on June 14th, was transferred to Hammond Hospital, at Point Lookout, where Acting Assistant Surgeon R. N. Wright reported: "Admitted with a wound by a minie" ball through the pelvic region, perforating the rectum. The faeces were discharging through both wound orifices. There was total loss of motion and sensation in the lower extremities; his spirits were good; constitution recuperative and energetic. Sulphate of quinia in three-grain doses was given every three hours, and doses of one-sixteenth of a grain of strychnia until he had taken four doses. Stimulating diet was given. August 30th: The patient is now so far improved that with the aid of a cane he walks about without difficulty; he has a good appetite, sleeps well, and will soon be in a condition to travel. Stimulants were administered occasionally, as circumstances required, and simple dressings were applied to the wounds. In my opinion, his wounds will unfit him for military duty for some time if not permanently." He was discharged the service at Convalescent Camp, December 31, 1863. Examiner A. W. Giddings, of Anoka, Minnesota, reports, September 4, 1873: "Gunshot wound in the right thigh, upper third. The ball passed through the rectum, paralyzing the sphincter muscles of the rectum and the bladder, so that he is unable to retain either faeces or urine. Labor causes the cicatrix in the rectum to become irritated and bleed, followed by soreness. He also has loss of sensibility in the right thigh and in the lumbar region. He is obliged to grasp the penis with his hand to enable him to get up and walk across the floor without a discharge of urine; disability total." His pension was paid him September 4, 1873. Case 889.—Corporal S. G. Hodgens, Co. D, 10th Pennsylvania Reserves, was wounded at Oak Grove, June 30, 1862. He was sent to Broad and Cherry Streets Hospital, July 29th, and Acting Assistant Surgeon John Neill made the following special report ofthe case: "Admitted with a gunshot wound of the sacrum; the ball entered behind, near the middle of the sacral bone, in an oblique direction from left to right, and has not been removed. He states that about two weeks before admission some faecal matter was discharged from the wound, which only occurred once, and nothing of the kind has been noticed since. Examination of the rectum reveals no injury of the gut, and the presumption is that the ball passed obliquely downward, burying itself in the gluteal muscles on the right side. At the time of admission his health was very poor; the wound was slightly inflamed, and discharged a small amount of pus. Several spicula? of bone were removed from the wound, and he complained of a deep-seated dull pain in the gluteal region on the right side, between the tuberosity of the ischium and the trochanter major and passing down the thigh. The wound was dressed for a few days with flaxseed poultices, followed by warm-water dressings, and a good diet, tonics, and stimulants were ordered. Under this treatment his health improved very rapidly. The wound looks well and is almost healed. His faecal discharges have been perfectly natural since his admission to the house, and he is now able to walk around the ward." He was discharged the service December 5, 1832. Examining Surgeon John R. Wilson, of Washington, Pennsylvania, reported, December 13, 1863: "A musket ball entered the lower part of the sacrum near the junction of the coccyx, penetrating the sacrum aud lacerating the rectum; the wound is now nearly healed, but leaves a weakness of the back, which is disappearing; disability probably temporary." Examiner W. D. Craig reported, September 14, 1872 : "The ball struck the sacrum about three inches above the extreme point ofthe os coccygis, and passed downward on the right side of the anus, lodging about four inches from the place of entrance, where it still remains embedded in the gluteal muscles. There is from half an ounce to an ounce of pus discharged from the wound every day. The ball is a constant source of nervous irritation. The limb is very painful and cannot bear much exertion. The soreness, nervous irritation, and loss of motive power have increased very much within the last two or three years." His pension was last paid to September 4, 1^73. Case 890.—Private J. Ipes, Co. L, 6th Ohio Cavalry, aged 33 years, was wounded at Petersburg, June 8, 1864. Surgeon W. B. Eezner, at a cavalry corps hospital, and Surgeon T. R. Spencer, U. S. V., at an Alexandria hospital, recorded a severe shot wound of both buttocks. The patient was transferred to Filbert street, Philadelphia, July 13, 1884, where a fracture of the pelvis was diagnosticated; and was transferred to Satterlee Hospital, July 19th, where Surgeon I. I. Hayes, U. S. V., recorded as evere shot wound of both buttocks and rectum, and the patient's discharge for total disability, June 10, 1855. Surgeon J. E. MacDonald, U. S. V., gives a similar certificate, without specifying the nature ofthe disability. SECT. II.] WOUNDS OF THE RECTUM. 311 Abstracts of several other cases of incomplete recovery from shot wounds of the rectum will further exemplify the disabilities consequent on such injuries, when compli- cated by vesical lesions or by pelvic fractures. Figure 255, on page 305, and the adjacent wood-cut (Fig. 259), the latter drawn from a sec- tion of the pelvis of a frozen cadaver, may remind the reader of the relations of the rectum to the other parts contained in the pelvis and to the bony walls. The faeces retained by contract ion of the superior sphincter almost of necessity overflow through a perforation in the upper part of the gut. Hence Dupuy- tren advised1 a division of the sphincter under these cir- cumstances, a practice occa- sionally adopted by our sur- geons, with most satisfactory reSUHS, anCl WUlCll UaS been FiG- o-.j_M.aian section of the pelvis of a frozen adult male cadaver, showing the pubic synchon- l i Jl-TTNlf-, drosis, the divided tunics and cavity of the bladder, with the orifice of the ureter, the prostate, the mUCll employ CO. UV UOCLOrS urethra, cavernous and spongy bodies and testis, the rectum with its external and internal sphincters, P,. tt i T"i i i the recto-vesical duplicature of the peritoneum, and the pelvic fasciae. [After Henle.] J. bimon, Fischer, f'ehr, and others, in the late Franco-German War, as will be more particularly noticed in speaking of the treatment of this group of injuries. Case 891.—Private M. Sullivan, Co. K, 93d Illinois, aged 39 years, was wounded at Chattanooga on November 25,1863. Surgeon J. S. Prout, 26th Missouri, records " a gunshot wound through both hips and bladder." Surgeon J. Perkins, U. S. V., at the general field hospital, reported a "shot wound of the gluteal region, the ball coming out at the right groin." At Nashville, Surgeon C. W. Hornor, U. S. V., records "a severe gunshot fracture of the pelvis, the ball perforating the bladder and rectum." At Jeffersonville, Surgeon M. Goldsmith, U. S. V., reported "a gunshot wound of right groin." At Madison, Surgeon G. Grant reported "gunshot wound of both hips." At Camp Butler, Illinois, Surgeon A. B. Campbell, U. S. V., recorded "a gunshot wound of the right hip, the ball perforating the bladder and rectum," for which injury the patient was discharged May 30, 1865, and pensioned. Examiner C. C. Latimer, of Princeton, reported, September 16, 1869, that "the ball entered the left ischium, passing through the bladder and rectum. He is wholly helpless, and confined to a chair or to his bed all the time, and having a dozen or more urinary fistulae, through two or three of which faeces passed." His disability was rated as total and of the first grade. This pensioner was paid to June 4, 1873. CASE 892.—Private W. H. Bulla, Co. F, 2d Iowa Cavalry, was wounded at Farmington, Mississippi, May 9, 1862. the injury being described on the field record as a "wound of the thigh and rectum, by ball." He was conveyed on the hospital steamer D. A. January to St. Louis, and thence to Jeffersonville, where he was admitted to hospital on the 11th, and furloughed on May 22. 1862. He was promoted to a lieutenancy on February 21, 1864, and mustered out of service May 15, 1885, and pensioned. Examiner Henry Frasse reported: "The ball entered the lower third of the right thigh, passed upward and inward from the posterior face of the femur, and is now lodged in the thigh; the thigh is atrophied and weak. A second ball entered on the right side of the anus, and was cut out from the coecygeus. Whenever the bowels move, the faeces pass out involuntarily. The third ball passed just under the patella and lodged on the tibia, and was cut out ofthe left leg. His general health is excellent; disability total." The lieutenant's pension was paid him September 4, 1873. Case 893.—Private H. Einker, Co. B, 48th Pennsylvania, aged 25 years, was wounded at Petersburg, April 2, 1885, and was sent to Washington, where he was admitted to Carver Hospital on the 5th. Surgeon O. A. Judson, U. S. V., noted the injury as a "gunshot fracture of the sacrum and wound of rectum." This soldier was discharged, June 28, 1865, in consequence ofthe injuries. Pension Examiner J. G. Koehler reported, June 20, 1838: "Eeceived a slight gunshot wound over the lower spine. The wound is now closed and he is able to labor; disability temporary." Rinker's claim for pension was rejected on account of the report of absence of disability. 1 DUPUYTREX. Lecons Orales, 2"" ed., T. VI, p. 471. 312 INJURIES OF THE PELVIS. ICIlAl'. VII. The first of the five following cases, though the ulterior history is unknown, would appear to have been an instance of recovery with an unusually small amount of disability. In the second case, there was stricture, and, in the third, paralysis of the sphincter; while the Case 897 is a recovery with the alleged complication of shot fracture of the great trochanter, and Case 898 a rapid recovery after fracture of the pubis: Case 894.—Private J. TV. Brannon, Co. B, 22d Georgia, aged 18 years, was wounded at Gettysburg, July 3, ISti:!. He was treated in Seminary Hospital until the 27th, and transferred to Camp Letterman, where Acting Assistant Surgeon II. II. Sutton reported: "The patient was wounded by a mini6 ball, which entered a little above the left hip joint, passing through the ilium and sacrum and through the rectum, and passing out a little higher on the opposite side. On admission, he had much pain in the posterior part of the pelvis and a difficulty in passing urine, but did not need the passage of the catheter. There is a free discharge from the openings of the wounds; he has diarrhoea; otherwise, his health is good. Perfect rest was enjoined, extra diet given, and iron, quinine, acetate of lead, opium, and ipecac administered. August 12th: The diarrhoea has stopped, and the patient is slightly improving in other respects; the discharge from the opening made by the exit of the ball is still free; stimulant and tonic treatment continued. August 25th: The patient is improving daily; there is a little soreness about the pelvis, which, however, is not increased by a little walking. The wound made by the entrance of the ball has nearly healed; that by the exit discharges slightly. The same treatment was continued and full diet given, and, by September 3d, the patient feeling well, and the wound being healed, he was allowed to walk a little." - He was transferred to West's Buildings Hospital on October 6th, and paroled on November 12. 1803. Case 895.—Private J. M. Latta, Co. B, 29th Iowa, was Avounded at Jenkins Ferry, Arkansas, April 30, 1861, and was reported by Assistant Surgeon W. L. Nicholson, of his regiment, as mortally wounded by a shot perforation of the pelvis. On June 16th, he was admitted to hospital at Camden with "gunshot wound of the pelvis," but there is no record of treatment or disposition. He was mustered out of service on June 17, 1865. Pension Examiner D. H. O. Linn, of Magnolia, Iowa, reported, August 27, 1870: "The ball entered the left groin and passed directly backward, making its exit in the left hip. In its course it seems to have partially paralyzed the rectum, so that to effect a passage he has to resort to a powerful cathartic or enema. It also seems to havo injured some of the muscles and nerves in this region, so that walking a short distance produces stiffness of the leg and considerable pain at the knee." J. II. Lice, late assistant surgeon 29th Iowa, in an affidavit made July 18, 1870, testifies that he has frequently been consulted in this case, and describes the wound as follows: "The ball entering near the left groin, passing over the edge of the pubis, and coming out through the left natis. Said wound frequently breaks, and discharges for several weeks in succession." This pensioner was paid to June 4, 1873. Case 896.—Sergeant F. M. Simon, Co. H, 105th Ohio, aged 30 years, was wounded at Perryville, Kentucky, October 8, 1862. He was treated in hospitals at Perryville and Louisville, where the injury was noted as a gunshot wound of side and hip, respectively, and finally at Gallipolis, whence he was discharged the service March 8, 1863, for "gunshot wound of the pelvic cavity." Examiner E. Mygatt, of Poland, reported, May 7, 1833: "The ball entered the glutei muscles two inches to the left of the anus and one inch above its line, passed obliquely through the rectum, crossing the perineum, and, passing under the right pubis, emerged through the adductor muscles of the right thigh one and a half or two inches below the groin." Examiner John McCurdy reported, September 6, 1872: * * "The result is stricture of the rectum, paralysis of the sphincter, and an almost constant discharge of pus and faeces, thus rendering a very frequent change of dressing necessary; the right limb is much atrophied, caused by its limited motion on account of the wound." On September 8, 1873, he again reports that "there is a stricture of the rectum at the seat of the wound, and an abscess below the rectum and ischium ofthe right side, and paralysis ofthe sphincter ani and consequent inability to retain the contents ofthe rectum; pus is almost constantly passing away with the faeces; disability total." This pensioner was paid to September 4, 1873. Case 897.—Privat^T. J. Doughman, Co. G, 89th Ohio, aged 28 years, was wounded at Chickamauga, September 20, 1863. He was treated in hospital at Chattanooga and afterward at hospital No. 3, Nashville, where the case was reported as a "gunshot wound of both hips and fracture of the ilium," and he was furloughed February 19, 1864. He was discharged while on furlough, February 29, 1864, and on the certificate of discharge Assistant Surgeon J. V. Anderson, 15th Indiana, records: "Compound comminuted fracture of the right and left ischium, the missile also dividing the rectum." Examiner E. Mead, of Cincinnati, reported, June 11, 1864: "The ball entered the left thigh at the great trochanter, passing entirely through the posterior portion of the pelvis, and, making its exit at a point nearly opposite in the right thigh, fracturing the ischii; one piece of bone was removed; large cicatrices of bed-sores exist; he is obliged to use crutches." Examining Surgeons J. F. White and W. J. WolHey reported, August 2,1871: "The ball entered, grazing and fracturing the left great trochanter, passed through the rectum, and emerged in the right buttock." Examiner G. K. Taylor reported, September 11, 1873, that he had several cicatrices from wounds, one of which, unhealthy, tender, and discolored, covered the entire coccyx; there were also numerous cicatrices over the back, resulting from bed-sores. He was paid to September 4, 1873. Case 898.—Private William I). Bush, Co. G, 13th Georgia, was wounded at Gettysburg, July 2, 1863. He was taken to Seminary Hospital on July 3d, and transferred to Camp Letterman on August 2d, where Acting Assistant Surgeon II. II. Sutton reported as follows: "A mini<5 ball entered the left groin three-fourths of an inch below Poupart's liga"ment and two inches from the spine ofthe pubis, shivering the horizontal ramus; it then passed through the lower part ofthe pelvis, wounding the rectum, and made its exit through the greater sacro-ischiatic notch. October 10th : The passage of faeces from the posterior wound had ceased and the wound was nearly healed, and the suppuration from the anterior wound was free and healthy; his general health was good." He continued to improve until November 10th, when he was convalescent, and was transferred to West's Buildings Hospital. On November 12th, Surgeon T. II. Bache, U. S. V.. reports that he was paroled and sent to City Point for exchange. SECT. II.] WOUNDS OF THE RECTUM. 313 Though the subject is commonly passed over very cursorily by authors, the large proportion of pensioners invalided on account of disabilities resulting from this division of injuries of the pelvis admonishes us that the surgery of the rectum merits much consider- ation from military surgeons. The relation of cases in which patients have survived such injuries, only to endure afflicting infirmities, will therefore be continued. In the four follow- ing cases, fistules persist, either urinary, stercoral, or communicating with diseased bone: Casio 899.—Private T. Fordham, Co. II, 18th New York, aged 31 years, was wounded at Unity's Bluff, May 16, 1864, and sent to Hampton Hospital on the 18th. He was transferred to McDougall Hospital, New York, on July 12th, and the injury was noted by Assistant Surgeon S. II. Orton, U. S. A., as a "gunshot wound of the pelvis," for which be was treated until October 27, 1864, when he was discharged the service for "recto-vesical fistula," being totally disabled. On May 1, 1867, Examiner B. J. Morris, of Plattsburg, reported: "The ball entered tbe pelvis just above the anus, passing through the rectum and penis, injuring the prostate gland, causing total inability to retain the urine, which continues to pass through the wound. He is totally unfit for work." On September 4, 1873, Examiner T. B. Nichols, of Plattsburg, reported him as "so injured in the pelvic region, where the urethra was cut through by a musket ball, that he has no control of his water; his clothes are always wet; he cannot labor, and it is no small job to care for him; an addition of six dollars per month to his pension, although bringing no relief to his misery, would be some consolation." This pensioner was paid June 4, 187:!. Case COO.—Private I. Irons, Co. F, 14th New Jersey, aged 25 years, was wounded at Cold Harbor, June 1, 1864. He was sent to Washington, and was treated in Judiciary Square Hospital until the 19th, when he was transferred to Douglas Hospital, where Assistant Surgeon W. F. Norris, U. S. A., reported the ease as a "penetrating gunshot wound of the rectum, the ball entering the lower portion of the abdomen at the root of the penis, grazing the arch of the pubis, and emerging at the left buttock." He was discharged the service August 18, I860, for "gunshot wound of the pubis and rectum;" disability total. Examining Surgeon M. D. Benedict reported, August 19, 1865: "A musket ball entered the pubis and passed obliquely back- ward through the abdomen, emerging through the left natis, fracturing the pubis and ischium, and perforating the intestine. The wounds are open and fistulous, and faeces are still discharging through them." Examiner Charles Hodge, jr., reports, October 29, 1866: "A ball entered the lower part of the abdomen, breaking the pubis at the symphysis and cutting the suspensory ligament of the penis. Several pieces of bone have been discharged from the anterior wound. The ball passed inward aud to the left, and made its exit from the back about one and a half inches from the middle of the spine; both wounds are still open, as well as several others caused by abscesses connected with the wound, and the contents of the bowels were discharged through them. The left leg is so contracted, owing to the cutting of large nerves by the ball, that he can but just touch the toe to the ground, but cannot bear any weight on it when he is lifted up on his crutches. He is confined to his bed, and constantly requires the personal aid and attention of another vierson; disability total." His pension was increased to twenty-five dollars a month, and was last paid September 4, 1873. Case 901.—Private F. E. Hodgman, Co. I, 24th Michigan, aged 32 years, was Avounded at Gettysburg, July 1, 1863. On September 2d he was admitted to Camp Letterman Hospital, where Assistant Surgeon H. C. May, 145th New York, reported as follows: "Wounded by a mini6 ball entering the left groin and emerging at a point one inch posterior to the right trochanter major, wounding the rectum in its course. November 4th: No history of case previous to October 12th; passed faecal matter through both wounds. During the last four weeks there has been no faecal passage from the wound of exit, and none from the wound of entrance for two weeks past; the wound of exit is closed; the wound of entrance is still open; general health good; transferred November 5th." He was admitted to Newton University Hospital on the following day, and, on July 24, 18J4, transferred to general hospital at Cleveland, Ohio, whence he was discharged the service March 8, 1835. Examiner W. M. Eames, of Ashtabula, reported, October 28, 1865: "The wound was caused by a ball striking the thigh near the point of exit ofthe femoral artery, and passing backward and downward till it pierced the rectum and passed out at the natis on the opposite side. The wound still discharges, though more than two years have elapsed, and the rectum has not yet healed. The secretions of the bowels, especially gases, still pass into the wound and cause great trouble. He is very lame, and the wound is quite painful." The same surgeon reports, September 4, 1873: "He was struck by a ball in the left groin, which passed through the body and out at the left buttock; the injury has affected the muscles of the left leg so as to produce cramps and almost constant neuralgic pain, and is liable to bring on lameness; the rectum is still sore, and gives evidence that there is a fistulous opening by occasionally suppurating and by constant soreness; disability three-fourths and permanent." This pensioner was paid to September 4, 1S73. Case 902.—Private D. C. Feathers, Co. B, 14th Wrest Virginia, aged 23 years, was wounded at Cloyd's Mountain, May 9, 1834. He was probably taken prisoner, as he was first recorded as having been admitted to No. 1 hospital, Annapolis, from the steamer George Leary, on October 9th. On November 2i3th he was transferred to Camp Parole, and furloughed in January, 1865; readmitted, transferred to Patterson Park Hospital, and again admitted to Camp Parole, where he was discharged April 11, 1865. Surgeons James C. Fisher and W. D. Stewart, U. S. V., reported the case as a "gunshot wound of the pelvis, involving the r,ectum," and Surgeon Stewart, in the certificate for discharge, stated: "Gunshot wound of the right hip; the ball entering and passing through the right os innominatum and pelvis, the injury resulting in caries of the bones." Examiner J. Nichols, of Washington, reports, April 14, 1865: "Gunshot wound in the region of the right hip, the ball passing thence into the bowel, perforating the gut. The wound remained open for two months. The parts are yet very weak, though healed, and the joint nearly useless." Examiner Thomas Kennedy, of Grafton, West Virginia, reported, September 30, 1373: "The ball remained in the body; the cicatrix is one inch in diameter; the muscles are shrunk and cicatrix depressed; disability one-half." This pensioner was paid to September 4. 1873. 40 314 INJURIES OF THE PELVIS. |CHA1". VII. In the next four cases, three of the pensioners had fsecal fistula},1 and one suffered from partial stricture of the rectum. In two of the cases, contraction of the muscles and partial paraplegia of one of the lower extremities augmented the disabilities: Case 903.—Private D. Ploss, Co. D, 112th New York, aged 25 years, was wounded at Cold Harbor, June 1, 1864, transferred from a field hospital, and, on the 7th, was admitted to Mount Pleasant Hospital, Washington, where Assistant Surgeon C. A. McCall, U. S. A., noted a "gunshot wound of the pelvis, the ball passing through the rectum." He was furloughed August 15th, but did not return, and was reported as a deserter. He was subsequently admitted to hospital at Fort Porter, New York, whence he was discharged, on a certificate of disability, July 6, 1865. Examiner O. H. Simons reported, November 15, 1872: "Wound of both hips; the ball entered immediately above the external abdominal ring of the left side, and made its exit through the right natis, about four inches above the anus. The wound at the point of entrance has closed; that of exit still remains open, and gives passage to flatus and faecal matter, though only at times." On September 4, 1873, the same examiner reports that "an artificial anus exists at point of entrance, through which faecal matter passes, rendering him, at times, an object of disgust even to himself. Labor brings on attacks of diarrhoea. He is a feeble looking man and unfit for the perform- ance of any manual labor; disability total." This pensioner was paid to September 4, 1873. Case 904.—Private W. Pebworth, Co. K, 4th Kentucky, aged 24 years, was wounded at Chickamauga, September 19, 1883. Surgeon W. C. Otterson, U. S. V., reports, from hospital No. 8, Nashville, that "a round musket ball entered the body two inches above and inside of the anterior superior process of the left ilium, and came out behind, two inches from the right sacro-iliac articulation. Four months after the injury neither wound has healed, though the general health is good, and there is a fair prospect that the patient will go through life with two abnormal anuses. Faecal matters are occasionally discharged through either wound. The bowels move through the natural channel with a fair degree of regularity. Discharged February 23, 1884." He was pensioned, but there is no further medical evidence other than a certificate by Assistant Surgeon J. P. Liddall, 22d Indiana, of the same tenor as Dr. Otterson's report. Case 905.—Private J. Sears, Co. B, 8th Michigan, was wounded at Chantilly, September 1, 1862, and sent to Baptist Church Hospital, Alexandria, September 6th. Acting Assistant Surgeon W. Leon Hammond reported as follows: " Wounded by a ball, which entered the left anterior femoral region at the iliac portion of the saphenous opening one and a half inches below Poupart's ligament, and passed downward and backward across the iliacus, perforating the rectum, and passed out of the right great sacro-sciatic notch, and finally emerged from the gluteal region two inches from the coccyx, leaving an orifice which became an artificial anus. The treatment consisted of emollient enemata twice daily; injection of the wound-track with largely diluted tincture of iodine; injection of solution of morphia to relieve the neuralgic pains, and compression. The artificial anus closed by the healing process in forty-seven days." This soldier was discharged from service December 12,1862, as totally disabled. Examiner W. B. Thomas reported, June 13, 1833: "The ball entered immediately beneath the middle of Poupart's ligament of the left side, traversed the body, wounding the rectum, and passed out three inches from the spinal column, through the right of the gluteus muscle." Examiner B. D. Ashton reported, September 23, 1873, that "the ball entered the left groin, passing through the rectum and out at the coccyx; the rectum contracted and the internal sphincter adhered to the coccyx. The passage for the faeces is small; the left leg is partially paralyzed; disability one-half and permanent." The pensioner was paid September 4, 1873. Case 903.—Private A. White, Co. H, 21st Massachusetts, was wounded at Chantilly, September 1, 1882. He was admitted to Baptist Church Hospital, Alexandria, on the 5th. Acting Assistant Surgeon W. Leon Hammond reported that "a minie" ball entered the right gluteal region one inch above the trochanter major, passing through the right great sciatic notch, perforating the rectum and passing out of the left great sacro-sciatic notch, and emerging at the left natis two and a half inches from the axis of the sacrum, producing an artificial anus. For nine days after admission the faecal evacuations passed entirely through the left wound, after which faecal discharges began to pass both from the wound and rectum, and continued to do so for five days, when the artificial anus closed The treatment consisted of an enema twice every day, and injection of the wound with cold water, afterward warm water, and, finally, with diluted tincture of iodine. After each injection, I applied strong compression along the track of the wound. The patient walks with the foot everted and pendant, with no control over the foot; flexion and extension of the foot are impossible, but flexion and extension of the thigh and leg are perfect." On December 5th, he was transferred to McDougall Hospital, and was then discharged from service December 18, 1862. Examiner A. Lambert, of Springfield, reported, March 16,1863, that "he was shot through the right hip above the great trochanter, injuring the spine and intestine, so that faecal matter passed from the wound in the left buttock, and the right leg is partially paralyzed. The ball seems to have entered just above the great trochanter, and issued from the left buttock just above the cleft of the nates, and to the left of the spine; disability total." This pensioner was last paid to March 4,1887. A letter from his mother, dated November 4, 1873, states that he was lost in the ship "Everesta" in a voyage from Fayal to America; date not given. Cases 908, 909, 910, on the next page, relate also to pensioners, one suffering with rectal stricture and two with stercoral fistules.2 There were not wanting, bowever, cases 1 BLAXCO (Guirison de la fistule analepar la sonde d, demeure, in Journal des connaiss. mid-chir., No. 2, 1867) adduces a shot penetration through the perineum into the rectum, the ball producing a wound 3-4 centimetres broad and 7 centimetres long, which became a troublesome faecal fistula. A rubber cylinder was inserted, its upper extremity reaching beyond the internal wound-orifice in the rectum; the faeces passed through the tube, and the injury, which had previously resisted all efforts at healing, closed rapidly. It is diflBcult to conceive of the tolerance of such a cylinder by the bowel, even after division of the sphincters; and this expedient must be regarded as curious rather than as of practical utility. 2 MASSAKOWSKY (PAUL) (Statistischer Bericht uber 1415 franzbsische Invaliden des deutsch-franzosischen Krieges 1870-1871, in Deutsche Zeit- schrift fur Chirurgie, \ifr2, 13. I, S. 321). In eight cases of injuries of the pelvic viscera, the rectum was injured five times, the rectum and bladder twice, and the bladder alone once. In the three latter cases urinary and fecal fistulae remained, SECT. II.1 WOUNDS OF THE RECTUM. 315 in which feecal fistulse in this region closed spontaneously, and at as early a period as shot perforations of the upper part of the large intestine are sometimes observed to close. Cask 907.—Private J. W. Smith, Co. K, 76th Ohio, was wounded, while on the steamer Louisiana, at the engagement at Arkansas Post, January 11, 1863, and was admitted to hospital at Memphis on the 19th, with a gunshot wound of the thigh. He was transferred to hospital at Mound City in April, and Surgeon Horace Wardner, U. S. V., reported that "a musket ball struck the left hip near the origin of the gluteal muscles and passed through the rectum. The ball was lost in the muscular substance. Fa'cal matter passed through the opening at intervals for three weeks. The treatment consisted of the application of simple dressings to the wound; the discharge continued until April 1st, when the wound-orifice healed, after which he walked about for two weeks, and the wound then reopened and continued discharging at intervals until April 14th. He was received into this hospital on April 23d, weak and considerably emaciated. Treatment: Simple dressings externally and anodynes internally. No efforts were made to find the ball except by probing, bis lungs being so diseased, and he being so emaciated and reduced in strength, that it was not considered prudent to subject him to any severe operation. He did well, and was able to walk about at the time of his discharge from service. May 15, 1863." His name is not on the Pension Roll. Casks 908-914.—l'rivate M. Nengebaur, Co. B, 11th New Jersey, aged 20 years, was wounded at Petersburg, June 16, 1864. Surgeon O. Everts, 20th Indiana, reported a shot perforation of both hips. Surgeon A. F. Sheldon, U. S. V., from Campbell Hospital, reported a shot perforation of the rectum. Assistant Surgeon J. T. Calhoun, U. S. A., from the Ward Hospital, Newark, confirmed the diagnosis of the field surgeon. Pension Examiner J. H. Clark reported, July 17, 1835, that "the ball entered the left natis and passed out at a corresponding point on the right, passing through the rectum, producing constriction, and making defecation difficult." Examiners Woodhull, Osborne, and Mercer reported, September 11, 1873, " wound of gluteal region" of each side, injury of rectum."—Private 0. T. Spencer, Co. H, 1st Pennsylvania Artillery, aged 30, was wounded at Fair Oaks, May 31, 1862. Surgeon E. Shippen, of bis regiment, reported a gunshot wound of the pelvis. This soldier was discharged for disability by Acting Assistant Surgeon A. C. Bournonville, October 22, 1862. Examiner C. C. Halsey reported, June 26, 1868, that "the ball entered the right iliac region and passed out through the right buttock. The entrance orifice remains open, constantly discharging pus; there is a fistulous passage into the bowels, which do not move unless stimulated by enemata. Fluid injected into the rectum and faecal matter often pass through the wound, and pus passes by tbe rectum. The original disability has increased, and the patient requires constant personal aid and attention " The same examiner reported, September, 1873. that the disabilities were undiminished.—Private N. W. Halsey, Co. C, 37th Massachusetts, aged 33 years, was wounded at the Wilderness, May 6, 1834. Surgeon J. C. McKee reported, from Lincoln Hospital, "a shot wound ofthe perineum and rectum," and sent the man to modified duty in the Veteran Reserves, March 29, 1885. He was discharged and pensioned June 29, 1865. Examiner E. Wright, of Lee, reported, January 14, 1868: "Ball entered right thigh, passed in front of the femur, penetrated the pelvis, wounding the rectum, and escaped through the right natis; has fistula, causing much inconvenience; disability probably temporary." This pensioner was paid September 4, 1873.—Private C. Sparks, Co. A, 21st New York Cavalry, aged 26, is alleged to have been wounded at Fort Fisher, February 17, 1865. Surgeon B. A. Vanderkieft, U. S. V., reported, from Annapolis, that this man was transferred, convalescent from chronic diarrhoea, to Baltimore,"February 27, 1835. Surgeon A. Chapel, U. 8. V., reported, March 2, 1865, from West Buildings Hospital: " Ball entered right gluteal region, back part, passed through the rectum, and made its exit at left gluteal region; wound received, February 17, 1865,'at Fort Fisher. Furloughed March 3, 1865, to report to chief mustering officer for muster out." This man has not filed an application for pension.—Private M. Kenney, Co. K, 2d Cavalry, aged 27, was shot in a street affray at Washington, September 19, 1831. He was taken to the E Street Infirmary. Medical Cadet E. R. Hutchins recorded1 that a pistol ball entered the left buttock, passed through the rectum, and emerged in the inner right femoral region The finger introduced in the rectum discovered a ragged wound about three and a half inches from the anus. Faecal matter passed by the orifice in the thigh. On September 22d, the sphincter was divided; the faeces continued to pass by the wound in the thigh until October 4th, when the natural evacuations took place, with great relief. The wound-track in the thigh was unavailingly dilated with compressed sponge to promote elimination of fragments from the ischium, and, on February 19, 1862, an incision was made and some pieces of necrosed bone were removed. Assistant Surgeon S. A. Storrow, U. S. A., reports that this man recovered completely, and was discharged July 9, 1862.—Private C. Fundy, Co. B, 5th Louisiana, aged 27, was wounded and captured, August 29, 1834, at Smithfield. Surgeon W. S. Love, P. A. C. S., reported "a gunshot wound through both thighs and rectum." Surgeon A. Chapel, U. S. V., reported, from West's Buildings Hospital, that " the ball entered the left thigh at Poupart's ligament, and came out of the right buttock, having cut through the rectum. Recovered, and sent to Point Lookout, January 8, 1835, for exchange." —Lieut. S. Harrison, Co. B, 5th Louisiana, aged 24, was wounded at Winchester, September 19, 1861. Surgeon W. S. Love, P. A. C. S., reported "gunshot wound of side." Surgeon A. Chapel, U. S. V., reported, from West's Buildings, "gunshot wound of left hip, the missile passing through the rectum." The patient was transferred to Fort Delaware, May 10, 1835. Forty of the fifty-nine cases of recoveries from shot wounds of the rectum have been noted in this subsection, fifteen2 with wounds of the bladder, and four3 with shot fractures of the pelvis. Fatal Shot Wounds of the Rectum.—Of the forty-four reported instances, seven4 have been detailed among the fatal cases of wounds of the bladder, and five on pages 309, 310. Abstracts of thirteen other instances will be related here, including the one fatal •HUTCHINS (K. It.), Boston Med. and Surg. Journal, 1863, Vol. LXV, p. 255, Vol. LXVI, p. 113. 2 Viz: Cases 786, Wesson; 788, Janisch; 789, Blake; 790, Estee; 791, Mooney ,■ 805, Shafford; 807, H---; 812, Smith; 819, Tipps; 821, Fore; 820, Currier; 823, Grubb; 825, Warren; 828, White; 835, Harger. 3Viz: CASES 742, Shermer; 745, Denegan; 74R, Morgan; 747, Davy. 'Viz: CASES 851, B-----: 852. Belyea: P55, Wait: 860, D. Smith; 863. Baggs; 864. Tweedy: 865, Potter. :>1G INJURIES OF THE PELVIS. [(iial*. vu. case (921) in (lie group of nine shot-fractures of the sacrum with lesion of the rectum (compare 2I<>), and two (922, 927) of the three fatal cases of shot-fracture of the ischium with wounds of the rectum. The third fatal case of this group (Murphy) will be detailed on page o2<). with Wounds of the Blood-vessels. In one case, death resulted from tetanus: Cask. 915.—Private I. Catherall, Co. A, 15th New Jersey, was wounded at Gettysburg, July 3, 1863, and sent to Phil- adelphia, to South Street Hospital, on the sth. Acting Assistant Surgeon J. R. Tryon reported that "he was wounded by a minie' ball, which passed in a little to the left ofthe extremity ofthe coccyx, entering the pelvic cavity through the lesser sacro- sciatic foramen, and lodging in front of the rectum and behind the bladder. The ball remained untouched until the 9th, the day he arrived at this hospital, when, on probing the wound with niy fingers, it was detected and immediately removed, together with a considerable amount of his clothing. The man remained quiet and comfortable that night under the influence of a laudanum enema and a poultice to the wound. On the morning of the 10th, he seemed quiet, and suffered no pain; he was kept in bed, and ordered a light nutritious diet, and had a laudanum enema at bed-time. On the 11th, he complained of slight numbness and stiffness of the jaws with some pain in the wound, and a large poultice was ordered to be applied wet with tincture of opium. A grain of opium was given every hour, also egg-punch and beef-tea, and a half grain of sulphate of morphia thrice daily. July 12th, is no better this morning; treatment continued; this afternoon he is perfectly rigid; the bowels have been freely moved, but a communication is found to exist betweeu the wound and the rectum; some pleurothotonos and opisthotonos. The wound is freely discharging and looks better. He died on the morning of July 13, 1863. An autopsy revealed the extent ofthe wound as above stated, and a large rent iu the rectum." The fatal termination in the next case was due to intermediary haemorrhage from a hemorrhoidal artery. Another instance will be found with Wounds of Blood-vessels: Case 916.—Private L. S. Dyer, Co. E, 31st Ohio, aged 17 years, was Avounded at Murfreesboro', June 27, 1863. Surgeon J. R. Arter, of the 31st Ohio, thus referred to the injury: "One case of gunshot wound ofthe hip will likely prove fatal. The ball struck the left ilium one inch above and in front ofthe acetabulum, passing directly across in front of the sacrum, through the rectum, and out through the right ilium at a point corresponding to where it entered." He was admitted to the general hospital at Murfreesboro' on the same day, and Surgeon J. Y. Finley, 2d Kentucky Cavalry, reported as fol- lows: "Gunshot wound; the ball passing through the great sacro-sciatic notches and injuring the rectum. The faeces were passed for some time through the channel formed by the passage of the ball. Secondary haemor- rhage occurred on July 20th, probably from the middle hemorrhoidal artery (Fig. 260). Persulphate of iron was used as a styptic, and lint applied as a compress, but death resulted on the same day. No pyaemia existed." The case may be compared with the instances of shot-fracture of both ilia, on page 215, and illustrates the comments there submitted respecting lateral horizontal perforations of the pelvis in front of the sacrum. It is true that there was a difference of opinion between the two surgical attendants as to whether the missile perforated both ilia, or traversed the great ischiatic notch on either side. Either of these forms of injury is sufficiently rare to be remarkable. One is inclined to accept the report of the field surgeon, who had the better facilities for exploration of the shot track with the finger, and of detecting the fracture he describes with precision. Case 917.—Lieutenant S. H. Anderson, Co. B, 34th Mississippi, was wounded at Atlanta, May 14, 1864. Surgeon D. C. O'Keefe reports:1 "Gunshot wound, ball entering near upper and posterior border of right os innominatum, passing obliquely downward, through the upper portion of the rectum, toward the left thigh, and lodging. On admission, patient was suffering intense pain, with daily febrile exacerbations and constant faecal discharges from wound, which was suppurating very freely. Patient continued in this condition until May 30th, when diarrhoea set in, which continued, except when controlled by opiates and asti ingents, until his death, on June 5, 1864." Case 918.—W. Shaw, Co. K, 95th New York, aged 19 years, was admitted to Harewood Hospital on May 20, 1854, for a shot fracture of the pelvis, received at the Wilderness on May 5th. A ball had entered near the superior process of the left ilium and emerged in the middle ofthe gluteal region. The patient's general health was good; the wound, apparently healthy, discharged moderately. Small pieces of bone were removed, and by July 10th the wound of exit was healed and the discharge from the anterior opening was healthy. Improvement continued till September 1st, when the patient complained of pain in the left groin. On the 10th, extended necrosis ofthe ilium was detected by the probe; from this time the discharge from the wound increased; the patient sank gradually, and died, from exhaustion and diarrhoea, on February 5,1865. On post-mortem examina- tion, the viscera] portion of the peritoneum was found adherent on the left side to the parietal portion; the descending colon, adhering to the fascia ilea, was perforated, and communicated with an abscess below the psoas and iliacus muscles, which were atrophied, and the ilium was soft and diseased. There was inflammation of the rectum and of the mucous membrane of the bowels; the other organs were healthy. Via. 260.—Section of the pelvis, showing the distribu- tion ofthe hemorrhoidal arteries. [After ANGER.] 'O'KKEFE (D. C), Surgical Cases of Interest, treated at Institute Hospital, Atlanta, Georgia, in May and June, 1864. in the Confederate States Medical and Surgical Journal, 1865. Vol. II. p. 26. sF.rr. ii.] WOUNDS OF THE RECTUM. )U7 Another case of lateral perforation of the rectum, that may be compared with Case 916, proved fatal three and a half years after the injury: Cask 919.—Private II. Johnson, Co. M, 1st, Massachusetts I leavv Artillery, aged 23 years, was wounded at Spottsylvania, May 19, 1861, and admitted to Lincoln Hospital on May 22d. Assistant Surgeon J. Cooper McKee, U. S. A., reported as follows: "The wound of entrance was at the outer upper portion of the gluteus maximus muscle; tlie exit, in a straight line on the other side, directly opposite, the missile perforating in its course the upper portion of the rectum. The wounds have alternately healed up, and have then broken out afresh, with the occasional passage of (latus and the evacuation of faeces through both openings, and sometimes with a tendency to slough. This patient was furloughed and readmitted during the month of November, and, on January 18, 181(5, secondary haemorrhage occurred from the gluteal artery or its branches, which was arrested by compression with a T-bandage tightly applied around the abdomen and scrotum; no haemostatic was found necessary. No pyajmia existed. Tbe patient iieifeetly recovered, and, on March 31, 18(i."(, was discharged the service." In accordance with a request from the Surgeon General of Massachusetts, Dr. Stephen Tracy, of Andover, gives the following certified history of the case: "The above-named soldier was of a healthy family, and, so far as I can learn, without any hereditary predisposition to any disease whatever. He was a stout, healthy man, weighing about 165 pounds at the time he was wounded, in May, 1864. Tlie wound was that of a musket ball passing entirely through the pelvis laterally, involving tbe rectum to such an extent that the faeces passed through the external opening for six months or more. At the time of his discharge, in March, 1865, his condition maybe briefly described as follows: Tbe wound was still discharging pus somewhat copiously; also gas escaped from tbe intestine through it; emaciation considerable; he could walk only by the aid of crutches; appetite and digestion good. In June, 1865, he had gained so that he could walk by the aid of a cane; appetite and digestion good. The discharges from the wound continued much as at the time of his discharge; there was no increase of flesh, and he had a slight hacking cough. Iu September, 18o5. bis appetite and digestion continued good, and be bad gained some in strength but bad not gained in flesh; the discbarges from the wound and the cough continued without material change. December, 1865: Since last date, he has continued to lose fiesh slowly and bis strength has not increased; the cough and expectoration have increased; the discharges from the wound continue; he now complains of shortness of breath; the evidences of pulmonary tuberculosis are more complete and unmistakable; the appetite and digestion are good. March, 1863: His appetite and digestion are excellent, but in other respects he has failed very perceptibly since last date; the cough and expectoration have increased very much; he has had chills and night-sweats for several weeks; during the month he has had pulmonary haemorrhage several times, tlie quantity being estimated at one pint. From this date, his cough and expectoration constantly increased; bis strength and flesh continually decreased, and the discharges from the wound continued unchanged. His appetite and digestion continued remarkably good, but nothing of note occurred until July, 1867, when he had a diarrhoea which confined him to his bed for some two weeks. He rallied from this so that be walked and rode out a few times, but soon became so weak that he was unable to sit up, and gradually failed in all respects, excepting that his appetite and digestion continued remarkably good, until his death, on December 10, 1867. I have only to add that I am perfectly certain tl at the death of the above-named soldier was the legitimate and direct result of, and was directly and solely caused by, the wound he received as above named, and for which he was discharged and pensioned." The statements of the pension examiner agree with Dr. Tracy's in regard to the character of the wound. Case 920.—Private Luther M. B------, Co. I, 1st Massachusetts, aged 18 years, was wounded at Bull Run, August 30, 1862. and remained on the field until September 6th, when he was admitted to (J-eorgetown College Hospital, where Assistant Surgeon J. M. Brown reported that " it was found that the ball had entered a short distance behind the great trochanter of the right side, and, passing directly through the rectum, had left a fistulous opening. A compress was placed over the wound, the rectum washed out twice daily, and supporting treatment was employed. On September 30th, the side ofthe left thigh began to swell, and from its inflamed condition had the appearance of containing an acute abscess. On October 1st, tbe patient began to sink rapidly, and the whole of tbe thigh assumed a distended, brawny appearance, and, after some hours of delirium, he died at about eight in the evening. At the autopsy, it was found that the ball, after perforating tbe rectum, had passed onward and fractured a portion of the body ofthe left ischium and the acetabulum. The tissues were found to be greatly infiltrated by coagula and a small amount of faecal matter. This condition was observed to reach nearly down to the knee, and readily accounted for the swollen condition of the limb during life. The capsular and round ligaments were softened and almost absorbed." The injured portion of the left ischium (FlG. 261) was contributed to ()g innominaTum'Vhomnga shot frao- the Museum, with the foregoing notes, by Assistant Surgeon J. M. Brown, U. S. A. The tare of the outer border of the thyroid . , , , ., . , foramen. Si)ec. 116. acetabular portion ot the innominatum was not preserved. Case 921.—Private John A. Harter, Co. E, 145th New York, aged 2'J years, was wounded at the Wilderness, May 12, 1864, and was sent to Carver Hospital on the 14th. Acting Assistant Surgeon P. C. Gilbert reported: "Tbe ball entered to the right of the spine, three inches below the false ribs, and made its exit at the posterior part of the upper third of the thigh. May 15th: There is no peritonitis or injury of the medulla spinalis. Patient is pale, weak, and has a bad diarrhoea. There is an extensive and unwholesome discharge from the upper opening of a feculant character. Milk diet was given, with ten ounces of whiskey every twenty-four hours, and an ounce of castor-oil, with fifteen drops of tincture of opium, was ordered to be taken immediately. As soon as tho operation from the above prescription was over, the following was ordered: One grain of sulphate of morphia, five grains of tannin, three grains of cayenne pepper, and ten grains of sulphate of quinia; to be made into ten pills, one to be taken every four hours. May 16th: The diarrhoea has ceased; the appetite is poor, but tbe general condition of the patient is improved. The wound remains the same as yesterday. Milk diet and whiskey continued. At six o'clock P. M. he took whiskey reluctantly; and milk-punch was ordered during the night. On the 17th, 18th, and 19th, stimulating treatment was continued, but the patient sank gradually, and died May 20, 18J4." 318 INJURIES OF THE PELVIS. [THAI*. Ml. Fsecal infiltration in the pelvic connective tissues and consequent exhausting suppu- ration appear to have led to the fatal terminations in the two preceding cases; in the two following, the bladder was implicated: Case 922.—Sergeant T. A------, Co. C, 119th New York, aged 28 years, was wounded at Chancellorsville, May 2,1863, and treated in a field hospital of the Eleventh Corps, at Brook's Station, until the 25th, when he was sent to Alexandria and admitted to the Third Division Hospital. Acting Assistant Surgeon T. C. Barker reported as follows: "Gunshot wound in the left natis, extending toward the lower part of the rectum. He entered the hospital in the evening with low typhoid delirium, and the wound was not suspected or discovered until the next morning. Neutral mixture was given every four hours, and low diet ordered. May 26th: Respiration abnormal; thoracic sounds dull; one ounce of urine drawn off by the catheter; pulse 120 and feeble. Stimulants were given, and turpentine stupes applied to the thorax. May 27th: More feeble; pulse 140; his urine has been drawn off twice daily; some has passed involuntarily each day; treatment continued. May 28th: Faecal matter passes occasionally through the wound; the pulse 140; two grains of sulphate of quinia every three hours, and aromatic sulphuric acid with whiskey was ordered. On the 29th, a probe was passed through the wound into tho rectum just above the sphincter, and out at the anus. Enemata of soap and water was given, and turpentine stupes were applied to the pubic and umbilical regions; the quinine was discontinued late at night. The patient grew more feeble and unconscious, and was sinking; there was tenderness and some fulness in the pelvis and lower abdomen, indicating peritoneal inflammation. He died May 30, 1863." Surgeon E. Bentley, U. S. V., forwarded a more complete history with the patho- logical preparation represented in the cut (FlG. 252), and notes ofthe autopsy: "Upon exposing the lungs, a few purulent deposits, the size of pustules, were found posteriorly. The heart was flabby and very pale, the inner surfaces ofthe cavities being almost bloodless. Tho liver, spleen, pancreas, and kidneys were natural; the stomach was apparently healthy, and the small intestines were generally normal in appearance. The great omentum was somewhat injected and coated with plastic lymph, which had been freely exuded, agglutinating the intestines in many places. Approaching the pelvis, the signs of peritoneal inflammation became more marked. The bladder and rectum showed the effects of intense inflammation; indeed, their tissues were incipiently gangrenous. The track of the ball was traced from its entrance in the left buttock, above the tuber ischii, downward and forward to the left side of the rectum, above the sphincter, perforating the gut and emerging from its right side below the peritoneal fold. It then entered the bladder on the right side of the fundus and passed innominamm anThead*of"the* femur! onward to the upper and outer margin of the right thyroid foramen, fracturing the pubis, and the thyroid portion of the acetabulum opening the capsular ligament and grooving; the anterior part of the head of the right femur, was fractured by a round ball, and , „ ,-,,, , , , ... ... 11,, i caries ensued. Spec. 1183. J. and finally lodged between the external vastus and rectus lemons, six inches below the head of the femur." Case 923.—Lieutenant S. Banner, Co. I, 5th North Carolina Cavalry, aged 33 years, was wounded at Cold Harbor, June 3, 1864, and was admitted to Chimborazo Hospital on the same day. Assistant Surgeon W." W. Dickie, C. S. A., recorded the following notes of the case: "Wounded by a conoidal ball, which entered about the centre of a triangle formed by the symphysis pubis, the superior spinous process of the left ilium, and the umbilicus, passed through the bladder and rectum and descending colon, and lodged in the gluteus muscles, from whence it was cut out. The urine passed through the wound of entrance, and blood was drawn off when the catheter was introduced. On June Cth, there was a small discharge of bloody urine, with great pain; fever diminishing, and no appetite. On the 7th, a large quantity of feculent matter was discharged with urine from the abdominal wound; the pulse was full and strong. No material change occurred up to the 13th, when peritonitis supervened, and death ensued June 16, 1864." Case 924 was complicated by diphtheria, constitutional, it may be presumed, rather than local. Diphtheritic infection of wounds and blistered surfaces was indeed very uncommonly observed during the War in the military hospitals of either the Union or Confederate armies: Case 924.—Sergeant E. Ii. Harrington, Co. II, 15th Massachusetts, aged 23 years, was wounded at Cold Harbor on June 3, 1864. He Avas sent to Armory Square Hospital. Surgeon D. W. Bliss, U. S. V., reported that " the injury was caused by a missile which entered the right buttock an inch and a half above and behind the trochanter major, passed through the sacro-sciatic notch across the pelvis between the rectum and sacrim, and emerged at a point nearly corresponding on the opposite side." The patient was sent to New York, and admitted to the Central Park Hospital on June 9th. Surgeon B. A. Clements, U. S. A., reported that "the wounds were apparently healthy; but the discharge of faecal matter continued for a month. For two weeks after admission, there occurred but two passages from the rectum, and these were small compared with those which passed through the wounds. In the course of the third week the discharge through the right wound ceased, and the opening commenced to close from the bottom; the general health improved steadily; the discharge took place entirely from the anus, and everything looked promising till July 28th, when the patient was seized with diphtheria, of which he died iu twenty-four hours. The treatment pursued in this case was chiefly expectant—enemata, tonics, stomachics, and a full diet. The autopsy revealed the existence of diphtheria and acute pericarditis; a wound of the rectum on its posterior surface, the opening left being large enough to admit the little finger; and a fistulous track, substantially walled in by adhesions, and communicating the opening in the gut with the exit wound. There were strong indications of the ultimate closure of this; wTound." Fuller details of this case have been published by Dr. G. F. Shrady.1 1 SHRADY (G. F.). Wound of Rectum, in Am. Med. Times. 18C4. Vol. IX. p. 79. SECT, il.] WOUNDS OF THE RECTUM. 319 Many of the fatal cases of shot perforation of the rectum, possessing possibly features of interest, were briefly recorded as deaths from exhaustion, without memoranda of autopsies or any references to the morbid anatomy. Cases 925-928.—Lieutenant J. Zoller, Co. L, 2d New York Artillery, was Avounded at Deep Bottom, August 14, 1864. Surgeon James E. Pomfret, 7th New York Artillery, reports that the injury Avas regarded at the field hospital as a flesh Avound of tbe right buttock. At the Seminary Hospital, Georgetown, Surgeon II. W. Ducachet, U. S. V., stated that a "conoidal ball entered at the right "sacro-coccygeal junction, perforated the rectum, and emerged at the right of Poupart's ligament; the patient died, from exhaustion, February 16,1865."—Private T. G. Horton, Co. K, 65th Indiana, was wounded at Fort Fisher, February 17, 1865. Surgeon E. Shippen, U. S. V., reported a "severe shell wound of the right thigh and hip." Surgeon A. Chapel, U. S. V., reported, from West's Buildings Hospital: "Missile entered buck part of right gluteal region and passed through the rectum; the patient died April 14, 1865."—Lieutenant Colonel H. McKay, IHIth Ohio, aged 27 years, Avas wounded at Kinston, March 9, 1865. Surgeon C. A. Cowgill, U. S. V., reported, from Foster Hospital, New Berne: "Ball entered loAver margin of left ischium and passed out through the right pubis, wounding the bladder and rectum; died March 13, 1865."—Private L. Markmore, Co. I, 60th Ohio, aged 40 years, was Avounded at the Southside Eailroad, October 2, 1864. Assistant Surgeon Clinton Wagner, U. S. A., reported, from Beverly Hospital: "Missile entered right hip, passed between the coccyx and the tuberosity of the ischium, through the rectum, and emerged through the left obturator foramen, and thence, deflected by tbe fascia, passed down the thigh nearly to the knee joint. Death, October 21, 1864, from exhaustion." The assertion, on page 291, that in shot perforations through a thyroid foramen and sciatic notch "the ball can hardly avoid the great vessels in some part of its track," is not, perhaps, too absolute; but Cases 928 and 922 and the instance cited below,1 prove that the vessels may escape in shot penetrations of the obturator foramen. It is, perhaps, unsafe to set limits to the immunity the resiliency of the arteries occasionally affords them. An example of shot penetration through the thyroid foramen, fatal from secondary bleeding from a hasmorrhoidal artery, will be found with Wounds of the Blood-vessels. Guthrie lays down, at the close of his classical commentaries,2 that there may be shot lesions of the rectum unattended by injury to any other organ within the pelvis. This is literally true, though the instance given, of Captain Gordon of the Navy, is not very satisfactory, since in that case there were vesical trouble and partial paraplegia, and "small pieces of bone came away." Such an injury can hardly be inflicted otherwise than as illustrated by the diagram (Fig. 251) on page 301, the missile entering perpendicularly to the axis of the pelvis. This is reported to have occurred in the case of a celebrated general officer killed at Chantilly, September 1, 1862. Retreating, with his body inclined over his horse's neck, amid a volley from the enemy's advance, a ball, it is alleged, entered the anus and lodged in the lung. No external wound was visible, and the nature of the injury was not surmised until the body was embalmed. The instances adduced in this subsection adequately exemplify the complications attendant on shot wounds of the rectum. It is plain that lesions of this portion of the intestinal canal have not the grave consequences of injuries of the upper bowels, but are to be compared with injuries of those portions of the ascending and descending colon uncovered by peritoneum.' Fsecal extravasation outside the peritoneal cavity, while not involving the mortal peril of intra-peritoneal effusion, is yet a grave complication, and ever impending in shot wounds of the rectum. Our surgeons were not ignorant of the means by which Dupuytren advised that the tendency to stercoral infiltration in such cases should be obviated ; at least, in several instances (Cases 874, 876, 912) they resorted ■Fehr (Behandlung der Schussverletzungen im Allgemeinen, in LANGENBECK'S Archiv, 1873, B. XV, S 339) relates the case of Corporal H----, 1st Prussian G. L. regiment, shot through the right foramen ovale, the hall traversing the lower part of the rectum and escaping at the great sciatic notch. Faces passed through the wound of exit. Death on the eleventh day. Dr. Fkhr adds: " The wounded man might have been perhaps saved by the immediate splitting of the external sphincter; but I never thought of this until after the war, when an analogous case was cited to me which Simon had successfully treated in this manner." Guthuie (G. J.), Commentaries on the Surgery of the War in Portugal, 6th ed., 1855, § 420, p. 611: "The rectum may be wounded without any other organ being wounded within the pelvis ; of this I have seen several instances.'' :*20 INJURIES OF THE PELVIS. [CHAP. VII. Fig. 264.—Tube com- to division of the sphincters.1 But from the comparatively large number of cases of persistant stercoral fistulae found among the pensioners, it would appear that this practice was not as general as it might advantageously have been. Why the unanimity of surgeons as to the proper treatment of anal fistulse should be broken in view of traumatic cases, is curious. The same phenomenon has been observed in the Franco- German War of 1870. Professor Simon, of Heidelberg, in a paper that has attracted much, attention,2 while proclaiming that the principle of averting faecal accumulation and infiltration by division of the spbincters had long been recognized, expresses his astonishment that he was almost alone during the campaign, as far as be could learn, in resorting to this expedient. Stricture of the rectum was not reported to have been a common consequence of shot injury. Dr. Neudorfer thinks3 that such a complication may generally be averted by the judicious employment of bougies. The frequency of recto-vesical fistulse after shot injury would fig. aw.-com- naturally suggest a resort to. sutures;4 but it does not appear that oVbumiS . essor for haemor- . . ° . r> -i tt 1 . pressor. [AXCr1BtuseiiE?ituIi: any plastic operations were performed. Haemorrhage was not a frequent complication of sbot wounds of the rectum. Some of the more serious examples will be adduced with Wounds of the Blood-vessels. In a recent review of this subject, in the great systematic treatise of Billroth, and von Pitha, Herr Esmarch5 highly approves of the instrument proposed long since by our countryman, Dr. Bushe (Figs. 263, 264), a bladder introduced into tbe rectum and dilated by ice-water percolating from a tube, a form of compressor originally devised by Dr. Bushe for tbe suppression of haemorrhage after lithotomy.6 But in serious haemorrhages it is unsafe to rely on any resource but the ligature. The gut must be dilated by a fenestrated speculum and the bleeding orifice exposed, when the vessel may be seized by a long artery forceps and tied. This difficult operation has been described, with figures of suitable instruments, by Dr. Bodenhamer,7 in a recent article replete with sound observations. The actual cautery as a haemostatic should be left to the farriers, save in the exceptional cases in which, by galvanic cauteries or other instruments of precision, it can be applied directly to the 1 Dun"ytuen (Lecons Orales, T. VI, p. 471), speaking of shot wounds of the rectum, observes: "Dans ces eas, les matieres stercorales retenues par les sphincters dans le rectum, refluent nficessairement de maniere a passer continuellement par les ouvertures des plaies, ce qui les entretient pendant un temps fort long. Je pense que le meilleur moyen a employer dans ces circonstances serait de fendre largenient et profondement les sphincters de maniere & donner un tres-libre et tres-facile ecoulemcnt aux matieres stercorales a mesure qu'elles arrivent dans le rectum; alors les ouvertures accidente 11 os faites aux autres points du rectum se cicatriseraient bien plus promptement, puisque les matieres stercorales ne s'y presenteraient plus." 2 SIMON (Uber die kunstliche Erweiterung der Anus und Rectum, in Laxgexbeck'S Arch., 1872, B. XV, Heft T, S. 1G9) remarks: " During the last war I have observed several shot wounds of the rectum, and have treated three patients myself. In two cases, where, after a six weeks' treatment by other surgeons, faeces still escaped through the wounds, and where the patients were extremely reduced from faecal abscesses, burrowing of pus, and fever, the splitting of the sphincter backward induced a cure in a short time. The escape of faecal matter ceased immediately after the operation, and in fourteen days the wounds had healed. In the third case, the fistulous wounds refused to heal in spite of repeated incisions, and the regular operation for fistula became necessary." This paper was read at the first congress of German military surgeons at Berlin, April 13, 1870. In the course of it Professor G. Simon promised a future extended- monograph " Uber Mastdarmschiisse." FlSCIIEE (II.) (Kriegschir.'Erf., 1872, S. 136) says: " Exceed- ingly commendable appears to me the proceeding lately introduced by Simon, of cutting the sphincter in cases of shot perforation of the rectum with escape of faeces by the wound." SOCIX (Kriegschir. Erf., 1872, S. 98) adduces an instance in which this practice was successfully adopted. 3 XELDORFEU (J.) (Handbuch der Kriegschirurgie, 1867, S. 791, Verletzungen des Mastdarmes): •' Such traumatic strictures should not be allowed to form. Insert gutta-percha bougies, which may be made daily, as needed, of gradually augmented calibre, and left in place for a half hour or hour twice daily, taking care that bulky fasces do not accumulate above the stricture." J LOlIMKVLi; (Die Schusswunden, 1859, S. 172) remarks : "When the bladder and rectum are injured, the edges of the wounds of the two organs may unite, * * allowing tbe urine to pass by the rectum, and faeces and even solid substances, such as cherry kernels, etc., to pass into the bladder and out through the urethra." Compare Specimen 153, St. Thomas's Hospital Museum (Derc. Cat, Vol. II, p. 305). 6 1»IARCU (I-\) ( Verletzungen des Mastdarmes, in vox PiTiia und BILLROTH, Handb. der Allg. und Spec. Chir., 1872, B. Ill, Abfh. II, Lief. 5, S. t'J) teaches that: "On account of the great danger of such haemorrhages [from the hemorrhoidal arteries] it is the duty of the surgeon to go to work with inexorable determination. At every operation performed on the rectum with the knife, each severed vessel should be most carefully ligated." further on, Herr Esmarch cautions the young operator against reliance on tampons, and commends BUSHE'S compressor (Flos. 263, 26-1). 6BCSHE (G.), A Treatise on the Malformations, Injuries, and Diseases ofthe Rectum and Anus, New York, 1837, p. le."). PLATE IX, FIGS. 11 and 12. 7 BODEXHAMKH (W.), Traumatic Hemorrhage ofthe Rectum, in The Medical Record, 1872, Vol. VII, p. 361. sr.CT. 11.| WOUNDS OK THE RECTUM. 321 wounded part, or be employed to sear varicose surfaces, as after the operation of excision of hemorrhoids. Complications aside, wounds of the rectum are found to heal very readily.1 Anal Fistula.—In the First Medical Volume of this History, at pages 639 and 711, it is stated that there were reported twenty-seven hundred and seventy-six cases of fistula- in-ano in about six and a half million (6,451,853) cases of disease, among the white and colored troops; and, on pages 617 and 717, there are recorded five hundred and twenty discharges and eleven deaths from this affection, in a mean strength of 531,920 men. Sixty-two operations for fistula ani were reported.2 There is no mention of failure of the operation in any instance, and all of the patients recovered, and forty-two were returned to duty. In one case the ligature was employed; in the others, the ordinary operation by incision was practised. Acting Assistant Surgeon J. J. Black freely excised the callous edges of the sinus in one case, in which no consequent abnormal constriction of the anus is mentioned. Surgeon A. Hammer, in a case complicated by extensively ramifying sinuses, cauterized with nitric acid, with advantage, as he believed. In two cases, injections with tincture of iodine had been unavailingly employed. Fistules consequent on abscesses resulting from shot wounds are not included in this category, except possibly in the following instance, in which inflammation may have been propagated from a wound in the buttock: Case 929.—Private TV. Tamer, Co. B, 60th Georgia, aged 29 years, was wounded at Monocacy, July 9, 1864. He was treated at Frederick until the 25th, and then transferred to West's Buildings Hospital. Surgeon A. Chapel, U. S. V., reported "a gunshot flesh wound of the upper third of the left thigh. By September 2d the wound had healed, and the patient was detailed as nurse. Abscesses formed near the anus, resulting, about September 15th, in fistula-in-ano. On November 5th, I operated upon the fistula, dividing the sphincter ani muscle with a probe-pointed bistoury. The case progressed favorably, and the man was transferred to Fort McHenry in December, and returned for exchange January 2, 1865." The suggestion of Sabatier3 and Ribes4 as to the position of the internal orifice appears to have been commonly borne in mind; while, as to the order of formation of the internal orifice in complete fistula, the observations confirmed the view set forth by Mr. Ashton,5 rather than either of the antagonistic doctrines of Brodie6 and Syme.7 Anal Fissure.— Instances of this painful affection were reported as successfully treated by incision, and several surgeons spoke approvingly of the treatment by rupture of the sphincter by sudden forcible dilatation, •Esmarch (F.) (Verletzungen des Mastdarmes, in vox Pitha und Billroth, Handb. der Allg. und Spec. Chir., 1872, B. Ill, Abth. II, Lief. 5, S. 40) declares: "Every extensive wound of the rectum is to be considered as severe, and often as mortal." Elsewhere (S. 45) he remarks: "lu time of war shot wounds of the rectum occur not infrequently, although rarely without complications. I have observed two cases in which the ball passed through both buttocks, perforating the posterior wall of the rectum. Both recovered, although fasces continued to escape for a long time through the wounds of entrance and exit." 2 Abstracts of these cases may be referred to in the Register of Miscellaneous Operations, S. G. O., Vol. II, p. 246 et seq., under the following names: Privates Adams, 18th Connecticut; Altridge, 140th New York; Bentley, 24th Wisconsin; Beryer, 19th Pennsylvania Cavalry: Bruckman, 4th Wisconsin Cavalry; Campbell, 71st Pennsylvania; Chatterson, 93d New York; Clark, 7th Massachusetts; Culling, 2d V. It. C; Comstock, 121st New York; Cowley, 112th Illinois; Hospital Steward Cox, U. S. A ; Privates Curtis, 2Jth Iowa; Dalton, 2d Colorado Cavalry; Dounohoe, 57th Massachu- setts; Dumb, colored camp fDllower; Gordon, 19th Michigan; Haas, 96th Pennsylvania; Hardy, 29th Iowa; Henfler. 152d New York: Hight, 25th Virginia Battery; Holbrook, 99th Pennsylvania; Hutchinson, 9th New Hampshire; Jesscp, Uth V. R. C; Kelly, V. R. C; Kneeskern, 44th New York; Krug, 13th Missouri Militia; Lafarge, 2d Massachusetts Cavalry; Letterman, 108th Illinois; Louis, Purnoll (Maryland) Legion ; McCarthy, 139th New York; McClure, 82d Pennsylvania; McFarland, 1st D. C. Cavalry; McNally, 41st New Vork; Martin, 56th Illinois; Martin, M., 173d Ohio; Miller, V. R. C; Milton, 72d Illinois; Colonel Morton, 81st Ohio; Privates Nipe, 105th Pennsylvania; O'Brian, 8th New York Cavalry; O'Keefe, 5th Xew York; Phelps, 12th New Hampshire; Richau, 5th Illinois Cavalry; Riggs, i=5th Pennsylvania; Richy, 4th Pennsylvania Cavalry; Roseau, 5th Obio; Russell, 72d Illinois; Ryan, 6th V. R. C; Slavan, 125th New York; J. Smith, 116th Pennsylvania; L. V. Smith, 4th Maryland: J. Smith, 7th Massachusetts; Summers, 14th Indiana; Swartwood, 75th Indiana; Tucker, 119th Illinois; Tynan, 12th V. R. C.; Vandler, 4tb Michigan ; Von Blessing, 37th Wisconsin; N. C. Wilson, 4th South Carolina Cavalry; S. Wilson, 1st V. R. C. Nineteen of these men were discharged and forty two returned to duty. The operators were Drs. W. F. Norris, H. Wardner, and J. F. Thompson, three cases each; Drs. Carvallo, Miles, Hammer, and Liebold, two cases each; Drs. Agnew, Balzer, Black, Brockman, Chapel, Culbertson, Dougherty, Ellis, Farron, Green, Hood, Hubbard, Holmes, Herbst, Highland, Hutton, Jack- son, Judson, Legler, Longnecker, Mursick, Manfred, McKee, Neff, Owen, Sweet, Stahl, Taylor, J. H. Thompson, Tolzier. Wilson, and Young, one each. 3 Saiiatier, De la Medecine Opiratoire, 1822, T. II, p. 350. 4RlBEt>, Quarterly Journal of Foreign Medicine and Surgery, 1820. 6ASHTOX, Prolapsus, Fistula-in-Ano, and other Diseases of the Rectum, their Pathology and Treatment, 3d ed., 1870, p. 31. 6BKODIE (B. C), Diseases of the Rectum, 3d ed., p. 25 (Vol. Ill, p. 533 of Mr. HAWKINS edition of The Works). 'SYME, The Diseases of the Rectum, Edinburgh, 1838, p. 23. 41 322 INJURIES OF THE PELVIS. [CHAP. VII. A single case of cancer of tbe rectum was reported, the diagnosis having been based on a microscopical investigation. The subject of tbe case was an officer, who recovered; whence it may be inferred that he suffered only from a non-malignant hemorrhoidal tumor. Of diseases of the rectum it is unnecessary to speak at length. The reports added nothing to the information contained in the excellent works on the subject.1 Hemorrhoids.—Tbe frequency of piles, as indicated by the monthly sick reports, is expressed by tbe consolidated tabular statements of tbe First Medical Volume. There were reported 60,958 cases of piles with 40 deaths, in an aggregate of 6,454,853 cases of disease among tbe troops; and 1,598 men of a mean strength of 531,920, were discharged for disability resulting from hemorrhoids. Only nineteen instances of operative interference for tbe removal of piles were reported, and none of the fatal cases are included in this category. Excision was practised in two cases of external piles. Internal tumors were removed by the ligature in twelve, by the 6craseur in three, and by excision followed by nitric acid cauterization in two instances. Ten of the men operated on were returned to duty, and nine were discharged for disability. Incisions for fistulse and excisions for piles were regarded by many surgeons as minor operations, not to be recorded on the monthly reports. Of the different modes of operating for internal piles, ligation was the most popular—for the wholesome dread of haemorrhage2 in wounds of the rectum was as great as ever. But excision with cauterization had many advocates. A variety of clamps were used, that of Professor N. R. Smith, or Mr. H. Smith's similar instrument,3 with the blades Fig. 265.—H. Smith's clamp. l • l c [After smth.] guarded by ivory (fiG. zoo), having the preference. Foreign Bodies.—The reports during the War presented few instances of foreign bodies impacted in the rectum, whether swallowed or imprudently or mischievously intro- duced from without. In the case of General D-----, Surgeon Basil Norris removed a bone fragment (Fig. 266) that had lodged transversely above the sphincter for twelve days, inducing great irritation. Among the many valued contributions to tbe Army Medical Museum by Professor J. B. S. Jackson,4 Specimen 5961 is a cast of a stone five and a quarter inches long and three inches wide, which a sailor of 45 years forced into his rectum during; an attack of dysuria. The gut was ruptured, and the Fig. 266.—Rib of rabbit extracted from the ° ■' ° 1 rectum, spec. 951. foreign body was successfully removed from the peritoneal cavity through an incision in the umbilical region, an instance even more remarkable than the extraordinary examples of foreign bodies in the rectum adduced by Morand and others.5 •Mayo (H.) (Observations on Injuries and Diseases of the Rectum, London, 1633); Quain (R.) (The Diseases of the Rectum, London, 1855); Curling (Observations on the Diseases of the Rectum, London, 1863), &c., &c. 'ESMARCH (F.) (Verletzungen des Mastdarmes, in VON PlTHA und BILLROTH, Handb. der Allg. und Spec. Chir., 1872, B. Ill, Abth. II, Lief. 5, S. 51) observes: " Is the locality of the bleeding vessel known, it is safer to introduce the finger and to compress the bleeding orifice until the haemor- rhage completely ceases, which generally occurs in ten minutes. Should haemorrhage recur, the bleeding vessel should be ligated at all hazards." 3 SMITH (H.), The Surgery of the Rectum, 3d ed., 1871, p. 105. 1 Jackson (J. B. S.), Desc. Cat. of tlie Warren Anat. Museum, 1870, p. 467): Preparation 2J37 is "a portion ofthe rectum showing the mechanical injury that was done by the passage of a bougie. From a gentleman, aged 60." Dr. Jackson remarks: "The above is only one of several cases I have seen in which the passage of some instrument in the rectum has been the immediate cause of death. ' 6Maiichettis (P.) (Observationum medico-chir. rar. sylloge cum tractat. Ill, de ulceribus et fistulis .ani, Patav., 1664, Cap. 7); Mo band (De plusieurs observations singuliires sur des corps itrangers, les uns appliquis aux parlies naturclles, d'autres insinuis dans la vessie, et d'autres dans le fondement, in Mim. de I'Acad. de Chir., 1757, T. Ill, p. 605); IJevlx (Pricis d'dbs. sur les corps etrangers arretes dans Vaesophage, etc., in Mim. de I'Acad. Roy. de Chir., 1743. T. I, p. 540). SECT. II.] WOUNDS OE THE BLOOD-VESSELS AND NERVES. 323 While preparations of malignant growth and of foreign bodies in the rectum abound in museums, there are very few specimens of wounds, and especially of shot wounds,] of this portion of the intestine. Wounds of the Blood-vessels and Nerves.—Physical lesions of the great vascular and nervous trunks distributed in the pelvis have been little studied, for they generally are mortal before surgery can intervene. In army practice, cases of this group will present not very infrequently the gravest problems to the practitioner. The first ligation of the common iliac, it will be remembered, was made by William Gibson,2 to arrest haemorrhage from a shot wound. The Museum possesses an example (Fig. 268), con- tributed by Dr. James Robarts, of perforation of the right primitive iliac by a pistol ball. The patient lived twelve minutes alter the reception of the wound; so that, had a surgeon been near, it would have been possible to tie the vessel above and below the wound. Bogros,3in Velpeau's presence, dissected a subject with a similar wound. Larrey records4 a case of sword puncture of the iliac vein and artery treated, apparently with success, by provisional compression and the method of Valsalva. Such instances are exceptional; but injuries of the branches of the pelvic vessels and nerves, sciatic, pudic, and gluteal, often come under treatment, and their management requires the utmost discrimination. It is proposed to relate here abstracts of some cases in which the diagnoses were not fairly made out, instances of wounds or ligations of the primitive iliac artery and of the hypogastric artery and its branches, and cases of injury of the sciatic and crural nerves. Mention of the injuries and numerous operations on the external iliac artery will be deferred. Punctured and Incised Wounds.—The following case and one on page 335, a case of ligation of the common iliac, belong to this category: Case 930.—The following record appears on the case-book of the City Hospital, St. Louis, Surgeon John T. Hodgen, U. S. V., in charge: "Private Adam Schomacker, Co. E, 4th Cavalry, aged 27 years, of temperate habits, was admitted into hospital on May 2d, with a bayonet wound ofthe left side received at Cairo, April 25,1S'62, whilst attempting to pass the guard. He suffered extreme pain in the left thigh and leg, which swelled largely. He died June 27, 1862. At the post-mortem exam- ination the blade of the bayonet was found to have entered the superior portion of tlie thigh, passed through the sciatic notch, injuring the sciatic nerve, and wounding a branch of the internal pudic artery; whence a false aneurismal sac had formed. The sac had become diffused through the whole pelvic cavity, forcing the rectum to one side, greatly displacing the sigmoid flexure of the colon, rendering defecation difficult and painful. The aneurismal cavity contained about three quarts of blood." 'Specimen 1892 of Guy's Hospital Museum (Path. Cat, 1857, p. 75) is a "rectum perforated in two places from gunshot wound, which injured the obturator nerve." In the same museum, 187740 is a portion of rectum perforated bya bougie; 187760 and 187780 are similar preparations. In the Warren Anatomical Museum, 2267 (Jackson's Cat, p. 167) is an analogous specimen. At St. Thomas's Hospital (Desc. Cat, 185.), p. 305) are several preparations of stricture of the rectum, No. 153 showing ulceration and recto-vesical fistula induced by cherry stones. 2 GIBSON (W.), Case of a wound of the common iliac artery, in The American Med. Recorder, 1820, Vol. Ill, p. 185. "Velpeau, Nouv. ftlim. de Mid. Opirat, 2""> ed., 1839, T. II, p. 164. 4 LARREY (D. J.), Clin. Chir., 1829, T. Ill, p. 156: Case of Corporal J. Fleury ; apparently the external iliac vessels were wounded. FIG. 267.—Arteries of the pelvis. [After Leveille, in Saitey's Anat Disc., T. II, p. 640.] 321 INJUEIES OF THE PELVIS. | (II AT. VII. St/i'it Wounds.—Though it is proposed to defer the consideration of lesions and ligations of the external iliac, some instances will be given of wounds of its branches. It is hardly possible to unduly multiply illustrations of the management of wounded blood-vessels. Case 931.—Sergeant E. S. Fisher, Co. D, 40th New York, aged 21 years, was wounded at Spottsylvania, May 12, 1834. Surgeon O. Everts, 20th Indiana, from a Second Corps hospital, reported ''a gunshot wound of right hip." The patient was sent to Columbia Hospital, May lGtli. Surgeon T. E. Crosby, U. S. V., recorded, "a gunshot flesh wound at tlie crest of the right ilium. On May 29th, there was haemor- rhage, amounting to eight ounces, from the circumflex ilii. The haemorrhage was easily controlled by pressure, but the patient, already much exhausted, succumbed the same day." Case 932.—Private G. Edwards, Co. A, 155th Pennsylvania, aged 26 years, was wounded at Petersburg, June 18, 1864. Surgeon W. E. De Witt, U. S. V., reported, from a Fifth Corps hospital, " gunshot wound of left hip." The patient was sent to Alexandria, and thence to Broad and Cherry Streets Hospital, when Assistant Surgeon T. C. Brainerd, U. S. A., reported: "The ball entered at the left hip and was extracted from over the sacrum. There was comminuted fracture of the left innominatum ; pus is discharging from both wounds and from the rectum. On July 22d, there was haemor- rhage to the amount of eighteen ounces, proceeding apparently from the circumflex iliac artery. The bleeding was arrested by the application of the solution of the persulphate of iron, with compression. Haemorrhage to the extent of twelve ounces recurred, and resulted fatally on July 23, 1864." Case 933.—Corporal W. Matthews, Co. C, 11th Pennsylvania, aged 23 years, wounded by a mini6 ball at Hatcher's Eun, February 6, 1865, was treated in the depot at City Point until the 12th, and then sent to Hammond Hospital, at Point Lookout. Surgeon G. L. Sutton, U. S. V., reported a "gunshot flesh wound of the left hip; the ball entered the anterior surface just over Poupart's ligament, and passed backward and outward, making its exit near the trochanter major. On the 13th, 14th, 15th, 19th, 26th, and March 2d, haemorrhages occurred from the circumflex iliac artery, but not more than eight ounces of blood were lost at any one time. The haemorrhages on the first three days mentioned ceased spontaneously; in the other three instances it was arrested by application of persulphate of iron. Blue mass pill, quinine, and stimulants were given Pyaemia was present on February 25th. He died on March 3, 1865." Case 934.—Private Joseph S. Haden, Co. E, 13th Georgia, aged 23 years, was wounded at Gettysburg, July 1, 1853, treated in Seminary Hospital until August 2d, when he was transferred to Camp Letterman Hospital. Acting Assistant Surgeon J. A. Newcombe reported: "Wounded by a mini6 ball entering the pelvis at the left groin, and making its exit near the tuber ischii of the left side; neither the bladder nor rectum were injured. His general health was much impaired; the discharge offensive and ichorous. He improved from August 10th to 15th. On the 21st, he had diarrhoea with watery evacuations, which were bloody on the next day; the skin was icteroid, and the countenance pinched. The evacuations on the 24th were bloody, and contained a good deal of mucus; the tongue was tremulous, and the teeth covered-with sordes. His passages were invol- untary on the 26th. On the 2dth, haemorrhage from the wounds was controlled by compressing the external iliac. He died August 30, 1863." Fig. 268.—Shot perforation of the right primitive iliac artery. Spec. 6336. '. Wounds of the Internal Pudic Artery. those adduced on pages 256 and 304: -The following examples may be added to Cask 935.—Sergeant C. Moulton, Co. D, 2d Maryland, aged 24 years, was wounded at Poplar Grove Church, September 30, 1864. He was admitted into hospital No. 2, Annapolis, from the steamer George Leary, on October 9th. The following notes of the case were made by Surgeon G. S. Palmer, IT. S. V.: "Gunshot wound of the trochanter and neck of the left femur by a minie ball, which, entering the outer aspect of the trochanter major and emerging at the inner aspect, passed through the scrotum. On October 12th, 13th, 14th, and 15th, haemorrhages occurred from the internal pudic artery, with a loss of three ounces of blood in each of the first two instances, four in the third, and six in the last. Persulphate of iron, compress, and bandages were used, but death resulted on October 15, 1864." Case 933.—Private P. Smith, Co. G, 25th Alabama, aged 35 years, was wounded at Franklin, November 30, 1854, and w;is treated on the field until December 16th, when he was admitted into hospital No. 1, Nashville. Surgeon B. B. Breed, U. S. V., reported: "Gunshot flesh wound on the inner and posterior aspect of the right natis. On February 9, 1835, haemorrhage occurred from the internal pudic artery to the extent of six ounces; this was arrested by the application of persulphate of iron. On the morning of the 15th, haemorrhage recurred, and, patient being extensively reduced, it proved fatal before it could be arrested. The case was under the care of Acting Assistant Surgeon W. J. E. Holmes." Case 937.—Private W. S. House, Co. E, 2d Wisconsin, was wounded at Gettysburg, July 1, 1883, and was treated in White Church Hospital. Surgeon G. M. Ramsay, 95th New York, reported: "Gunshot wound of the left thigh and perineum. Haemorrhage occurred on July 11th, probably from the internal pudic artery. The location and condition of the wound forbidding the operation of ligation, it was treated by compression and styptics. The quantity of blood lost was sixteen ounces, aud the patient died on the following day. It was considered probable that there was internal haemorrhage, but, as no post- mortem was held, this was not determined." sect, n.] WOUNDS OV THE BLOOD-VESSELS AND NERVES. 325 Haemorrhage was the most important complication in many cases of wounds of the pelvis in which the precise source of bleeding was not determined. It was not always decided even whetlier the branches implicated were of the external or internal iliac.1 In no region was the application of the cardinal rule of tying a wounded vessel above and below the seat of injury more difficult of application, and in none were the consequences of a neglect of this principle more disastrous. Case 938.—Private Henry M------, Co. 1>. 8th New York Cavalry, aged 35 years, was wounded at Raccoon Ford in September, 18(53. His injury is recorded as a flesh wound of the groin in the casualty lists of the Army of the Potomac for September 13, 14, and 15, 18(53. He was sent to Lincoln Hospital, entiling September 17th, and was attended by Acting Assistant Surgeon W. C. Flowers, who made the following report of the case : "Wounded, September loth, at Raccoon Ford. Was kneeling with left foot forward when wounded. A mini6 ball struck the outer part of the left thigh four inches below the anterior superior spinous process of the ilium, passed inward and slightly upward across the perineum, rupturing the urethra, fracturing the right ischium extensively, and finally escaped two inches behind the right trochanter major. Soon after the injury there was extreme pain in the parts, accompanied with ischuria. He had not passed urine for over forty-eight hours. The urine, intermixed with blood, oozed slowly from the wound of entrance. The bladder was much distended. After much trouble, however, a catheter was passed, after many fruitless attempts had been made to introduce it, and he remained quiet for three or four days. During this period, he had.slight fever; tongue dry and slightly furred; much wandering at night, and, forty hours before his decease, he had a severe haemorrhage, the blood escaping from the wound of entrance in such quantities as to permeate the bed. Nothing was done to arrest it, since, through the carelessness of the night watch, the accident was unnoticed until active bleeding had ceased. After this he failed rapidly, and died on the evening of September 2~, 1833, having had a slight return of the haemorrhage within the hour preceding his death." Assistant Surgeon II. Allen, U. S. A., reported the autopsy as follows: '•Examination ten hours after death showed good muscular development and very marked rigidity. The parts in situ showed that the right lung extended from the first to the fifth rib, and the left from the first to the third rib, and both were bound to the ribs by adhesions. The apex of the heart was on a level with the fourth rib; the liver extended three inches to the left of the median line; the stomach was conspicuous; transverse colon natural, and the omentum was loaded with fat. The oesophagus was of a pale color, yellowish at its lower portion; the mucous membrane of the trachea was pale; the bronchial gland at the bifurcation of the trachea was enlarged, thickened, of a blackish color, and softened. The right lung was affected with lobular pneumonia, the lobules being especially prominent at the apex, where, upon the latero-posterior surface of the first lobe, a number of lobules were seen covered by a thin layer of recently exuded lymph. The parenchyma between these affected portions was apparently healthy, excepting that of the third lobe, which was markedly congested; the left lung was similarly affected; the first lobe, however, having been more congested than the lower. Sections of the hepatized lobules sank in water; the weight ofthe right lung was twenty-one and ofthe left twenty-four ounces. The heart was four and a half inches wide by five and three-quarters inches long; the right side contained a large, soft, black clot, and a smaller white fig. 269.—Lateral view of a preparation from a case one was found upon the left side; the valves were healthy; the pericardium of shot perforation of the perineum. Spec. 1716. contained one ounce of fluid of the color of blood. The liver weighed fifty-six ounces and was pale, and the capsule readily separated; the bile was healthy and of a rich ochre-red color. The spleen was very soft and of a dark flesh color, and weighed eight ounces. The right kidney, four and three-quarters by two and a half inches, was flaccid aud exceedingly pale; the otdy appearance of a sanguineous hue appearing at the base of the pyramidal bodies. Cortical substance and mamillae very pale. Weight of right, six ounces ; of left, seven and a quarter ounces. Pancreas, nine inches long, two inches wide at head, healthy. Intestines healthy throughout. Brain healthy ; cavity of arachnoid filled with an unusually large amount of fluid. The specimen sufficiently explains itself. It would be well to remark, however, that no ball was found. Extending from the ischium of the right side down the inner side of the corresponding thigh, a long ragged track was detected, measuring ten inches in length, lined with a thick black sloughing membrane. It was situated deep in the muscles ofthe limb. Its existence had not been detected during life." FlG. 2C9—a indicates the entrance orifice. Case 939.—Private S. Robinson, Co. I, 3d New Hampshire, was wounded at Drury's Bluff, May 13, 18(54. Surgeon J. J. Craven, E. S. V., from a field hospital of the Tenth Army Corps, reported that " a musket ball penetrated the right thigh and scrotum." The patient was sent to Hampton Hospital, Fort Monroe, on the 15th. Assistant Surgeon Ely McClellan, U. S. A., reported a "gunshot wound, the ball entering the left hip in front ofthe trochanter and emerging at the root of the penis, on the right side of the scrotum. On the 28th and 29th, haemorrhage occurred from one of the branches of the profunda or pudic arteries, and about two pounds of .blood were lost. The femoral artery, about three-fourths of an inch from Poupart's ligament, was ligated. Haemorrhage recurred fifty-six hours after the operation, and the patient died June 2, 18(54." 1 For operations on the branches ofthe iliac arteries, consult. J. BELL'S famous ease (Disc, on Wounds. 1795, p. 78); SYME (Obs.in Clin. Surg., 1861, p. 169); Veu-bau (Med. opirat, 1839, T. II, p. 1&2) ; UIIDE (Deutsche Klinik, 185:3, B. V, S.175) ; GUNTHER (Lehre von den Blut. Op., 1860, B. IV, S.. 11); Packard (J. H.) (A Hand-Boole of Operative Surgery, 1870, p. 107) ; GUTHRIE (Commentaries, 6th ed., 1865, p. 270); LIDELL (J. A.) (On the Wmmds of Blood-vessels, Traumatic Hsemorrhage, Traumatic Aneurism, and Traumatic Gangrene, New York, 1870, p. 219); LiZARS (J.) (A System of Practical Surgery, Edinburgh, 1838, Vol. I, p. 104). 326 INJURIES OF THE PELVIS. [CIIAP. VII. Of secondary bleeding from the obturator or hemorrhoidal vessels or their branches the following are probably examples. Case 941, already alluded to on page 316, is of peculiar interest on account of the course of the ball through the thyroid foramen and sciatic notch : Case 940.—Sergeant J. H. Warford, Co. A, 124th New York, aged 23 years, was wounded at Sailor's Creek, April G, 1S;5.">. He was treated in Second Corps hospitals until the 22d, and then sent to Jarvis Hospital. Assistant Surgeon D. C Peters, U. S. A., reported: " Gunshot wound of the right thigh, the ball entering about two inches below Poupart's ligament and three inches from the spine ofthe pubis. On June 12th, haemorrhage to the extent of two ounces occurred from the external pudic artery, being caused by sloughing from gangrene. The vessel was ligated in the wound. There was no return of the haemorrhage." He was transferred, on July 24th, to Hicks Hospital, and thence discharged, August 26, 1835. Pension Examiner W. P. Townsend, of Goshen, reported, October 17, 1835, that " a ball penetrated the right thigh in the inguinal space, and passed through the limb one inch behind and below the trochanter major; he had gangrene in the wound. There is now a fistula discharging. From injury to the muscles the limb is contracted on the pelvis. He walks on crutches. Disability total." Examiner J. Gordon reported, September 17, 1873, that " the cicatrix at point of entrance is very large, and sensitive from the effects of hospital gangrene. There is also much adhesion of muscles, fascia, and skin, with some contraction. Disability three-fourths." Case 941.—Private J. A. Murphy, Co. C, 17th Virginia, aged 20 years, was wounded at Williamsburg, May 5,1832, and was treated in a field hospital until the 17th, when he was sent to Cliffburne Hospital, Washington. Assistant Surgeon John S. Billings, U. S. A., made the following special report of this case: "He was wounded while in a kneeling position; the ball entered the external aspect of the thigh five inches below the trochanter major, and then, passing upward and inward, lodged in the buttock of the opposite side. When admitted he was cheerful and comfortable, presenting no symptoms worthy of notice. May 25th : As he began to complain of pain and tenderness in the left natis, an incision was made and the ball found, after a little search, embedded in the fibres of the gluteus maximus. June 1st: He has been going on well up to this date, when a sudden and copious discharge of blood from the anus occurred. A weak solution of persulphate of iron was given in enema, which readily checked the haemorrhage. Small doses of opium were given internally, and the patient was restricted to milk diet. June 3d : Hsemorrhage took place from the wound made for the purpose of extracting the ball, and also from the rectum ; the persulphate was again resorted to, and followed by an opium suppository, as he complained of intolerable tension and pain. Good nourishment was given, with one grain of opium and ten drops of tincture of iron every four hours. He perspired freely. Up to June 15th, he slowly and steadily improved; no more haemorrhages taking place, and the discharges being natural, with the exception of containing, now and then, a small clot of blood. The wound made by the entrance of the ball had entirely healed; the discharge from the wound made to extract the ball was purulent and copious, but contained no blood. On the evening ofthe 14th, however, haemorrhage occurred from the rectum, not very profuse, but sufficiently so, in his feeble condition, to utterly prostrate him. The same remedies were employed with the effect of checking the haemorrhage, and beef-gssence, brandy, etc., were given. June 16th : Has been very slightly improving up to this date, when haemorrhage again occurred from the bowels, and he died in half an hour. Examination six hours after death : The ball was found to have passed upward from the point of entrance in the thigh. It entered the pelvis at the obturator foramen, passing directly through the rectum, broke off the spinous process of the ischium of the opposite side, and lodged in the fibres of the gluteus medius. The bleeding vessel was one of the inferior hemorrhoidal arteries; the space between the sacrum and rectum was filled with coagula; the recto- vesical fold was elevated and its peritoneal surface was dark in color. The autopsy was made by Dr. E. Curtis." Wounds and Ligations of the Sciatic Artery.—The examples of lesions of this vessel that were reported were fatal. Gases recorded further on were treated—by Professor Brainard, by ligation of the primitive iliac; by Surgeon A. B. Mott, by tying the hypo- gastric ; by Surgeon W. Clendenin, by the application of the actual cautery. Two cases, here related, were treated by Surgeons Crosby and Duval, by ligation of the sciatic, apparently by single proximal ligatures ■} Case 942.—Private H. C. Leslie, Co. M, 7th New York Artillery, aged 18 years, received a shot wound at Cold Harbor, June 3, 1864, and, after some treatment in a field hospital of the Second Corps, was removed to Washington and admitted into Columbian Hospital on the 8th. Surgeon T. R. Crosby, U. S. V, noted "a gunshot wound of the sciatic artery, from which haemorrhage occurred on the 16th, to the extent of twenty-five ounces ; the artery was then ligated. He died June 19, 1864." Case 943.—Private W. B. Carrington, Co. H, 2d South Carolina, was wounded at Cedar Creek, October 19, 1864. He was sent, on October 20th, to the Prisoner's Hospital, at Winchester, in charge of Surgeon W. S. Love, P. A. C. S., who reported a "' wound by a conoidal musket ball which comminuted the transverse process of the sacrum. Haemorrhage from the sciatic artery occurred on November 3d, and the vessel was ligated by Dr. Duval (Confederate) and the ball was extracted. Death, November 4, 18J4.'" 1 DUGAS (L. A.), Aneurism of the Ischiatic Artery—Ligature of this Vessel, and consequently of the Primitive Iliac Artery; with Remarks, in the Southern Med. and Surg. Jour., 1859, Vol. XV, p. 652. This important paper contains a translation of an abstract of Professor Sappey's case of ligation ofthe sciatic. The student should further consult: BOUISSON (F.) (Mim. sur les lesions des artires fessiere et ischiadique, et sur les operations qui leur conviennent, in Gaz. Mid. de Paris, 1845, T. XIII, p. 161); DlDAY (Lettre sur un nouveau procidipour la ligatuie de I'artere fessiere. in Gaz, Mid. de Paris. 1845, T. XIII, p. 219); DIETEKICH (Das Aufsuchen der Schlagadern behufs der Unterbindung, etc., Nilrnberg, 1831) ; Zang (Darstellung Uutiger heilk. Operationen, Wien, 18,'3, B. I. S. 204) ; Shaw (J.) (.1 Manual for the Student of Anatomy, 1825, p. 149.) SECT. IL] WOUNDS OF THE BLOOD-VESSELS AND NERVES. 327 In connection with a report of Case 679, page 2^2 ante, Acting Assistant Surgeon E. G. Waters observes: "These wounds of the buttock are eminently dangerous, on account of the risk of wounding the gluteal or sciatic arteries. I lost two men from haemorrhage from this cause, men wounded at Spottsylvania, who lay in adjoining beds in my ward at Camden Street Hospital." The following is doubtless one of the cases referred to: Case 944.—Private J. Harris, Co. E, 49th Pennsylvania, aged 24 years, was wounded at Spottsylvania, May 9, 1864. He was treated in a Sixth Corps hospital until the 13th, then sent to Campbell Hospital, and on the 16th to Camden Street Hospital. Surgeon Z. E. Bliss. U. S. V., reports: "Gunshot wound of the right foot and thigh. One bullet entered behind the right great trochanter and passed inward and backward; the other grazed the dorsum of the right foot. Examination revealed that the great trochanter was injured. The patient did well until June 27th, when haemorrhage of an alarming char- acter occurred. It was supposed to proceed from the sciatic or pudic arteries. Twenty-five ounces of blood were lost. The bleeding was checked by compression, the indications to search for and tie the vessel not being sufficiently clear to warrant operative interference. He sank, and died June 29, 1864. An autopsy six hours subsequent to death revealed an immense accumulation of blood under the gluteus maximus of the same side, and the sac of what had been a traumatic aneurism. The sciatic nerve and pudic arteries seem to have been divided. The bullet was found lodged in front ofthe second sacral vertebra." It is probable that the following, the only other fatal case of wound of the buttock in tbe ward at the period mentioned, is the second instance that Dr. Waters had in mind: Case 945.—Private J. Stafford, Co. C, 1st New Jersey, aged 24 years, was wounded at Spottsylvania, May 10, 1864. He was sent to Emory Hospital, May 13th. Surgeon N. E. Moseley, U. S. V., reported a "shot wound of the right lumbar region." The patient was transferred to Camden Street Hospital on May 16th. Surgeon Z. E. Bliss, U. S. V., reported that the "ball struck the right flank above the crest of the ilium and lodged in the right natis. Death, May 23, 1804, from the effects ofthe wound." An instance of fatal bleeding from the sciatic artery was observed at Hampton Hospital: Case 946.—Lieutenant C. E. Hammond, Co. D, 6th Connecticut, aged 28 years, was wounded at Weirbottom Church, June 16, 1864. Assistant Surgeon Ely McClellan, U. S. A., reported that "he was admitted to the Chesapeake Hospital on the 19th, for a gunshot wound ofthe back and hip by a conoidal ball, and died from secondary haemorrhage from the sciatic artery on June 27, 1864." Wounds of the Ilio-Lumbar Artery.—Case 168, on page 36 ante, and the following are examples of fatal bleeding from this branch of the posterior trunk of the hypogastric: Case 947.—Private G. D. Vinson, 18th Tennessee, aged 20 years, wounded at Fort Donelson, February 14, 1862, was received into the City Hospital, St. Louis, on March 4th, where Surgeon J. T. Hodgen, U. S. V., reported that "he had received a gunshot wound of the right ilium. Haemorrhage occurred from the ilio-lumbar artery, on date of admission, to the extent of thirty ounces, and recurred at intervals until death supervened, on March 24, 1882." Wounds and Ligations of the Gluteal Artery.—Two instances were recorded of bleeding from this vessel successfully treated by compression, and eleven at least in which this resource was unavailing; and also two instances in which the vessel was successfully ligated,1 and three which proved fatal after ligation: Case 948.—Private George Allen, Co. I, 2d New York Heavy Artillery, was wounded at White Oak Swamp, August 14, 1864. He was treated on the field until the 23d, when he was admitted into Satterlee Hospital, Philadelphia. Surgeon I. I. Hayes, U. S. V., reported: "Gunshot flesh wound ofthe right buttock. A haemorrhage of from three to five ounces occurred on August 25th, from the deep branches of the gluteal artery; the bleeding occurred to the same extent on the 28th. In both instances it was arrested by compression made by a compress and roller. The wound had nearly healed, when, on January 13, 1865, he was transferred to the Veteran Eeserve Corps." Allen is not a pensioner. Case 949.—Private T. Patterson, Co. G, 31st Illinois, was wounded at Vicksburg, June 26,1863, and treated in a hospital of the Seventeenth Corps, for a "shell wound of the right hip," until July 29th, and then transferred, by the steamer R. C. Wood, to St. Louis, and admitted into Jefferson Barracks Hospital, August 1st. Surgeon J. F. Randolph, U. S. A., reported a 'gunshot wound ofthe gluteal muscles; hsemorrhage occurred from the gluteal artery on September 5th and 16th. This man was discharged from service, April 29, 1864," and pensioned. Examiner John W. Mitchell, of Harrisburg, Illinois, June 22, Mi.); reported that "a piece of shell carried away a portion of the left buttock; he had gangrene and exfoliation of the pelvic bone; the cicatrix was large and deep; the attachments of the muscles were injured by sloughing; the hip joint was very weak, and the muscles ofthe leg atrophied. Disability was rated total." This pensioner was paid June 4, 1873. NeudOkfkr (Handbuch der Kriegschirurgie 1867, B. II, S. 1108) says: "No contemporaneous surgeon has exposed this vessel on the living subject, and such an operation would hardly ever come to be carried out, since compression of the artery, digital compression of the aorta, and artificial coagulation of blood offer a series of resources that may be substituted for deligation." OL-N INJURIES OF THE PELVIS. [CHA1-. vu. Illustrations of fatal bleeding from wounds of the gluteal artery or of its branches were unhappily numerous.1 The following instances may supplement those already cited:2and:1 Cask 9."0.—An unknown Union soldier, probably wounded at Spottsylvania, was admitted to Judiciary Square Hospital, May 19, 1864. Assistant Surgeon Alexander Ingram, U. S. A., reported "a gunshot wound of the buttock. Soon after the patient's admission profuse and uncontrollable haemorrhage from the gluteal artery supervened, and proved fatal, May 19,1864." Case 951.—Private J. Hull, 27th New York Battery, aged 27 years, was wounded at Petersburg, June 18, 1864. Surgeon M. K. Hogan, U. S. V., reported, from a Ninth Corps hospital, "ball in right hip." The patient was sent to Columbian Hospital on June 24th. Surgeon T. 11. Crosby, U. S. V., reported that "pyaemia was well developed on June 25th, and the case was tending toward a fatal termination, when fatal secondary haemorrhage from the gluteal vessels supervened, July 2, 1864." Cask 952.—Private J. Ford, Co. H, 67th Indiana, was wounded at Grand Coteaux, November 3, 186::, treated on the field in a hospital of the Thirteenth Corps until the lCtli, when he was*admitted into St. James Hospital, New Orleans, whence Assistant Surgeon S. H. Orton, U. S. A., reported: "Gunshot wound of the right thigh. The ball injured the gluteal artery, the haemorrhage from which it was impossible to control, and death resulted on December 6, 1863." Case 953.—Lieutenant W. J. Cockburn, Co. H, 120th New York, aged 28 years, was wounded at Gettysburg, July 3, 1863, and admitted into a First Corps hospital on the same day. The following report was made by Surgeon W. B. Chambers, 97th New York: " Wounded by a conoidal ball passing into the pelvis. On July 10th, there was haemorrhage from the gluteal artery to the extent of twelve ounces, and recurred on the 17t h, the bleeding having been arrested in both instances by pressure." He was transferred to East Walnut Street Hospital, Harrisburg, on the 21st, whence Acting Assistant Surgeon R. II. Sailer reported that "he died July 22, 1883, from secondary haemorrhage." Case 954.—Private B. H. AlcCracken, Co. L, loth South Carolina, aged ii4 years, was admitted into Chester Hospital on July 19, 1863, having been wounded at Gettysburg on the 3d. Surgeon E. Swift, U. S. A., reported that "a conoidal ball entered the back, coursing down to the left hip, which was fractured. On August 2d, haemorrhage, to the extent of thirty-two ounces, from the gluteal artery, resulted in the patient's death on the same day." Case 955.—Private A. S. Greer, Co. F, 7th North Carolina, was admitted into Chester Hospital on July 17, 1863, for a wound received at Gettysburg, July 3d. This case is recorded as a "gunshot wound of the left hip. The patient had three attacks of haemorrhage from the gluteal artery; the last attack, on July 29th, resulted in the loss of from twelve to fifteen ounces of blood, causing death on the following day." The case is reported by Surgeon E. Swift, U. S. A. Case 9C6.— Lieutenant J. B. Korman, Co. A, 23d Kentucky, aged 25 years, was wounded at Dallas, May 26, 1864, treated on the field until June 6th, and then admitted into hospital at Chattanooga. He was thence transferred to the Officers' Hospital, at Nashville, June 10th. Surgeon J. E. Herbst, U. S. V., made the following report of the case: "Gunshot wound of the left hip; the ball, entering from behind, passed forward and fractured the ilium of the same side. The ball was detected by a probe, but there was such a depth of tissues, and the missile was so firmly embedded in the bone, as to baffle all attempts to extract it. Haemorrhage from the gluteal artery occurred on the 15th, and twenty-four ounces of blood were lost. The bleeding recurred on the following day to the amount of twelve ounces, and in both instances was controlled by pressure. Pyaemic chills were not decided. He died from pyaemia on June 20, 1864." Case 957.—Corporal E. John, Co. D, 99th Ohio, was wounded at Marietta, June 21, 1864. Treated first at Fourth Corps hospital, where Surgeon J. D. Brumley, U. S. V., believed that the hip joint was opened. This patient was sent to Chattanooga on the 25th. Assistant Surgeon C. C. Byrne, U. S. A., reported that "he was struck by a piece of shell in the right gluteal region and a deep wound was produced. On June 24th, haemorrhage from the right gluteal artery occurred, while the patient was on the cars; the amount of blood lost was not ascertained. The bleeding recurred on the 29th to the extent of twenty ounces; the blood coagulating, arrested the haemorrhage. The patient died July 4, 1864." Case 958.—Private J. Preston, Co. A, 122d New York, aged 17 years, was wounded near Fort Stevens, July 12, 1864, and was sent to Mount Pleasant Hospital. Assistant Surgeon C. A. McCall, U. S. A., reported: "Severe wound of the right thigh by a musket ball. On July 30th, haemorrhage occurred from the gluteal artery and four ounces of blood were lost. The patient stated that he had bled slightly five or six times, but that the bleeding had been easily arrested by compression. He died of pyaemia, August 18, 1864." Case 959.—Private J. Eagan, Co. M, 1st Massachusetts Artillery, aged 21 years, was wounded at North Anna River, June 1, 1864, and received treatment in a field hospital of the Second Corps until the 11th, when he was admitted into Lincoln Hospital. Assistant Surgeon J. C. McKee, U. S. A., recorded: "Wound in the right gluteal region by a minie" hall. Haemor- rhage from the gluteal artery occurred several times after his admission, and death resulted July 5, 1864." Case 960.—Private H. Treadwell, Co. G, 61st North Carolina, was wounded at Morris Island, August 26,1863. He was admitted into hospital No. 4. Beaufort, on September 1st. Assistant Surgeon John Trenor, jr., U. S. V., reported: "Flesh wound of the left thigh by a rifle bullet, which entered the buttock and passed close to the head ofthe femur, and made its exit opposite to the anterior face of the femur, passing between the head and ramus of the ischium. Haemorrhage from the gluteal artery took place on September 6th to the amount of thirty-live ounces; it was controlled by a free application of persulphate of iron on the orifices of the wound. The bleeding did not recur. The patient was probably forty or forty-five years of age and in a miserably debilitated condition, and had never fully rallied from the first shock of the wound. He died September 12,1863." 1 In the Surgical Memoirs of the War of the Rebellion, collected and published by the United States Sanitary Commission, 1870, p 210, a case of secondary haemorrhage from the gluteal artery, observed by Prof. P. F. Eve, is recorded: Case of L. T. Sherrill, Co. K, 18th Alabama, shot through the right nates, September 20, 18fi3. Haemorrhage occurred October 9th, and was restrained by pressure. Death, October 11, 1863. * CA6ES 631, p. 216 ; C48, p. 222; 702, p. 242. •Compare Guthbie (On the Diseases and Injuries of the Arteries, London, 1830); HODGSON (A Treatise on the Diseases of the Arteries and Veins, 1815. p. 397). SKCT. II. 1 WOUNDS OF THE BLOOD-VESSELS AND NERVES. 329 Fin. 270. — Ligation of the left gluteal. [After Foli.ix.] A—glu- teus maximus; B—gluteal artery ; C—gluteal veins. It was stated, in six instances, that ligatures were placed on the cardiac side of wounds of the gluteal artery. Two of the patients recovered.1 Dr. J. Ii. Brinton has transmitted, January 27, lS7i, an account of a ligation of the gluteal in the case of Colonel A. J. AVarner, partially detailed on page 232: Cask 678 {Continued).—"On the Cth of February following, another attempt was made bv Surgeon Clymer to find the ball. Tlie patient having been amrsthetized, an incision fully four inches in length was made over the track of the ball, which corresponded nearly with the centre of the gluteus maximus muscle. Tlie line of the incision was parallel to the fibres of the muscle. The subjacent parts were freely divided, and the ball was eventually found embedded in the substance of the ilium on the line of the posterior inferior spine, and just above the upper border of the great sacro-sciatic notch. It was removed without any very serious difficulty. During the manipulation, however, the gluteal artery was started. The haemorrhage! at first was very severe, apparently uncontrollable. The jet of blood possessed great force, and seemed to till the large cup-shaped cavity of the wound in an instant. At the request of Dr. Clymer, I took charge of the bleeding. My Iirst impulse was the ligation of the internal iliac, so difficult seemed any attempt upon the deeply seated bleeding vessel. A moment's reflection, however, led me to search for the latter, when, thrusting my finger to the bottom ofthe wound, I could readily feel the impulse of the jet of blood. I then requested Assistant Surgeon Moss, U. 8. V., to plug the wound with the end of a dry towel. This was done; at the expiration of a few seconds I quickly removed the plug, and while so doing was so fortunate as to see the gaping orifice of the main trunk of the gluteal artery, as that vessel emerged through the great sacro-sciatic foramen. I immediately compressed the trunk with the end of my index finger against the upper bony rim of the notch, thus arresting the haemorrhage instantly and completely. The seizure of the vessel with an artery forceps and its ligation was then an easy matter. No further haemorrhage, to any extent, occurred in this case; the ligatures separated in due time, and the patient made a happy recovery." Case 981.—Private E. West, Co. 11, 104th Illinois, aged 31 years, was wounded at Atlanta, August 7, 18(54, by a minie ball. He was treated on ihe field and in hospitals No. 1, Chattanooga, and No. I, Nashville, where he was admitted on the 17th. Surgeon B. B. Breed, U. S. V., reported a "severe flesh wound of the right side. Haemorrhage from the gluteal artery ensued on September 19th to the amount of eight ounces. The vessel w;is ligated in the wound, the proximal end being tied: no haemorrhage recurred. The wound was treated with simple dressings. The patient was transferred, December 20, 18J4." On January 10,18o">, he was admitted into hospital at Jefferson Barracks, thence discharged the service, February 5, 183". Pension Examiner C. Hard, of Ottawa, reported, April 1, 1805, that "the ball entered the right side at an angle of the floating ribs, and passed through to the right, producing extensive sloughing and adhesion of the muscles, almost disabling the right leg, and rendering him very lame." Examiner A. C. Eankin reported, September 19, 18B3, that "West was shot in the right side just below the last true rib; the ball passed downward and came out about the end of the coccyx. He has had hospital gangrene in his wound, which destroyed a large portion of the muscles of the hip. There is a large cicatrix extending from the crest of the ilium to the end of the coccyx, and several others on the hip and thigh, caused by abscesses. He has a hitch in his walk, from the muscles of his hip being adherent to each other. Disability total." This pensioner was paid to September 4, 1873. In a case of excision of the head of the femur2 and in the two following cases, bleed- ing from the gluteal was controlled by proximal ligatures: Case 962.—Private G. W. AI. Johnson, Co. I, 32d Tennessee, aged 20 years, was wounded at Fort Donelson, February 15, 1862, and was sent to St. Louis. He entered the City Hospital on February 21st. Surgeon J. T. Hodgen, U. S. V., reported "wounded in the left hip. On March 12th, haemorrhage occurred to the amount of twenty-five ounces, probably from the gluteal artery. The vessel was tied, and the ligature afterward separated. On March 24, 1862, death ensued, but was not occasioned by recurrence of haemorrhage." Case 963.—Sergeant J. Morrison, Co. A, 102d Illinois, aged 27 years, was wounded at Eesaca, May 15, 1864, and received slight treatment for a shot wound of the left arm in a field hospital of the Twentieth Corps, previous to his admission into No. 8, Nashville, on the 25th. On the same day he was transferred to Brown Hospital, Louisville, where Assistant Surgeon B. E. Fryer, U. S. A., reported as follows: "Gunshot wound of both buttocks; no laceration. On June 17th, the patient was placed under chloroform, and the left gluteal artery was ligated He was much reduced from a copious haemorrhage immediately before the operation. He reacted somewhat, and was ordered nutritious diet and stimulants. On the third day after the operation he had a chill, which was followed by well-marked pyaemic symptoms. He died from pyaemia, July 3, 1864. Post- mortem examination revealed pus in both the elbow and the right shoulder joints, and also in the right knee; but there were no thrombi in the veins." 1 Compare the case of CARMICIIAEL ( Wound of the Gluteal Artery and an Account of the Operation for Securing it, in the Dublin Med. Jour., November, 1833); GUTHBIE (Commentaries, 6th ed., p. 270). Note also THEDEN (J. C. A.) (Neue Bemerkungen und Erfahrungen, 1872, B. I, S. 83), a case of fatal recurrent bleeding from a shot wound of the gluteal artery treated by compression; and the case of JKFFRAY (Cyclopedia of Pract. Surgery, 1841, Vol. I, "p. '_'?8(. BECK (Chirurgie der Schussverletzungen, 1872, S. 546) says that in shot wounds of the buttock, complicated with bleeding, absolute rest will often be adequate, the patient being made to lie upon the belly. He mentions the case of an officer with such a wound, with recurrent haemorrhage arrested by position and compression, and thinks that ligation will be rarely required in shot wounds of the buttock. 2CASE of Private J. Melcar, Co. A, 8th Michigan Cavalrv. reported in Circular 2, S. G. O., 1869, p. 25. 42 330 INJURIES OF THE PELVIS. [CHAP. VII. In a case of shot fracture of the ilium complicated by bleeding from a branch of the o-luteal. Dr. Bentley endeavored to carry out the sound practice of placing ligatures above and below the wounded portion of the vessel: Case 964.—Private E. C. Davidson, Co. K, 6th Maryland, aged 16 years, was wounded at Petersburg, April 2, 180."). Surgeon W. A. Child, 10th Vermont, at the Third Division Hospital of the Sixth Corps, reported a shot wound of the right hip. The patient was sent to Slough Hospital, Alexandria. Surgeon E. Bentley, U. S. V., reported: "Shot wound of right hip and flesh wound of the right arm. The ball entered above and without the anterior superior spinous process of the ilium, and emerged above the great sciatic notch. The patient was in excellent condition on his admission, on April 7th. The wound in the hip, which was by far the graver injury, cleaned off nicely with simple water dressings. On April 13th, about six ounces of blood was lost from the exit wound in the hip; the haemorrhage was readily checked by pressure over the gluteal artery, indicating that it proceeded from a branch of that vessel. On April 15th, bleeding recurred in the morning to the extent of four or five ounces. At four in the afternoon, Dr. Bentley cut down and tied the gluteal artery and several of its branches, and the haemorrhage was completely controlled. Stimulants were cautiously administered in small and frequently repeated doses, and he rallied rapidly after the operation. He was placed on a highly nutritious regimen. He rested well ou the succeeding night, and passed a good day on the 16th. He continued to do well on the 17th and 18th; but, on the 19th, at half past two in the morning, the nurses aroused the ward officer by reporting a fresh bleeding, and nearly a quart of blood was lost before the haemorrhage was checked. He gradually sank, and died April 19, 1855. At the autopsy, eighteen hours after death, the right ilium was found denuded over a space of two by four inches, and fractured just below the anterior superior spinous process." Evidently lesions of the gluteal artery and its branches are not insignificant.1 It is probable that, when the blood-vessels are fairly severed, properly adjusted compression will control bleeding from them in almost all cases; but when an artery the size of the gluteal is but partly divided, so that it cannot retract and be closed by the natural process of hsemostasis, then the only safe resource is the treatment insisted on by Guthrie, and the practitioner must at all hazards accomplish the difficult operation of placing ligatures on the vessel above and below the seat of injury. Wounds and Ligations of the Internal Iliac or Hypogastric Artery.—Primary lesions of this vessel rarely came under treatment; but several instances were reported in the War, in which it was opened secondarily by sloughing. Wounds of its larger branches,2 as has been seen, were not uncommon, and, on three occasions, for bleeding from them, ligatures were placed on the hypogastric, on the principle of Anel's operation. Two of these cases are printed on page 332, the third on page 334. The complexity and frequent variability in the distribution of this vessel3 renders the diagnosis of its lesions to the last degree obscure. Some cases of injury of the vessel were reported, however, as follows: Case 935. —Private S. Eyder, Co. D, 5th Michigan Cavalry, aged 29 years, was wounded at Hanovertown, May 28, 1864. and treated in a field hospital of the Fifth Corps until June 4th, when he was admitted into Emory Hospital. Surgeon N. B. Moseley, U. S. V., reported: "Wound of the left thigh by a minie" ball. On the 18th, haemorrhage occurred from the internal iliac to the extent of three ounces, and the patient died, on June 19, 1864, from accumulation of Hood in the abdomen." Case 966.—Private S. Martin, Co. F, 101st Ohio, aged 19 years, was wounded at Stone Eiver, December 31, 1862, and, on January 9, 1833, was admitted into hospital No. 5, Nashville, with a "gunshot wound of the left side of the abdomen. On January 16th, haemorrhage to the amount of thirty ounces occurred from the internal iliac artery, and death resulted on January 17, 1863." The case is reported by Assistant Surgeon J. D. Wvlie, of the 35th Illinois. Case 967.—Sergeant H. Osgood, Co. D, 83d New York, tvas wounded at Fredericksburg, December 13, 1862. Surgeon C. J. Nordquist, 83d New York, reported "a gunshot wound of the hip." The patient was sent to Lincoln Hospital, and was admitted December 23d. Surgeon H. Bryant, U. S. V., reported: "Gunshot wound of pelvis; fracture of the superior spinous process of the left ilium, and probably wounding a lumbar nerve and the internal iliac artery. Tetanus supervened, December 25th. On December 2?th, profuse secondary haemorrhage took place, and death the same day." 1 On operations on the gluteal and ischiatic arteries, besides the authorities cited, the reader may consult an article by the solid FOLLIX (Traiti ilimentaire de pathologie externe, 1869, T. II, p. 489;; also a paper by Blasius (Eigenthumlicher Schmerz beim Gluteal-Aneurysma, in Deutsche Klinik, 185:', B. XI. *. 105); and a case by CAMPBELL (G. W.) (Ligation of Gluteal Artery for Traumatic Aneurism, in Brit. Am. Jour., Vol. Ill, p. 103). 2 "La brifivetfi, la profondeur de la situation de l'iliaque interne doivent rendre ses lesions fort rares, car nous n'en cuim;i;.5>niks pas d'exemple."— BeUAUD (A.), Plaies des vaisseaux iliaques, in Diet de Mid.. T. XVI. p. 230. 3 "The internal iliac artery descends from the front upper part of the sacro-iliac junction to the lower part of the same articulation. In this descent it is bounded behind by the sacral plexus of nerves and gives ofF several arterial trunks; but the manner by which the last is accomplished is much varied indifferent subjects. For the most part, it is an inch or more long before any important branches leave it; it is then frequently divided into two principal trunks, an anterior and posterior, from which proceed the several branches that supply the internal and the external parts of the pelvis. The rule of origin of the secondary trunks from these two principal ones, even when the latter exist, is not fixed; for sometimes they arise from one. ? unetimes from the other, and then again from the trunk of the hypogastric itself."—Hoi:NE!t f\V). Special Anatomy. 6th ed., 1843, Vol. IT, p. 253. sect. II.] WOUNDS OK THE 1U.0OD-VESSELS AND NERVES. 331 The subject of wounds of the iliac blood-vessels has been very fully and ably discussed by Dr. J. A. Lidell.1 An illustration adduced by him, and a few other examples may be cited before detailing the instances of deligation of this trunk:2 Case 968.—Surgeon M. M. Stimmel, 26th Ohio, reports that "Private Abel Mock, Co. K, 26th Ohio, was admitted into the field hospital of the 6th division, Army of the Ohio, May 27, 1S62, having been wounded the same day while on picket near Corinth. A musket ball entered the abdomen in the left inguinal region, about two inches above the centre of Poupart's ligament, and passed obliquely backward to the point of exit, near tlie lower margin of the iliac fossa. The descending colon was perforated, and, when I first saw the patient, protruded some six or eight inches from the wound, allowing the escape of faecal matter. This man died, fifteen hours after the reception ofthe wound, from immediate haemorrhage. There was no post- mortem examination, but in my opinion the ball was not deflected from a straight line in its passage. Some of the important branches of the iliac artery were doubtless divided. The bladder was evacuated a few minutes before the wound was received, else it must have been perforated." Cask 969.—Private J. Lotters, Co. K, 37th Ohio, was wounded at Princeton, West Virginia, May 16. 1862. Surgeon C. Schenck, 37th Ohio, repotted the injury as severe. Surgeon J. F. Gabriel, 11th Ohio, stated that the "ball passed through the right upper portion of the sacrum. The wounded man entered the post hospital at Raleigh, West Virginia, May 26th, and died June 6, 1862. At the autopsy it was found that the missile had wounded the posterior trunk of the internal iliac artery and embedded itself in the right iliacus internus muscle. The immediate cause of death was secondary haemorrhage." Case 970.—Private E. Ryan, Co. K, 137th New York, aged 45 years, was wounded at Gettysburg, July 2, 1833. Surgeon J. M. Farrington, 137th New York, reported " a gunshot wound of the hip." The patient was placed in the Twelfth Corps Hospital. Surgeon H. E. Goodman, 28th Pennsylvania, reported that the "ball passed through the sacrum. On July 17th, haemorrhage to the amount of twelve ounces occurred from a branch of the internal iliac. This patient died July 1-S, 1863. The pelvis was filled with blood. The missile was not found." The actual cautery was unavailingly employed as a haemostatic in the following case: Case 971.—Private Oliver M. Heath, Co. G, 6th New Hampshire, aged 23 years, was wounded at the second battle of Bull Run, August 31, 1862, and was sent to Emory Hospital, September 6, 1862. Surgeon W Clendeniu, U. S. V., reported : "Vuln. sclopeticum: Death, September 16. 1862." This, doubtless, is the case reported in full by Surgeon Clendenin in the Sanitary Commission Memoirs. It is there stated that "the ball entered the buttock near its centre, passing through the glutaei muscles, perforating the os innominatum and lodging in the pelvic cavity." * * "The cace progressed well until the morning of the twelfth day, when blood began to ooze from the wound, at first slowly, but during the day it became more copious. Styptics, compression, etc., were used persistently, but without much success; haemorrhage supervened from time to time until the patient's life was seriously endangered thereby. The wound was enlarged for the purpose of ligatiug the vessel; but. failing to find the bleeding vessel, the surgeon (Surgeon W. Clendenin, U. S. V., was in charge) applied the actual cautery, by which the haemorrhage was arrested. On the succeeding day, profuse bleeding again supervened ; the actual cautery was again applied very thoroughly, but without effect, and the wound was subsequently twice cauterized, yet the haemorrhage continued. The patient died on the sixteenth day from the loss of blood. Post-mortem examination : The bullet had passed through the ilium, and was found lying upon the floor of the pelvis. It had wounded in its course the deep superior branch of the gluteal artery (external to the ilium), and, within the pelvis, the posterior trunk of the internal iliac artery. The first blood had undoubtedly come from the deep superior branch of the gluteal, which was arrested by the cautery. The subsequent bleeding was from the posterior trunk of the internal iliac, and, consequently, it was beyond the reach of the cautery." 1 Surgical Memoirs of the War of the Rebellion, collected and published by the United States Sanitary Commission, New York. 1870. Consult the memoir on Traumatic Hsemorrhage, already cited, by Brevet Lieutenant Colonel JOHN A. Lidell, U. S. V., Vol. I, Section I, Chapter XI, p. 219, Case LXXII. 21. Stevens, of Santa Cruz, has the merit of priority in ligating the internal iliac, for aneurism, December 27,1812. The account of his successful operation in the case of "Maila, a negro woman from the Bambara country, * * the property of the heirs of P. Terrall, esq.." may be found in the Med. Chir. Trans., 1814, Vol. V, p. 421. This woman died ten years subsequently, and Professor Owen dissected the pelvic blood-vessels, and the preparation was deposited in the Museum of the Royal College of Surgeons (Disc. Cat, 1848, Vol. Ill, p. 218, Series XXXV, No. 1596). The sciatic, and not the gluteal as supposed, had been the seat uf aneurism. The operation has now (1874) been repeated at least twenty times : 2. On May 12, 1817, by Atkinson (Med. and Phys. Jour., Vol. XXXVII, p. 267), in the case of T. Cost, aged 29, with gluteal aneurism, who died, partly from hsemorrhage, nineteen days after the operation. 3. AVEUILL (Op. Surg., 1825, p. 55) is authority for the statement, that a Russian surgeon was pensioned by the czar for successfully accomplishing the third ligation of the internal iliac on the living subject. I suspect this to be the operation commonly ascribed to Akexdt, of St. Petersburg (see Am. Med. Recorder, 1824, Vol. VII, p. 814). 4. Specimen 150460 of Guy's Hospital shows a ligation of the internal iliac by R. C. THOMAS, esq., of Barbadoes. The vessel is plugged with coagula above and below the ligature. The preparation was given by THOMAS to A. CoorER (Cat. of Path. Prep, at Guy's Hospital, 1860, Vol. I, Circul. System, p. 81). 5. S. POMKROY White, of Hudson, New York, tied the left internal iliac successfully for gluteal aneurism, in the case of a tailor, Volkenburg, aged 60, October 23, 1827 (Am. Jour. Med. Sci., Vol. I, p. 304). Neudorfeb and other Europeans erroneously cite this as "Hudson's case." 6. ALTMULLER, of Cassel, ligated the internal iliac, June 21, 18:13. in the case of a woman, M. E. Truppe, with gluteal aneurism. The patient lived eighty-three days (Deutsche Klinik, 1853, B. V, S. 175). 7. Valentine Mott (Am. Jour. Med. Sci., 1837, Vol. XX, p. 13) performed successfully the second American ligation of the internal iliac, December 29, 1834, in the case of R. Charlton, aged 38, a colored man, with gluteal or ischiatic aneurism. 8. Dr. Zesobi TORACCHI tied the internal iliac, April, 1844, for traumatic or gluteal aneurism, in the case of a soldier of 36, who survived the operation twelve hours (Gazzetta Medica Toscana, August, 1844. as cited in the Arch, gin de Mid, 4« serie, 1846. T. XI, p. 344). 9. Dr. H. J. BlGEr.ow (Am. Jour. Med. Sci., 1849, Vol. XXII, p. 29) tied the internal iliac for traumatic aneurism, September 30, 1848, in the case of an Irish woman, stabbed in the buttock by her husband. Death from peritonitis, October 7, 1848. 10. Dr. G. Kimball (Am. Jour. Med. Sci., 1850, Vol. XX, p. 92), in the case of A. Wentworth, aged 35, with aneurism, tied the internal iliac, November 19, 1849. The patient died, from recurrent haemorrhage, December 6, 1849. 11. The operation by Triplkr (Am. Jour. Med. Sci., 1854, Vol. XXVII; p. 365), a ligation of the right gluteal and afterward of the internal iliac, November 13, 1853, in a man cut in the buttock, is well known through Guthrie's severe criticism (Commentaries, 6th ed., p. 270) The patient survived the operation three days. 12. Syme's instructive account of his successful ligation of the left internal iliac, in the case of F. S-----, aged 22, with aneurism, is recorded in his Observations in Clinical Surgery, Edinburgh, 1861, p. 165. 13. The relation of a case in which SYME tied successfully, November 20, 1861. the common, external, and internal iliacs, W2 INJURIES OF THE PELVIS. [CHAP. VII. Dr. J. W. Thompson, of Paducah, prints, in the Nashville Medical lournal} the history of a ligation of the internal iliac, from which the following abstract is made: Case 072.—Private Thomas P------, 16th Tennessee Cavalry, was wounded at Harrisburg. .Mississippi, duly 10, 1864, and entered Forrest Hospital a few days subsequently. The left buttock had been penetrated by a minie ball. For four or five dav* there was moderate bleeding from the wound; but, on July 26th\ the haemorrhage suddenly became alarmingly copious. Dr. Thompson endeavored to tie the gluteal artery, from which the haemorrhage was supposed to proceed. He reached the bleeding vessel and placed a ligature around it, but the coats were so much decomposed that the thread cut through. Dr. Thompson, in consultation with Drs. S. N. Denham, D. II. Bryant, H. Branham, and Russell, decided to tie the hypogastric. Ana'sthesia being induced, an incision was made from a point an inch above and internal to the anterior superior spinous process of the left ilium, obliquely downward to the internal abdominal ring. The dissection was completed on the grooved director until reaching near the cavity of the abdomen. The peritoneum was then separated from the iliac fossa and pressed toward the linea alba. Dr. S. N. Denham then passed a ligature around the internal iliac about half an inch from its origin from the primitive iliac. The haemorrhage was arrested instantly upon tightening the ligature. The patient was much prostrated by the anaesthetic, and it was necessary to pretermit its employment before the operation was completed. The after-treatment consisted of opiates, with a mild nourishing diet. The symptoms were at first favorable; no evidence of peritoneal inflammation arising. On the sixth day there was a sudden gush of blood, and death ensued in a few minutes, August 1, 1834. Dr. J. W. Thompson asserts that this is the eleventh example of ligation of the hypogastric, and remarks that from the intricate anatomical relations of this vessel, its ligation is an operation of exceeding difficulty. Case 973.—Sergeant-Major E. Raymond Fonda, 4£th Xew York, aged 28 years, was wounded at Drury's Bluff. May 7, 1864, by a minie" ball, which entered one inch to the right of the coccyx, passed upward and out to within half an inch of the surface, just above the trochanter major of the right side. The ball was cut down upon and removed on the same day; it did not injure the bone. The wounded man was treated in a field hospital until the 10th, when he was admitted into Hampton Hospital, Fort Monroe; thence transferred to Xew York, and admitted to Ladies' Home Hospital on the 23d of May. Surgeon A. B. Mott, U. S. V., reported: "When admitted, the patient was very much emaciated; the wound healed unhealthy and inflamed, the discharges thin and offensive, and there was a disposition to slough. The sloughing increased on the 23th; the discharge was sanious and thin, the patient weak and restless. On the 28th, the wounds were still unhealthy in condition and showing evidence of gangrene. June 1st: Tlie discharge was slightly increased and the wound painful. Five ounces of sherry wine daily, with extra diet, was ordered. On the 8th, the wounds were still painful, and the discharge continued to look unhealthy. Haemorrhage occurred on the 13th, coming probably.from the sciatic artery; persulphate of iron was applied and the wound plugged. On the 14th, there was a very profuse haemorrhage, which was arrested by persulphate of iron with pressure. Haemorrhage recurred on the loth, and was checked by the application of Lambert's tourniquet with compresses. The patient was much reduced in strength; pulse 130. Beef-tea and five ounces of sherry wine were given and frequently repeated during the day. There was no haemorrhage the next day; beef-tea and wine continued. The patient was much better on the 17th; his pulse 100. After consultation, it was decided that the only chance for the patient's recovery would be to ligate the right internal iliac artery. He was put under the influence of a mixture of chloroform and ether, and the operation was performed by Surgeon A. B. Mott, U. S. V. The haemorrhage was immediately checked. Quite an extensive slough had already taken place where the ball was extracted; the parts looked healthy. Beef-tea and five ounces of brandy were given frequently during the day. On June 20th, an enema of warm water and castile soap was administered; beef-tea, oysters, and brandy were given. The wounds were doing well on the 29th, and brandy and good diet continued. On July 2d, the patient's pulse was 80, his general condition better. One-half ounce of castor-oil was given, producing a gentle movement ofthe bowels. The ligature came away on the 6th, followed "by haemorrhage, which very much reduced the patient; pulse 130. Brandy and good diet were continued. There was no haemorrhage on the 9th; brandy continued to be given. The patient was gaining strength by the 13th; wine and good diet were given. Again, on the 18th, haemorrhage occurred very freely, almost exhausting the patient; his pulse was 150. On the 21st and 22d, haemorrhage recurred, frequently during the latter day; pulse was very weak and rapid. He died at six o'clock P. M. on July 22, 1834. The necropsy showed the external incision nearly healed, except a small opening which led to the ligated portion of the artery. The adjacent parts had become adherent, forming a gangrenous sac containing about one ounce and a half of pus and coagulated blood; the proximal end of the artery had sloughed to the bifurcation." after opening the sac of an iliac aneurism, in the person of a seaman, R. L------, aged 31, is recorded in the Proceedings of the London Medico- Chirurgical Society (Med. Times and Gaz., N. S., Vol. I, 1862, p. 62.")). 14. Of Mr. HiGGlN'sox's unsuccessful ligation of the internal iliac for haemor- rhage from the gluteal, I have not found the original version. It is described in Hie Proceedings of the Liverpool Medical Society, April 5, 1863 (Med. Times and Gaz., 1863, Vol. I, p. 330). 15. Dr. T. G. MORTON (Pennsylvania Hospital Reports, 1868, Vol. I, p. 209) describes a successful ligation ofthe left internal iliac, in the case of J. Miles, aged 24, with gluteal aneurism. 16. The original account of a successful ligation, in 1869, of the internal iliac for diffused gluteal aneurism, by Professor C. GALLOZZI, of Naples (Considerazioni sul un caso di guarigiom di ligatura dell'arteria iliaca interna), in the case of a youth, D. Gramatico, 1 have not seen. It is cited in VIRCHOW, HlRSCH, and GtfRLT's Jahresbericht, 1869. B. II, 53. 312, and in the British Medical Journal, January 22, 1870. 17-19. To the foregoing are to be added the three unsuccessful ligations of the internal iliac practised by Drs. Mi'KEE, J. W. THOMPSON, and A. B. 3IOTT, adduced in the text, and, possibly (20), an operation ascribed by GUNTHER (Lehre von den Blut. Op.t 1860, S. 9) and others to (Everest, which I am unable to verify. Professors GROSS and Ericiisex ascribe an unsuccessful operation to J Kearney Rodgers, and Dr. ASHHURST places "Rogers'' among the unsuccessful operators on this vessel. J. K. RODGK.us was present at Dr. V. Mott's opera- tion. D. L. ROGl'RS (Cases in Surgery, Newark, 1849, p. 93) tied the external iliac for inguinal aneurism, and the Cyclopaedia of Practical Surgery (1841, Vol. I, p. £78) states that: "Mr. R< gers has published a case in which he was also successful" in tying the gluteal artery. It does not appear that either of these surgeons ligated the hypogastric. POWER (Anat. of the Arteries, etc., Am. ed., 1862, p. 286) erroneously includes Guthuie'8 ligation ofthe common iliac in this category. There is a paper by I'ICK (Diss, exhibens historiam, commemorabilem deligationis arteriie iliacx internee, Cassel, 1836) which professes to give a statistical summary of the earlier ligations of the hypogastric; but GUXTHER (B. IV, S. 9) justly deplores the confusion this writer has brought about, by including cases of deligation of the common and external with those of the internal iliac artery. ' THOMPSON (J. W.), Ligation of the Internal Iliac Artery, in the Nashville Jour, of Med. and Surgery. N. 8., 1866, Vol. 1, p. 108. SECT. II.] WOUNDS OF THE BLOOD-VESSELS AND NERVES. 333 Wounds and Ligations1 of the Common Iliac Artery.—As it has been demonstrated that wounds of the aorta are not always, of necessity, immediately mortal (pp. 15, 24 ante), it mMit be inferred, a fortiori, that wounds of the great secondary trunk would not be invariably attended by immediate fatal bleeding. Illustrations of this truth are, however, very rare. One instance was reported of shot wound of the right common iliac, fatal on the second day: Case 974.—Private E. R. Smithers, Co. (!, 14 Jd New York, aged 23 years, was wounded near Petersburg, June 18, 1864, and, on the following day, was admitted into Hampton Hospital, Port Monroe. Assistant Surgeon Ely McClellan, U. S. A., reported as follows: " Gunshot wound of the right natis, the ball passing into the pelvis at the sacro-iliac symphysis. On June 20th, haemorrhage occurred from the common iliac artery; there was a loss of three quarts of blood, and death ensued June 21, 1864. A post-mortem examination was made, and the ball was found lodged at the superior sacro-iliac symphysis, and the common iliac artery wounded." To the three examples of ligation of the common iliac referred to in the preliminary report of 1865,2 a fourth instance must be added, to complete the contribution of the war-experience to this division of what the European writers term "high surgery." The fourth example was an operation by the lamented Brainard,3 which was, in a restricted sense, successful. A detailed account of this case has been already published : Case 975.—Colonel Joseph R. 8eott, 19th Illinois, was wounded at the battle of Murfreesboro', December 31, 1862 A musket ball entered the thigh just below the groin, at the outer side of the femoral vessels, grazed the inside of the femur, and came out at the buttock. At the time of the injury there was haemorrhage, which was controlled, as was supposed, by pressure on the femoral artery. The compression was continued for three weeks, during which time no haemorrhage recurred. The wound suppurated and some small scales of bone came out at each orifice of the wound. He was sent to his home in Chicago, and did very well, although the wound remained open behind until April Cth, when a small tumor formed in front, which was opened. A day or two after, a haemorrhage took place from both openings. On April 9th, at night, a copious bleeding was partly controlled by pressure, but recurred at intervals. On April 10th, Professor Brainard was summoned, and applied a compressor over the femoral. This seemed to arrest the bleeding; but in about two hours it returned, and was so great as io threaten death, and Dr. Brainard resolved to tie the external iliac, not doubting, from the history of the case, that the haemor- rhage proceeded from branches of the profunda femoris, close to its origin. With the aid of Professor Freer and the Drs. Hurlburt, the external iliac was tied by Lisfranc's method ; but the bleeding was as profuse as ever, and it became evident that the ischiatic artery was the one giving blood. The danger was urgent, and Dr. Brainard at once extended his incision upward and outward and placed a ligature on the common iliac. The wound in the thigh was then enlarged, and a great quantity of coagula turned out. Warm applications were made to the limb, and brandy and broth ordered. On April 11th, the limb was cool, but not cold; pulse 100; uausea troublesome. On April 12th, pain and tenderness in the left renal region; pulse 120 ; wounds beginning to suppurate. On April 24th, ligature came away from external iliac, and, on May 1st, from common iliac. The wound of operation was healed on May 12th. He remained in good condition until July, the posterior wound still discharging pus and small bits of necrosed bone. At this date, he was attacked by colliquative diarrhoea, followed by typhoid fever, and died on July 8, 1883. It is to be regretted that the report of Surgeon A. J. Phelps, U. S. V., of the casualties in the Fourteenth Corps at Stone River does not supply the omission of Dr. Brainard in relation to the side on which the injury was inflicted. Surgeon Phelps records the case 1 To Dr. Stephen Smith's elaborate summary (A Statistical Examination of the Operation of Deligation of the Primitive Iliac Artery, embracing the Ditto,-ir^,,i abstract) of Thirty-two Cases, in the Am. Jour, of Med. Sci., N. S., 18(i0, Vol. XL, p. 17), Professor GCrlt (LANGENBECK's Arch., 1862, B. Ill, S. ab') has added (33), a fatal case observed by himself, in Laxgenbeck's Klinik,- and another (34). by BUNGEH, of Marburg (PICK, Diss. exh. historiam commem. deligationis arteriie iliacee, etc., Cassel, 1836). A few others have since been reported, viz: 35. DeLisle (Statistical Sanit and Med. Rep. for the Year 1860. London. 1862, p. 453); artery tied June 25th, 1859; death in 13 weeks. 36. BlCKERSTETII (Edinburgh Med. Jour., July, 1862); T. A., aged 39; operation for tumor March 4, 1862; ligation came away April 6th; patient recovered. 37. Symk (Med. limes and Gaz., June 14, 1862, p. 625); It. L----, seaman, aged 31, successfully treated for iliac aneurism by opening the sac and tying the common, external, and internal iliac arteries. 38. COCK (GUT'S Hospital Reports, London, 1864, 3d Series, Vol. X, p. 207); Wm. W----, aged 27; successful ligation of right common iliac for aneurism, June 30,1863. 39. McKiXLAY (W. B.) (Edinburgh Med. Jour., 1864, Vol. IX, Part II, p. 808) ; successful ligation of external, and afterward common iliac, in the case of George T----, aged 30. 40. HARGRAVE (W.) (Dublin Med. Press, 1865, Vol. II, p. 169); fatal case of ligation of the left common iliac for tumor in the left iliac fossa in a man aged 43. 41. Baxter (A. J.) (Chicago Med. Jour., 1866, Vol. XXIII, p. 460) ligated, July 22, 1866, the right common iliac for aneurism ofthe abdominal aorta; death, July 22, 1866. 42. Maunder (Med. Times and Gaz., Oct. 26, 1867, p. 458) tied the right common iliac in a case of inguinal aneurism ; patient died seven days after the operation. 43. CZEKNY (BILLROTH, Chir. Briefe, a. s. w., Berlin, 1872, S. 131) tied successively the external, the common iliac, and the aorta, in a case of shot fracture of the upper third of femur, in a soldier wounded August 4, 1870; death in a few hours. 44. Ladureau (Rec. de mem. de mid. milit, October, 1871) ligated the common iliac in a case of spontaneous aneurism in a man aged 40 ; death on the 30th day. 45. W. MoitRANT Baker (Saint Bartholomew Hosp. Reports, 1862, Vol. VIII) tied the common iliac in a youth of 17, for aneurism in the gluteal region ; death in 40 hours. 46. BUSCH (F.) (LANGENBECK's Archiv fur Klin. Chir., 1873, B. XV, S. 481), on May 18, 1870, ligated the common iliac in the case of a butcher accidentally stabbed in the right iliac region; death on the 4Cth day after the operatirn. 2 Circular No. G, S. G. O., 1865, p. 78. 'Brainard (D ), Ligation of the Common Iliac Artery, in the Chicago Medical Journal, 1864, Vol. XXI, p. 97. Reprinted in the Am. Jour. Med. Sci., 1864, Vol. XLVII, p. 565, in the Sanitary Commission Memoirs, and elsewhere. 334 INJUKIES OF THE PELVIS. [CHAP. VII. as a "gunshot wound of the groin and thigh." From the allusion to "pain in the left renal region," in Dr. Brainard's report, it may possibly be safe to infer that the shorter and deeper left primitive iliac was the trunk ligated. Of the three other ligations of the common iliac, full histories have been published of two. Dr. J. Cooper McKee's operation has been only briefly noted in the preliminary report and in the Museum Catalogue.1 Case 976.—Private John Hardy, Co. H, 95th New York, aged 25 years, was wounded at Weldon Railroad, August 20, 18(14, and, on the 24th, was admitted into Lincoln Hospital, Washington. Acting Assistant Surgeon E. W. Atwater reported: " This patient came into my ward in good condition; his wounds discharging healthy pus freely. He continued to improve until the night of September 5th, when the officer of the day was called to arrest hsemorrhage from his wound; this was promptly done by plugging the wound with lint saturated with persulphate of iron. I saw him at my usual morning visit, when the dressings were removed and others applied, without a return of the haemorrhage. The haemorrhage recurred on the night of September 6th, and again on the 8th and 11th. At a consultation held with the surgedn in charge on the 6th, it was decided that the gluteal artery was wounded. The patient was given more nourishing diet, with stimulants, and the wound was kept closed and cold applied to the parts externally. On the 12th, it was decided to ligate the internal iliac, and this was done at four o'clock P. m. The wound was then opened and the bleeding was as free as before; a ligature was immediately applied to the common iliac, when the hsemorrhage seemed to be arrested. The patient was taken back to his bed at six o'clock and two grains of opium were given him, and one grain ordered to be given hourly until he was easy; during the night he took six grains. Beef-tea and brandy were administered freely. On the morning of the 13th, he was doing well. Beef-tea and brandy were continued; the temperature of the left leg was kept up by cans filled with warm water. At six o'clock P. m., he had another haemorrhage from the wound, after which he continued to grow worse. Brandy and carbonate of ammonia were administered freely during the night, but without effect. The patient died at eight o'clock a. m., September 14, 1864." The post-mortem examination was made by Acting Assistant Surgeon H. M. Dean, who reported that " the oesophagus and trachea were normal. Both lungs were perfectly normal; the right weighed ten ounces, the left, eight and a half ounces. Pericardium normal. The right side of the heart contained a medium-sized fibrinous clot, the left side a small one; the parenchyma and valves were healthy ; the organ weighed ten ounces. The spleen was firm and somewhat enlarged, and weighed fourteen and a half ounces. The liver appeared normal, and weighed fifty-nine and a half ounces. He had a gunshot wound of the left gluteal region; a minie" ball, passing through the walls of the pelvis, was found lying in the pelvic cavity, against the wall of the right side. By carefully raising the intestines from the pelvic cavity the ball was raised with them, and appeared to be protruding from the large intestine, the apex and one-half of the ball being visible. There was a small quantity of blood in the pelvic cavity. There was an incision seven inches in length, commencing about three and a half inches from the median line on the left side, just below the ribs, passing downward, parallel to the median line, about five and a half inches, when it was made to course slightly inward. The internal iliac artery and the common iliac were ligated, and the ligatures were in situ. The track of the ball was not examined." It is proper to add to the reports by Drs. Atwater and Dean, that both of the ligations were made by Assistant Surgeon J. Cooper McKee, in charge of Lincoln Hospital at this date. With a wet preparation of the injured parts, Dr. McKee forwarded to the Museum a photograph2 made from the cadaver at the autopsy. It is represented^ reduced size in the wood-cut (Fig. 271). In the brief narrative of this case in his quarterly report of surgical operations, Dr. McKee mentions that " very little blood was lost in the course ofthe operation." A full account of a ligation of the right common iliac artery for diffuse aneurism, resulting from a bayonet stab inflicted seven months previously, implicating the anterior trunk of the right internal iliac, has been published by the operator, Professor Ralph N. Isham, of Chicago.3 A synopsis of the report is presented here, with a diagram to indicate the line of incision. Though the artery was brought into view in Dr. Isham's operation, the novice must not be betrayed by this drawing into the supposition that such 1 Circular No. 6, S. G. O., 1865, p. 78, and Cat. ofthe Surg. Sect, of the Army Medical Museum, p. 461. 2 Contributed Photographs Army Medical Museum, Vol. II, p. 5. 3 IsiiaM (It. X), Ligation ofthe Primitive Iliac Artery for Traumatic Aneurism, in the Chicago Medical Journal, 1866, Vol. XXIII, p. 222, and reprinted in The Medical Record, 1867, Vol. I, p. 193. Fig. 271.—Drawing from a photograph of the cadaver in McKee's case of ligation of the internal and common iliacs. The left half of the pelvic and upper femoral regions are pre- served in the Museum as Specimen 34C4, Sect. I. SECT. II.] WOUNDS OF THE BLOOD-VESSELS AND NERVES. 335 a fair view of the vessel is commonly obtained in operations on the living subject, or in dissections on the injected cadaver. Even in thin subjects the vessel is very deep. In the shrunken wet preparation from Dr. McKee's patient, the distance from the surface to the seat of ligation is over five inches. In a ligature of the internal iliac, Syme, "finding that any attempt to bring the vessel into view would be quite impracticable, proceeded to pass the needle under it with such guidance as was afforded by a very distinct perception of its coats."1 Case 977.—Surgeon John Groenings, .'l.'th Wisconsin, reports that Private August Tapka, Co. H, 35th Wisconsin, was accidentally wounded by a bayonet thrust, at Camp Washburne, Milwaukee, March 18, 1864, and was returned to duty July 12, 18(>4. Surgeon Samuel Kneeland, U. S. V., reports that this soldier was admitted to University Hospital, New Orleans, August 29, 18ti4, with a bayonet stab in the right gluteal region, and that he was furloughed September 19, 18G4. Acting Assistant Surgeon R. N. Isham reported that he entered the Marine Hospital, Chicago, September 30, 1834, and died October 11, 1864, and sent a report of the progress of the case from which the following abstract is prepared: There was bleeding to the amount of fifteen ounces at the time of injury. The urine, which was drawn by the catheter for four days subsequently, contained much blood. Great swelling in the iliac fossa and right buttock occurred immediately. He was sent to his regiment, iu Arkansas, after two months, but he could hardly walk with the aid of a cane. He suffered from what he described as a "hammering pain" in the tumor, whicli was observed to pulsate. Topical applications, made at the hospital whither he was sent, in Xew Orleans, failed to afford relief. On his admission to the Chicago hospital, he was suffering great pain in the tumor and right lower extremity. He was anaemic and presented the constitutional symptoms attending great loss of blood. The tumor was red and glistening, and extended from the crest of the right ilium to the natal fold. The cicatrix of the bayonet stab was nearly in its centre, and beside it was a puncture recently made for exploration by a surgeon on the transport steamer. The puncture was dilated to the size of a half dollar and filled with coagula, through which, October 2d, arterial blood escaped. There was numbness of the limb and dysuria. A bruit, but no audible pulsation, was perceptible on auscultation. On October 2d, an injection of solution of perchloride of iron was ' resorted to, with temporary arrest of the haemorrhage, and injections were repeated on recurrences of the bleeding. It was decided to tie the common iliac. On October 7th, the patient being placed under chloroform, assisted by Surgeon L. H. Holden, U. S. A., and Acting Assistant Surgeon Terry, Dr. Isham proceeded to the operation. A curvilinear incision was made from in front of the extremity of the twelfth rib downward and forward to the crest of the ilium (Fig. 272), and along the crest, terminating near the anterior superior spinous process. The muscles and transverse fascia were successively divided, and, the peritoneum being held out of the way by two fingers, the deep wound was enlarged to the extent of the external incision. The peritoneum was lifted unin- intwl K» tko U„„,l *«,™*v,^». ..,:t\, ♦!,„ •,„„,•„„ „i FlG. 272.—Diagrammatic drawing of the incision in Isham's case of ligation of the jured by the hand, together with the intestines, and right primitive iHac nrtery) for a gayonet stab inducing traumatic aneurism of the the vessel was exposed to view, not a drop of blood anterior trunk of the internal iliac. obscuring the parts. The ureter was lifted with the peritoneum. A Mott's artery needle was passed under the vessel. The tightening of the ligatures not only arrested the circu- lation in the limb, but diminished the tumor, so that its tense surface became flaccid. The wound was closed; the limb was enveloped in cotton and placed in an easy position, and warm-water bottles were arranged near it; a half grain of morphia was given, and oyster-broth. He had a good night, and the limb was of natural temperature. Pulse 113. A dose of four drops of tincture of veratrum viride was given at seven in the morning; at eight in the evening the pulse was reduced to 80 beats. October 9th: Pulse 90; the discharge from the sac being offensive, the clots were turned out, and the sac was injected with a solution of permanganate of potassa. October 10th: Discharge from sac very offensive. October 11th: Died at ten A. m. The autopsy revealed no evidence of peritonitis. A well-organized clot extended from the seat of ligation to the aorta. The wound was in the anterior trunk of the internal iliac, within the sacro-ischiatic notch. The walls of the enormous sac were gangrenous. There were no appearances to account for the haematuria. Dr. Isham was satisfied, after the autopsy, that the method he adopted was preferable to "the old operation," an opinion to which the editor, for one, cannot subscribe. The history of the fourth instance of ligation of the common iliac artery reported during the War has long been before the profession, and has excited less discussion and criticism than the extraordinary nature of the treatment might naturally have elicited. An examination of the pathological preparation (Fig. 273), or a perusal of the operator's 1 SYME, Observations in Clinical Surgery, Edinburgh, 1861, p. 1(17. 336 INJURIES OF THE PELVIS. [CHAP. VII. narrative of the case, leaves no room to doubt that this was an example of aneurismal varix, and that the deviation from the general rule of placing a ligature above and below the wounded part of the artery was not advantageous:1 Case 1)78.—Private G. W. Clark, Co. I, 4th New Jersey, aged 24 years, was admitted to the regimental hospital at Warrenton, August 31, 1863. Assistant Surgeon B. A. Watson. 4th New Jersey, gives no diagnosis, but records that the patient was transferred to general hospital at Washington, September 7, 1863. He entered Armory Square Hospital, September loth. Surgeon D. W. Bliss, U. S. V., records the case as "venous congestion; patient transferred to Newark, November 12, 1863." He entered "Ward Hospital, Newark, November 13, 1863, and in the monthly report Acting Assistant Surgeon A. M. Mills recorded the diagnosis : "(Edema and varix of the left thigh." In the surgical report by Surgeon George Taylor, U. S. A., for the quarter ending March 31, 18.34, the history of the case is recorded substantially as printed in the American Journal of Medical Sciences, 1864, Vol. XLVIII, p. 36. An outline of the narrative will suffice: In 1855, this man was accidentally wounded by the blade of a pocket-knife plunged into the inner part of the left thigh two inches below Poupart's ligament, lie stated that there was free bleeding at the time, readily arrested by compression, and that the wound healed, and he resumed his avocation as a farmer at the end of a week. No subsequent trouble arose until August, 1863, when a swelling of the calf of the left leg was observed, and pain was experienced in the left inguinal region. The swelling augmented, and the patient was sent to general hospital at the dates already noted. On December 26, 1833, Acting Assistant Surgeon J. B. Cutter observed an aneurismal thrill on firm pressure of the hand on the tumefied thigh, and a bruit over the tumor on auscultation. Surgeon G. Taylor and others verified these observations, and it was decided that the external iliac artery should be ligated. On February 6, 1801, anaesthesia being induced by a mixture of chloroform and ether, Acting Assistant Surgeon J. B. Cutter made an incision five inches in length, commencing outside of the left external abdominal ring and curving upward to a point an inch above the anterior superior process of the ilium, divided the oblique and transverse muscles, and ligated the external iliac. Copious venous hsemorrhage during the operation, was ascribed by Dr. Cutter to "obstruction of the femoral vein by the aneurismal sac." The ligature came away on March 12th. On March 31st, the patient was reported by Dr. Cutter as "weak and debilitated from long confinement to bed, sitting up for an hour or so. Has not attempted the use of his leg as yet." In the surgical report from Ward Hospital for the quarter ending September 30, 1864, Assistant Surgeon J. Theodore Calhoun, U. S. A., transmits a narrative substantially the same as that printed in the American Journal of Medical Sciences, 1835, Vol. L, p. 392. It is stated that "since the beginning of June the limb had become enormously distended;"' that "previous to the operation the thigh measured thirty-seven inches in circumference;" that "a number of openings on the thigh had lately put on a gangrenous appearance." Assistant Surgeon J. T. Calhoun being in charge of the hospital, it was determined to ligate the common iliac, and, on September 17, 1864, the operation was performed by Acting Assistant Surgeon J. B. Cutter. Anaesthesia being induced, "an incision was made six inches in length just above the old incision-made for the ligation of the external iliac artery. The abdominal muscles were carefully divided until the fascia transversalis was brought plainly into view; it was found firmly adherent to the peritoneum, which was thickened and fastened to the surrounding parts. It was found impossible to separate the peritoneum and get behind it; so the peritoneal sac was opened, and the artery secured in that way. The wound was brought together with silver sutures and adhesive plaster, and was dressed as is usual with wounds containing a ligature. The super- ficial haemorrhage was very abundant, but was of a different character from that of the previous operation. With very little trouble the veins were secured by ligature, aud the operation proceeded withotit further inconvenience." September 18th: The patient passed a pretty comfortable night. The temperature of the limb has not fallen at all. Warm applications have been made to the foot only. There is great diminution in the size of the limb; it is fallen away about one-third. September 19th: Considerable tenderness of the abdomen. Limb still diminishing in bulk; is about half its former size. September 20th: Vomiting; labored respiration. September 21st: Death. Sectio cadaveris: "Eighteen hours after death the whole surface of the peritoneum was coated with lymph, and there was a small collectionof serum. Thelymph in some places was in flakes; in other situations it was the consistency of thick gruel, closely resembling pus. No adhesions between the lips of the wounds." The vessels were removed and injected. The preparation was sent to the Army Medical Museum by Assistant Surgeon J. Theodore Calhoun,2 who took charge of the hospital in October, 1864. A photograph of the preparation is included in the Photographs of Surgical Cases and Specimens, S. G. O., Vol. II, p. 24, and a reduced copy of this print is presented in the accompanying wood-cut (Fig. 273). FlG. 273.—Aneurismal varix of the femoral vessels, showing, with the varicose veins, a portion ofthe aorta, the iliacs, with a ligature upon the left common trunk, and a constriction where a ligature has been placed on the left external iliac, and two constrictions ofthe femoral, due, apparently, to imperfection in the injection. Spec. 3597. JL 1 CUTTEU (J. B.), Successful Ligation of External Iliac Artery for Traumatic Aneurism cf the Femoral, with a Statistical Table, showing the Results of the Operation of Tying the External Iliac Artery, in the Am. Jour. Med. Sci., 1804, Vol. XLVIII, p. 36. CUTTER (J. B.), Ligation of tlie Common Iliac Artery: Sequel of Case of Ligation of External Iliac Artery for Aneurism of the Femoral Artery, in Am. Jour. Med. Sci., 18G5, Vol. L, p. 391. - As this excellent officer and esteemed gentleman is dead, the editor refrains from publishing the letter, filed in this Office, in which he comments on the operation. The specimen is eri'oneously accredited, in the Catalogue of the Surgical Section of the Army Medical Museum, p. 469, to Assistant Surge.m Cltaton Wagner, U. H. A. sect, ill WOUNDS OK THK I'.LOOD-VKSSELS AND NERVES. ^7 Few surgical precepts appear better established than that which inculcates that in arterio-venous aneurisms,1 if the tumor is stationary, all operative interference should be avoided; but if interference is imperative, the artery should be tied on either side of the wound in it.2 The foregoing case is an additional argument for the proscription of the methods of Hunter and of Anel in the treatment of this form of aneurism.3 Wounds and Ligations of the Spermatic Artery.—Lesions of this branch of the aorta will again claim attention with Wounds of the Testis. A single instance of bleeding arrested by compression, and a case in which the artery was tied, may be adduced here: Case i>70.—Sergeant H. Frazier, Co. E, 28th Massachusetts, aged 41 years, received a wound at Eort Steadman, March 25. 1865, and was sent to a field hospital of the Second Corps. He was transferred to Stanton Hospital, Washington, on the 30th. Surgeon B. B. Wilson, U. S. V., reported: "Wound of the penis, left testicle, and upper third of the left thigh. There was haemorrhage on April 4th, from the left spermatic artery, with a loss of twenty-four ounces of blood. The artery was not ligated, as the bleeding was controlled by pressure. Simple dressings to the wound and stimulating treatment were employed. He recovered, and was discharged May 30, 1865." He is not a pensioner. Case 980.—Color-Sergeant E. W. Crippen, Co. C, 27th Illinois, aged 29 years, was wounded at Missionary Ridge November 25, 18ii:>, and admitted into a field hospital of Sheridan's Division, Fourth Corps. Surgeon F. W. Lytle, 36tli Illinois, transmitted the following account of the case: "The left testicle was shot away by a musket ball, leaving the tunica albuginea, with the cord, hanging through a ragged wound in the scrotum. The same bail made a-wound in the left thigh through the skin. One ball, thought to be the same, entered behind the internal malleolus of the left ankle and passed out near the centre of the heel and near the sole ofthe foot. The spermatic artery was ligated on the 28th, and the debris of the testicle removed; the edges of the wound were pared and united by sutures, leaving an opening for discharge. On December 1st, the patient was doing well, union having taken place in the scrotum by first intention. He complained of great pain in the ankle, tbe parts around which were swollen, doughy, erythematous, immovable, and extremely painful. The parts were freely laid open and poultices applied; the constitutional irritation was considerable. The leg was suspended in an anterior splint. December 9th: Parts in about the same condition, only they were suppurating freely. The pain in the ankle was intense and produced a great deal of constitutional irritation. Poultices were applied, morphia was administered, and generous diet allowed. On the 14th, no change in the appearance of the ankle, which was discharging freely. The patient lost about six ounces of arterial blood by haemorrhage from the wound; the bleeding ceased without.any interference. His appetite was bad and he had a chill; his tongue was coated with a dirty whitish fur. Milk-punch was freely given, with generous diet. The following day the patient was very low; the chill he had on the previous day, not being very well marked, was more like a rigor. Quinine and stimulants were freely given. He had hiccough during the night before, and all the day of the 17th. His pulse was scarcely perceptible, and he was profoundly prostrated. On the 18th, he was about the same; hiccough ceased during the night; hippocratic countenance. Haemorrhage, on the 19th of December, 1863, to the amount of at least one pound, from the ankle, was arrested by persulphate of iron, but the patient died on the same day.'' The bleeding from the posterior tibial was, of course, the important and mortal complication in this case. It is improbable that simple haemorrhage from the spermatic artery should ever present serious difficulties. In the foregoing review of the reported cases of wounds and ligations of the arteries of the pelvis, a group of practical importance, comprising the wounds and ligations of the external iliac, has been reserved for future consideration. 1 Arterio-venous aneurism was first noticed by Sennert (Opera omnia, Parisiis, 1641, Lib. V, Cap. XLIII, p. 797) (for the vague passages cited from Pare, Andrea de la Ckuce, and Fabricius Hildanus are of little moment); but the true nature of the affection was first discovered by William Hunter (Med. Obs. and Inquiries, 177,7, Vol. I, p. 323; Idem, 1762, Vol. II, p. 390; Idem, 1767, Vol. Ill, p. 110; Idem, 1771, Vol. IV. p. 385). The patbolopjy of the different varieties of aneurism by anastomosis has been worked out, however, by contemporaneous surgeons, and especially by those ofthe school of Paris. The student may profitably consult the dissertation of MORVAN, De lanevrysme variqueux (These de Paris, 1847, No. 41); and the theses of Henry (Considerations sur I'anccrysme artirio-veineux, Paris, 185G, No. 70) and of GOUPIL (De I'anivrysme artirioso-veineux, Paris, 1855) are also of value. The subject is carefully treated in the systematic work of BROCA (Des Anivrysmes, Paris, 1856, p. 24). The principal facts of interest to the military surgeon have been collated by Bardkleden (K.) (Uber das traumalische Aneurysma arterioso-venosum. Beobachtung eines solchen nach Schussverletzung, Inaug. Diss., Berlin, 1871). 2 Dr. G. W. Norris (Am. Jour. Med. Sci., 1843, Vol. V, p. 27) records an instance in which he successfully put this method in practice, and adds some very instructive comments on the treatment of arterio-venous aneurisms. Dr. NORRIS's operation was for aneurism at the bend of the elbow; but a recent case, in which Mr. James Spence, of Edinburgh, successfully treated a traumatic varicose femoral aneurism by ligating the artery above and below the wounded part, is strictly in point. The history of the case, which strikingly exemplifies what has been insisted on in the text as the correct conduct under such conditions, is printed in the Edinburgh Medical Journal, July, 1869, and is reprinted in tho American Journal of Medical Sciences, October, i860, Vol. LVIII, p. 562. 3FOLLIN (Traiti ilimentaire de Path, externe, 1865, T. II, p. 374) collected ten instances of arterio-venons aneurisms of the lower extremity, of which five were treated by placing a ligature on the cardiac side of the aneurism. All five ended fatally. He collected also nine examples of arterio- venous aneurisms of the upper extremity treated in like manner: three terminated fatally; there were relapses in five cases, and u cure was reported in one case. After the suspension of the current of arterial blood by a proximal ligature, "the venous blood still entering the distal portion of the artery may block up the vessel and lead to gangrene, or else anastomoses restore the circulation in the distal portion, and a relapse occurs. 43 3S,S INJURIES OF THE PELVIS. [CilAiv VII. Wounds of Veins.—A few instances were reported in which injury of the veins of the pelvis was tho most important complication. It may be supposed that lesions of tin1 common iliac vein, or of its two principal tributaries, would be almost immediately mortal;1 though an instance has been given at page 190 (Case 657) of a patient surviving for over twenty-four hours a shot division of the internal iliac vein. In wounds of the external iliac vein or of the femoral vein near its entrance into the pelvic cavity, should the primary bleeding be controlled, gangrene of the lower extremity does not necessarily ensue immedi- ately. In the following case, already cited by Dr. Lidell,2 the patient survived seventeen days, and in Case 984, on the next page, the fatal termination was as long delayed: Case 981.—Private D. Wilson, Co. F, HOtli Ohio, aged 44 years, was wounded at Fort Steadtnan, March 25,18(>r>, and was sent to Armory Square Hos- pital on March 28th. Assistant Surgeon C. A. Leale, U. S. V.,reported that "a ball entered the right thigh at the middle of the sartorius border of Scarpa's tri- angle, cutting across the femoral vein, and passed beneath the ramus of the pubis, fracturing it across the perineum, and lodged deeply in the gluteal muscles. Haemorrhage followed continuously, and at times was checked by styptics. When admitted he was delirious, and his limb was infiltrated with serum. He died, April 11,1865, of asthenia. The necropsy showed the bone in the track of the ball very much comminuted, and the femoral vein partly closed by adhesive inflam- mation and filled with emboli." Venous haemorrhage was an important intercurrent feature in the following case: Case 982.—Private J. Schulthasis, Co. D, L,th New York Heavy Artillery, was wounded at Viner's Farm, Virginia, May 31, 1864, and was admitted into Douglas Hospital, Washington, on June 4th. The following report was made by Assistant Surgeon W. Thomson, U. 8. A.: "Gunshot fracture of trochanter major and pelvis. There was haemorrhage to the extent of two ounces, on the 7th, from the haemor- rhoidal veins; the bleeding ceased spontaneously, Fig. 274.—the veins of the pelvis. [After Hexle.1 J. an4." Examiner Henry M. Lyman, of Chicago, reported, March 21, 1868: "Ball entered the space between the trochanter major and the tuberosity of the ischium; it did not puss through, and is said to have been allowed to remain. There is what seems to he a thickening of the fibrous tissues behind the trochanter. The adjacent bones were not fractured. He cannot stoop over without throwing his leg back, and then only with pain. Disability two-thirds and permanent." In an examination for an increase of pension Examiner J. S. Hidden reported, December 17, 1873, that "a musket ball entered the 1 Compare, in the First Surgical Volume, the cases and remarks on pages 4(i8 and 519, and wounds of the cavse, and, in the Second Surgical Volume, Cask -134 on page 138. a 1,1 deli. (J. A.), On Wounds of the Veins. This is the title of the fifth chapter of the important paper on Wounds of the Blood-vessels, already frequently cited in this Section. Dr. S. W. Gross's statistical monograph on the wounds of veins and the applicability ofthe ligature in such injuries is printed in the American Journal of the Medical Sciences, 1867, Vol. LIII, p. 30"). Other authorities on the subject are: Laxokxiieck (H.) (Beitrage zur chirurgisclien Pitholngie der Venen, in Archie fiir Klin. Chirurgie, 1861, 1!. I, S. 1) ; TliAVERS (On Wounds and Ligatures of Veins, in Surgical Essays, Am. ed.. I8J1, p. 167); Oli.iek (Des plaies des veines, These de concours d'agregation, 1857); Ami'ssat (Recherches expirimentales sur les blessures des artires et des veines. Paris, 1S43); Hoffmann' (A.) (De la ligature des veines, These, Paris, 1856): Ni< aisi: (Des plaies et de la ligature des veines, Paris. 1S7J); IJusil's (Uber seitliche \'i nenligatur. Halle, 1 s~l); STATU (A.) (De ligatura venarum laterali, Inaug. l)i>s., Berlin, 1862); I'L'CHELT (Das Vi ainsystem in seinen krankhaf'ten Verhaltnissen, Leipzig, 1843-44). RF.CT. II. 1 WOUNDS (VI'' Till', liLOOD-VKSSKLS AND NERVES. 339 Fig. 275.—Shot laceration of the right femoral vein. Spec. 3094. ;. Ileshy portion of the right hip, six inches downward and backward obliquely from the superior spinous process of Ihe ilium, and was never extracted. There is atrophy of the muscles, exercise producing pain and cramps down Ihe thigh to the knee; inability to raise the foot over anything without great effort. Dining the past year numbness and partial paralysis has set in and is on the increase; it is permanent in the present degree." This pensioner was paid September 4, 1873. Lesions of the femoral vein presented some features of interest clinically and from the point of view of tho pathological anatomist; but most of these cases may be suitably considered either in the chapter on wounds of the lower extremities, or in treating, further on, of phlebitis or pyrjemia. A single illustration may be presented (Fig. 275) of a shot wound of the femoral vein, as the case to which it belongs has been already related (Oask 868) at page 304. This patient survived thirteen days, though there were repeated copious venous haemorrhages. The subject of the following case lived eighteen days: Case 984.—Private J. Shephard, Co. D, 9th Iowa, was admitted into the field hospital of the 2d division, Sixteenth Corps, on October 9, 1864, having been wounded by a conoidal ball at Allatoona on the 5th. Surgeon Joseph Pogue, tioth Illinois, reported that "the ball entered below the pubis and made its exit at the right trochanter major, making a very severe wound. The discharge from the wound was of a sanious purulent character, frequently accompanied by venous hemorrhage, the latter becoming more copious daily. He died October 2 i, ISil. Autopsy twelve hours after death : Ball passed in on the left side of the scrotum above the testicle, and out anterior to the trochanter major of the right femur; it hud severed the spermatic cord of the right testicle, passing posterior to the femoral vessels. The track of the ball was extensively ulcerated; the femoral vein severed, and containing purulent matter." Wounds of Serves.—It is altogether probable that there were instances of injuries of the pelvis in which the most important pathological elements were constituted by lesions of the sacral plexus, of the sciatic and crural nerves, or of smaller branches. It may be doubted, however, whether there were many such cases in which the attendant or resulting phenomena were described with the precision requisite in a study of such obscurity. The editor, at least, has hitherto been unable to accomplish any satisfactory analysis of the material bearing on the subject, and must be content to adduce some abstracts of cases which may possibly be of service to other investigators, and to again refer to the labors of Dr. S. Weir Mitchell1 and Drs. Morehouse and Keen. Specimen 3538, of the Army Medical Museum,2 from a shot laceration of the crural nerve, was preserved, by Dr. William Thomson, from a patient who survived the injury twenty-five days and died of tetanus, and a drawing illustrating its pathological histology will be given in treating of Tetanus, in the Third Surgical Volume. Dr. Larue,3 aided by Professor Robin, has been studying shot lesions of the nerves during the Franco-Prussian War. Case 985.—Private B. Cunningham, Co. B, 51st Ohio, aged 21 years, was wounded at Stone Kiver, December 31, 18o2, and was treated in hospitals on the field, at Nashville, Xew Albany, and Madison, entering the last July 24, 188:.?. Surgeon A. M. Wilder, U. S. V., reported as follows: 'Wounded by a ritle ball, which entered from behind at the middle third of the right thigh, then passed forward and downward through Hunter's canal, wounded the great sciatic nerve, and emerged from the anterior aspect of the thigh. At the time of injury the profuse hajmorrhage was controlled only by the application of the tourniquet. His leg was flexed upon his thigh and could not be straightened; he complained of much pain in the heel, toes, and dorsum of the foot; the leg was somewhat numb and was not painful. The wound was entirely healed at the time of his admission, and the man's general health was very good; he slept well at night without anodynes. A wash composed of fluid extract of aconite, chloroform, tincture of opium, and diluted alcohol, gave great relief to the pain. The left limb presented every appearance of 'paralysis agitans,' which was probably occasioned by reflex action ofthe nervous system." He was transferred 'Inthe work by Dr. S. Weir Mitchell (Injuries of Nereis and their Consequences, Philadelphia, 1872), and in the reports resulting from the associated labors of Drs. MITCHELL, Morehouse, and Keen (Circular No. fi, S. G. O., 1864, on Reflex Paralysis, and Gunshot Wounds and Other Injuries of Nerves, Philadelphia, 1864), will be found the most valuable data supplied by the experience of the War in regard to injuries of the nerves of the pelvis, and, indeed, to injuries of the nerves in general. 2 WOODHULL (A. A.), Catalogue of the Surgical Section of the Array Medical Museum, 1866, p. 510: Private A. F-----, Co. V, 31st Maine; wounded at the Wilderness, May 6th, died May 31, 1864. 3 LARUE (E.), £tude clinique sur les blessures des nerfs par les armes a fen, in Gazette des Hopitaux, Janvier 6, 1872, p. 9. :U0 fX.IURIF.S OF TIIF PRLV1S. |CMAI\ VII. to Ohio, and admitted to Seminary Hospital, Columbus, September 13. 1884, and was discharged on September 20th. Acting Assistant Surireon W. H. Drury certified: "Paralysis of the right leg and hyperaesthesia, caused by wound of the popliteal nerves." Examining Surgeon T. II. Smith, of Xew Philadelphia, reported, December, 23, 1837 : "Wounded by a ball passing through the thigh, wounding the femoral nerve. The foot is so drawn that the toes point downward, and he cannot flex the foot at the ankle. I think the disability is permanent. The limb does not seem to have the sense of feeling." The Examining Board at Dayton, Surgeons A. Jewett, A. S. Dunlap, and J. S. Beck, reported, September 9, 1873, that the "ball entered the right thigh posteriorly, rather to the outer side, and came out on the front and inner side about the middle of the thigh. The tendo achilles is greatly contracted, so that the heel will not touch the ground, and the foot is held firmly nearly at a right line with the leg." This pensioner was paid September 4, 1873. Cask 983.—Private 11. H. Blue, Co. E, 73d Indiana, aged 25 years, was wounded at Lost Mountain, June lii, 1834. From hospitals at Chattanooga, Nashville, and Madison, Drs. McGowan, Herbst, and Eauch described the case as a shot wound implicating the abdominal walls on the right side, and possibly complicated with fracture of the right ilium. This soldier was discharged May 30, 1865, and pensioned. Examiner S. J. Weldon, Covington, Indiana, reported, January 6, 1872: "Gunshot wound of the right side, fracturing the ribs. The ball entered about two inches above the crest of the ilium, remaining in the body; its location is not detected, but I believe it to be embedded in the lumbar muscles; it interferes with the ability to lift, walk, or run, and renders him unable to follow his occupation as a farmer. The numbness indicates either pressure upon some of the sacro-lumbar nerves or lesion of them." On September 5, 1873, Dr. Weldon further reports: * * "The disability consists of lameness ofthe right leg, numbness, and loss of muscular power in that limb. Disability one-half." This pensioner was paid September 5, 1873. Cask 937.—Private R. Nelson, Co. B, 119th Pennsylvania, was wounded at Chancellorsville, May 3, 1833. The injury was reported as a shot perforation of the pelvis, from the Sixth Corps Hospital, the Hammond, Satterlee, and Turner's Lane Hospitals, lesions of the ilium and rectum being noted at some ofthe hospitals. This man was discharged from Turner's Lane. December 23, 1834, for "total disability from partial paralysis of the left lower extremity from gunshot wound of the left hip." Examiner II. Lenox Hodge reported, at that date, "a gunshot wound appears to have involved both hips, and also the pelvis, passing through the rectum. The left leg is shrivelled and paralyzed, probably in consequence of injury to the nerves." Examiner S. Lovell, Attleboro', Pennsylvania, reports, September 3, 1873: "A minid ball passed into the pelvis near the left acetabulum, perforating the rectum. He was for a long time unable to use his left leg. His system is still much shattered from the effects of the wound. His left leg shows, by the flaccid condition of its muscles and by its shrunken appearance, that he depends but little on it for walking. That he is but the wreck of his former self is evident, but I cannot see that his disability has increased materially. I think his disability permanent in its present degree, and that it has not been caused or protracted in any way by vicious habits; disability total." This pensioner was paid June 4, 1873. Casio 988.—Private A. Kates, Co. A, 19th Infantry, aged 24 years, was wounded at Chickamauga, September 19, 1863. He was treated in a Fourteenth Corps field hospital until the 29th, when he was sent to hospital at Chattanooga, and there the injury was noted as follows: " Gunshot wound; the ball entered to the left of the spine and four inches above the tuberosity of the ischium, and emerged two inches below and outside of the anterior superior spinous process of the ilium; the posterior portion of the ilium was probably slightly injured. The patient was in a good condition when admitted." He was transferred to Indianapolis, and discharged April I, 1835. Acting Assistant Surgeon J. Saunders, of Fort Wayne, March 10, 1835, certified: "Perforating gunshot wound of tlie pelvis, implicating the hip joint." Examiner J. E. Dodds, of Blooniington, stated, April 17, 1835: "The ball entered about the middle of the left side of the sacrum, passed transversely forward, and was extracted by making a deep incision at the outer inferior edge of the left ilium. The missile shattered, somewhat, the bones ofthe pelvis, it appears, from the many pieces of bone, small spiculse, and scales that have been removed. It appears, also, that the missile injured the nerves, as evinced by the persistent pains in the back, hip, and knee, interfering with'free and natural movement of the lower limb, and undue susceptibility to cold and so forth. At the point of the ball's ingress there is a pit of about two-thirds of an inch in depth. The wound seems now to be closed and healed. His disability is three-fourths." No account of this pensioner has been received since September 4, 1863. Case 989.—Corporal P. Carlin, Co. E, 125th Ohio, aged 21 years, was wounded at Missionary Ridge, November 25, 1833. At Chattanooga, Nashville, and Parkersburg, the case was reported as a shot wound ofthe left groin or hip, by Surgeons F. Irish, G. Perin, J. W. Foye, and W. A. Banks; fracture of the pelvis being also noted at some but not all of the hospitals. This soldier was discharged November 18, 1834, and pensioned. Examiner G. O. Hildreth, of Marietta, reports, September 4, 1836: "A musket ball entered the left lower part of the abdomen and lodged behind the left femur near the hip joint. It seems to have fractured the upper end of the femur. Complete anchylosis of the hip joint exists; also partial anchylosis of the left knee joint. The stiffness of the knee seems to have been the result of inflammation that followed the injury. He is unable to pull on a sock or boot, as the knee does not bend enough to enable him to touch the foot. He complains of coldness and numbness of the left foot; also of pain about the hip and down the outer side of the thigh, probably from injury of tho sciatic nerve. The leg is somewhat shortened; the foot is turned out, but bears flat on the ground when walking. The flexion ofthe knee is sufficient' to admit of walking. There seems to be a movement in the pelvis, but not in the hip joint. He says exercise is always painful, and, though he goes about more or less, ha does not engage in regular labor." Examiner John W. Trader, of Sedalia, Missouri, stated. September 9,1839: "The muscles of the thigh are atrophied, and from the injury done to the sciatic nerve there is severe pain upon any unusual or active exercise." He further reported, September 4,1873, a "gunshot wound of the left hip, the ball entering the left hypochondriac region, ranging downward and outward, making its exit through the gluteus muscles, dislocating the hip. The hip joint is completely anchylosed. and the knee partially. The muscles of the leg are very much atrophied. The injury completely disqualifies him for manual labor; disability total." His pension was last paid to September 4, 18T3. Case 990.—Corporal J. H. Beadle, Co. F, 55th Illinois, was wounded at Shiloh, April G, 1862, and was treated in hospital at Quincy, Illinois, where Sirgeou R. Xicholls, U\ S. V., reported that "he was wounded by a musket ball, which entered over the centre of the sacrum, fracturing it at its junction with the ilium, a:i I passed out below the anterior superior spinous proces.s. SECT. II.] WOUNDS OF THE BLOOD-VESSELS AND NERVES. 341 He was discharged December (i, 1802, at which time he walked about; the wounds were discharging at both the orifices of entrance and exit of the ball, with bare bone to be felt at the point of entrance." On the certificate of disability appear the following notes by Dr. Xicholls: " The ball entered the body of the right spinal column, fractured the sacrum at the sacro-iliac junction, and emerged three inches above and behind the trochanter major of the right femur." Pension Examiner Geo. W. AY right, of Canton, Illinois, reported, August 5, 1871 : " Musket ball entered the left hip posteriorly an inch from the left margin ofthe sacrum, passed through the bone, ranging forward and outward toward the right side, and passed through the right ilium near the centre of the bone. Important nervous communications were severed, causing paralysis of important muscles in both the hip and thigh. Corporeal labor causes great pain in the parts; the lower extremities are weak, and his disability is total." This pensioner was paid September 4, 1873. Cask 991.—Private 1\. Weaver, Co. K, 45th Pennsylvania, aged 3H years, was wounded at Cold Harbor, June 3, 1864, and treated in a field hospital until June 7th, when lie was transferred to Harewood Hospital, where Surgeon H. B. Bontecou, U. 8. V., reported a severe shot wound ofthe right inguinal region, and had prepared a photograph, which was forwarded to the Museum and is copied in the wood-cut adjacent (Fit;. 27li). On May 30, 1835, this invalid soldier was discharged the service and pensioned. Examiner J. Severgood, of Lancaster, reported, March 0, 1839, that " he was originally pensioned for a gunshot wound of the right inguinal region. The wound was an exceedingly serious and dangerous one, in consequence of which the whole limb has become somewhat atrophied. At present, he gives every indication of laboring under confirmed phthisis; he has cough, expectoration, pains in the chest, loss of appetite, pallid countenance, and is greatly emaciated ; he is in a precarious condition." Examiner J. B. 1 lower, of Marietta, reported that Weaver died April 25, 1839. and that " he had been suffering from a gunshot wound in the right groin and hip, causing partial paralysis ofthe right leg. Tlie spinal cord was also more or less affected, and there were several ulcers on his body, caused by the impurity of his blood, a consequence ofthe poison infused into his system by said shot wound." Case 992.—Captain E. E. Brasher, Co. I, 14th Indiana, was wounded at Antietam, September 17, 1832. aud was treated in a Second Corps hospital, and subsequently at the Avenue House, Washington, Surgeon T. Antisell, U. S. V., reporting the case as a "gunshot wound through the left iliac region, in consequence of which he is unable to perform the duties of an officer. He has done no duty since he was wounded. There is partial loss of motion and sensation of the left lower extremity, which, on account of the injury to the nerve, is likely to be permanent." This officer was discharged from service December 19, 1862, but re-entered the Army as captain in the 120th Indiana Volunteers, and was promoted to the rank of major, and subsequently killed in action at Franklin, November 30, 1804." Case 993.—Private T. W. Buck, Co. E. 7th Virginia, aged 23 years, was wounded at Gettysburg, July 3, 1863. He was treated on the field until August 21st, when he was admitted to Camp Letterman Hospital. Acting Assistant Surgeon H. H. Sutton reported : "A ball from a Sharp's carbine entered the left side of the sacrum at the third segment, passed in the pelvis "and there lodged. The ball in its passage injured the sacral plexus of nerves, and consequently the leg of the corresponding side became paralyzed; but the natural feeling and movements of the limb were gradually returning when the patient was admitted. His general health was good; the wound gave much pain at times from the forming of abscesses; there was a continued discharge, but the amount was small. Stimulants and tonics were given, and the wound was dressed with simple cerate, alternated when necessary by flaxseed-meal poultices. On September 1st his condition was unchanged, and the same treatment continued. His condition was still unchanged on the 15th." On the following day he was transferred to West's Buildings Hospital, whence he was paroled, September 25, 1803. Case 994.—Private W. D. Cole, Co. E, 23d Massachusetts, aged 42 years, was wounded and captured at Drury's Bluff, May 16, 1864. He was admitted into hospital No. 1, Annapolis, on August 14th, from the steamer New York, with partly healed wounds of the abdomen, right hip, and left arm. He was transferred to Camp Parole, and thence to Rulison Hospital on December 6th. Assistant Surgeon John Bell, U. 8. A., reported that he was "discharged March 28, 1865," and remarked that "this is a case of very extensive cicatrices of the abdominal walls, the result of wounds from buckshot at short range, and is complicated with injury of the sciatic nerve." Examiner J. G. Metcalf, of Mendon, reported, April 5, 1867: "The wounds were not entirely healed under ten months; he has been lame in the right leg from the date of injury. At this time, the side of the cicatrix is frequently painful, and the right leg becomes more lame upon exercise; he cannot labor at light work without pain." Surgeons II. Chase, J. B. Treadwell, and Hugh Doherty, Examining Board at Boston, reported, April 6, 1873: "Ball entered the abdomen at the left of the umbilicus, and emerged through the tensor vagina femoris on the opposite side, without entering the abdominal cavity. The walls of the abdomen are sensitive at all times, and severely so if extended." This pensioner was paid September 4, 1873. Case 995.—Private J. Carmody, Co. H, 10th Michigan, aged 22 years, was wounded at Cold Harbor, June 3, 1864. He was sent from a Fifth Corps hospital to Lincoln Hospital on the 12th. Assistant Surgeon J". Cooper McKee, U. S. A., reported : " The ball entered two inches behind the anterior superior spinous process of the ilium, and in the track of the gluteal nerves. Patient may have been exposed to cold while on the field and on transports. There is no proof that a nerve was injured. On June 10th, tetanus appeared; narcotics were freely used both internally and hypodermically, and bromide of potassium, in one- drachm doses, was also tried. Ice was applied to the wound without benefit. The spasm was arrested, but by what agency it is hard to state. Death resulted June 15, 1834." FlG. 276.—Cicatrix of a shot wound followed by paralysis. [From a pho- tograph.] 34:> INJURIES OF THE PELVIS. [CHAP. VII. Cask 990.—Private J. Elliott, Co. C, 30th Ohio, aged 22 years, was wounded :it Missionary Ridge. November 25, 1803, and admitted into a Fifteenth Corps field hospital. Surgeon J. M. Woodworth, 1st Illinois Light Artillery, reported : " Gunshot wound : the ball passed through both hips, fracturing the sacrum. Fragments of bone were removed, four hours after the injuiy, by Surgeon S. P. Bonner, 47th Ohio; no au aesthetic was used He was doing well on the twenty-fifth day." On December 22d, he was admitted into a hospital at Chattanooga with a " gunshot wound of both hips;" transferred, and admitted into No. I, Nashville, with a "wound of the right hip and partial fracture of the ilium." He was transferred to hospital at Jeffersonville, March 23d, thence to hospital at Madison, April 8th, and, on September 9, 1864, he was discharged the service. Examiner William Blackstone, of Athens, reported, February 20, 1865: " His disability arises chiefly from partial paralysis and wasting of the flexor muscles of the right leg, caused by a wound inflicted by a musket ball which injured the gluteal muscles, the right ischium, and the great sciatic nerve of the right side. He is also disabled by ulcers, caused by frost-bite, on the side of .first, second, and fifth toes of his right foot." Another report, from Examiner C. L. Wilson, of December 30, 18,3,, states: " Partial paralysis and atrophy ofthe muscles ofthe right hip, from a gunshot wound which injured the right ischium and right great sciatic nerve; also, occasional ulceration and constant tenderness of the right foot and toes from frost-bite. The effects of the wound and the frost-bite combine to make him lame and unable to perform fully his labor as a farmer." Surgeons S. M. Smith, E. B. Fullerton, and J. W. Hamilton, Examining Board at Columbus, transmitted the following on September 5, 1873: " Wounded through both hips, the ball striking and entering the left side, passing through the right side deep in the tissues, and wounding the bone—the ilium. The muscles ofthe right limb are emaciated." Of the subjects of, the twelve foregoing abstracts, one died of tetanus, one was subsequently killed in action, one died after four years of suffering ; a fourth, a pensioner, is probably dead, as no account of him has been received at the Pension Office for seven years ; a fifth, a Confederate, has not been heard from since the date of his parole ; but seven remain under the inspection of the pension examining surgeons, and it is to be hoped that the ulterior histories of these cases will be carefully observed. Besides these twelve examples of the results of shot injuries of the nerves of the pelvis in this and in the preceding Section, fifteen instances in which nerve lesions were an important element are recorded among the cases of injury of the pelvic bones or viscera,1 and two analogous instances may be found in the Fifth Chapter of the First Surgical Volume? These twenty- nine examples present a great variety of illustrations of the phenomena of direct and reflex paralysis, paresis, and muscular atrophy. The latter was the most frequent of the morbid conditions they had in common, the expression " the lower extremity was shrunken and useless " occurring in many of the reports. The relation between lesions of the nerves and alterations of the muscular tissue has been of late a favorite subject of pathological enquiry.3 Without entering on the subject here, it may be remarked that in most of the foregoing cases prolonged inactivity of the limb would alone adequately account for a considerable degree of muscular atrophy. In the treatment of traumatic neuralgia, Dr. Mitchell4 found constitutional alterative remedies insufficient. In cases of old neuritis or sclerosis, iodide of potassium and, more rarely, corrosive chloride of mercury were administered, with little if any advantage. Quinine and arsenic were equally ineffective, save in so far as they might be of use in combating the malarious element, that especially fostered neuralgia. Whatever consti- tutional means tended to restore the lowered tone of the system, appeared to diminish the intensity and frequency of recurrence of the neuralgic trouble. M. Legouest5 employs in traumatic neuralgia narcotic fomentations and friction, cold-water douches, simple or medicated vapor baths, and hypodermic injections of morphia or atropia, with advantage sometimes, often without benefit. In the paralyses, faradization is the main resource. •Cases 239, Mills, p. 78; 274, Cook, p. 89; 299, Tucker, p. 100; «"03-0o4. Iteens, D---, p. 225; 662, Whitney, p. 2-7; G78-679, Warner, Brookins, p. 2)2 : (In text) Young, p. 236; 739, 745, Busch, Denegan, p. 252 ; 748. 7.34, Barton, Phillips, p. 253; 755, Durfee, p. 254 ; 758, Young, p. 255. • Cases of Private Thomas D---, Co. F, 1st Michigan, p. 445, and of Private T. K---, Co. A, 6th Cavalry, p. 448. 3 Vulwan (A.), De laltiration des muscles qui seproduit sous Vinflucnce des lisions traumatiques ou analogues aux nerfs. Action trophiquc des centres nervcux. (Comptes rendus de VAcademic des Sciences. 8 Avril, 1872.) " Jnsqu'a quel degr6 cette influence trophiquc est-elle indispensable au tissu musculaire ? Question a 6tudier. Quel est le mecanisme intime de cette influence ? Question qui me parait sans solution possible, dans 1 etat actuel de la science.'' 'MITCHELL (S. W.), Injuries of Nerves and their Consequences, 1872, p. 279. 6 LEGOUEST (L.), Chirurgie d'Armee, 2dni<; ed., 1K72, p. Ii77, SECT. III.] WOUNDS OF THE GENITAL OKGANS. 343 Section III. ON INJURIES OF THE GENITAL OKGANS. Wounds of the genital organs may bo considered as a subdivision of injuries of the pelvis.1 As observed in warfare, they constitute a comparatively small group,2 and are not very dangerous, though important because of the disabilities they induce, and their influence on the moral faculties.3 It may be remarked that the names of only a small proportion of those who recovered from wounds of the genital organs are found upon the Pension List; and, in this comparatively small number, the causes of disability assigned are often foreign to the lesions of the organs of reproduction that probably constituted the real causes; hence there are very few detailed histories of cases of injury of this class. We shall examine, first, cases of wounds of the penis;4 secondly, at some length, wounds of the urethra, with cases of traumatic stricture and operations for organic stricture, subjects that have been separated, for convenience sake, from their more natural relations with injuries of the bladder and prostate; and, lastly, injuries of the scrotum, testis, and spermatic cord. Wounds of the Penis.—These injuries were not very rare; they were commonly inflicted by cutting instruments or by shot. The examples reported during the War were of all grades* of severity, from removal of the prepuce to ablation of the entire organ. Incised Wounds.—These comprised accidental, voluntary, criminal, and therapeutical mutilations,—and one instance of a bayonet wound of the penis. There were reported fifty-two operations for phymosis—thirty-one by circumcision, and twenty-one by slitting up the prepuce on the dorsal surface. Only seven of these operations were practised on account of congenital elongation and contraction of the prepuce; eight were performed for phymosis incident to gonorrhoea ; and twenty-one to expose condylomata or chancres. In some of the cases of the latter group, very serious consequences ensued from the inocula- tion of the exposed raw surfaces, and in several instances sloughing phagedsena invaded 'In the classification in use in the British Army these injuries constitute a distinct class. Matthew, the surgical analist of the Crimean War, observes that "there appears no very sufficient reason for separating these wounds from those of the pelvis, except as showing the increased mortality invariably induced by lesion of bone in this as in other situations." 2 Thus, M. Chenu (Camp, d'Orient, p. 200) reports 205 such cases in 34,300 wounded, or .06 per cent. In the British Army, in the same campaign, the proportion was .07 per cent., or 74 in 10,270 determined cases. M. Chenu (Camp, d'ltalie, T. II, p. 518) records 87 cases in 17,054, or .05 per cent., and Dr. B. Beck (Chir. der Schussverletz., 1872, S. KiO) mentions 24 cases in 4,344, or .05 per cent. 3 " Mutilations of the genital organs," observes M. Legouest (Chir. d'Armee, 1872, p. 708), '"have a marked influence upon the moral faculties of the subjects affected by them. Many thus wounded are a prey to a profound sadness that impels them to suicide. The loss of tbe testes is more easily tolerated than the total ablation "of the penis, the latter no longer permitting sexual relations. Some surgeons have raised the question if, in cases where, the testes remaining intact, the virile member has been carried away at the root, castration should not relieve the despair of the mutilated sufferers, by extinguishing desires it is impossible to gratify." "Nous pensons," continues M. Legouest, "quo la question doit 6tre resolue n. Assistant Surgeon W. Webster reports that he was suffering from "the effects of bayonet wounds ofthe back and penis, received at Fredericksburg, February 11, 1S64." No further particulars are recorded except that this soldier was "transferred to the headquarters of his regiment at Fort Trumbull, Connecticut, April 12, 1865." Two severe self-inflicted incised wounds of the penis in insane soldiers were noted, and there were several instances of similar injuries occurring in brothels,2 one luckless subject having the penis ik;. 2?7. - Transverse maliciously amputated about two inches from the p^isT s^i.lJvh.^theVorsa'i crura. The vascular supply of the penis in the artery and veins, the net- ■_ . n ,______- n i , -i >n nr-cn- FlG.^8.-'l he same parts as wo.-/of the cavernous flaccid Fig. 2'/7) and the turgid state (Fig. 278) is ^^-SfrfcrX bodies, and the spongv V ' to \ / being in a state ex erection. Sy«HE0NSheArethni■ indicated in the accompanying wood-cuts. LAitem.. .,.] ,. The chief requirements in wounds of the penis are to stanch the bleeding, and to dress the solution of continuity in such a manner that there shall be no obstacle, to the evacuation of the urine. It is recommended to tie the dorsal artery and the arteries of the corpora cavernosa3 when wounded, if they can be found ; but they rarely furnish jets after shot wounds. Le Dran,4 who appears to have had considerable experience in amputations of the penis, observed that they rarely spirted when cut across. Guthrie says :5 " I have not had occasion to tie an artery, even when the penis has been as good as amputated." However, in cases of criminal mutilations, more particularly,6 dangerous hsemorrhage has occurred. It may usually be controlled by cold and pressure. Schmucker commends7 pressure with agaric. Boyer, Guthrie, and Dupuytren8 advise compression by a circular bandage on a catheter introduced in the urethra. M. Legouest9 prefers to this effective and harmless plan the employment of a styptic solution of perchloride of iron. Professor Gross10 would substitute acupressure. 'If Demmes reports be accepted, bayonet wounds of the penis were common in the Italian Campaign of 1859. In his Studien (B. II, S. lb'l) he remarks: "While in bayonet injuries I repeatedly noticed copious bleeding, it was absent in all shot wounds of the cutis of the penis that came under my notice. Even lacerations and perforation ofthe corpora cavernosa caused only little secondary bleeding." 2PlROGOFF (Grundzuge der Allgemeinen Kriegschirurgie, 1864, S. 616) states: "In the Russian prisons I examined judicially several such mutilated persons. The silly sect, which bases its belief on the passage in the gospel of St. Matthew, Chap. XIX, 12, practises the mutilations on children only. But about twenty years ago the sect attempted to spread their creed among the Cossacks of the Don, when the authorities interfered. Of twelve of these fanatics that I examined, I found five with the genitals shaven closely to the body. The amputation of the penis had been performed without introducing a catheter into the urethra, and castration without ligation of the spermatic arteries, but, as it seemed, with torsion of the spermatic cords." 3LANGENBECK (C. J. M.), Nosol. und Therap. der Chir. Krankh., Gottingen, 1830, B. I, S. 599. 4 Le Dkax (Traiti des Opirat. de Chir., 1742, p. 207): " II est rare que le sang sorte en jet, a moins que ce ne soit dune artere un peu grosse. S'il y en a une qui donne, j'y fais une ligature avec I'iiiguille enfilfee. Le sang qui donne sort pour I'ordinaire des corps caverneux comme d une 6ponge qu'on presseroit, ainsi on ne peut l'arreter que par le styptique soutenu de la compression." 6 GUTIIHIE, Commentaries, etc., 6th ed., 1855, p. 594. '•CHEUL'S, Von den Wunden des mannlichen Gliedes, in seinem Handbuch der Chir., Achte Auflage, He'.delberg, 1857, S. 537. Pali.UCI, Observat sur la separation du penis, Paris, 1750, p. 247. 7 SCHML( Ki;n, Vermischte Chir. Schriften, 1782, B. Ill, S. 238. "BOYEK, Traiti des mal. Chir., 5™ §d., 1849, T. VI, p. 794 ; GUTHBIE, op. cit, p. 594; DUPUYTREN, Lecons orales, T. VI, p. 507. 'Legolest (Chirurgie d'Armee, 2n"J ed., 1872. p. 436). There is a suggestion of the unreliability of this plan in the sentence that follows: ' Lnfin, si l'liemorrhagie persistait encore, il faudrait avoir recours a la cauterisation par le fer rouge.'' lgC.iiO!-s is. D.), A System of Surgery, 5th ed., 1872. Vol. II. p. 1*73. This plan, unless in practice it should be found to lead to erections, would be unexceptionable. Sl'.CT. III.l WOUNDS OK THE PFJSIS. 345 Shot Wounds.—Three hundred and nine cases were reported of shot injuries of the penis, in which it is not mentioned that the urethra was interested. A very small proportion of these cases were uncomplicated. The most frequent complications were wounds of the scrotum and testes, wounds of the perineum and thighs, wounds of the pelvic walls or viscera. The eases involving laceration of the urethra are separately examined in the succeeding subsection. Of the three hundred and nine cases of shot wounds of the penis, forty-one or 13.2 per cent, terminated fatally. The great majority of these fatal cases were complicated by graver injuries elsewhere, particularly by frac- tures of the pelvis or femur. The fatality of the less complicated cases was due, in two instances, to tetanus, and in several to srnall-pox, pneumonia, pericarditis, and other intercurrent affections. One instance is mentioned of an uncomplicated shot wound resulting fatally from pytemia.1 Two observations by Surgeon S. W. Gross, U. S. V., and by the late J. Mason Warren,2 teach that projectiles may be innocuously encysted in the cavernous portion of the penis:"' Case 99S.—Private D. P------, Co. A, 16th Infantry, -'received a wound of the penis, at the battle of Shiloh, April 7, 185-2. Being immediately removed from the field and placed upon a hospital boat, I did not see him until six weeks subse- quently, when I examined him with a view to a discharge from the service. I found that the ordinary conical ball had become enevsted in the right corpus cavernosum, the point of the missile presenting to and being about one inch from the pubes. He stated that a good deal of inflammation had ensued, but that no efforts were made to extract the ball by his attendant in the hospital at Evansville. Indiana. He was a married man and the father of four children, but had not had an erection since he was wounded. As the ball gave him no pain, I could not induce him to have it removed. He wished to be discharged on account of lumbago, but the cause was deemed insufficient." This soldier was discharged July 23, 1864. Case 999.—A sailor, thirty years of age, was wounded, at Pensacola, Florida, in April, 1862, by a musket ball, which entered the outer and upper part of the left thigh, passed through the limb, emerging near the root of the scrotum, and again entered and disappeared. He was sent to the Marine Hospital at Chelsea. In May, Dr. Fox discovered the ball in the left corpus cavernosum. It gradually worked over to the right side. The man had no difficulty in.urinating, and no pain during erection. The apex of the conoidal ball was toward the body. On May 30th, Dr. Fox invited Dr. Warren to witness the removal of the foreign body. "It was firmly held by the fingers, and then cut down upon. The skin was first divided, then the strong fibrous covering of the cavernous body, and although the incision was quite free, the foreign substance resisted the use of ordinary forceps, the elastic force and suction of some of the tissues operating to prevent its extraction. The wound being now held well open, a pair of bullet forceps were introduced, and the ball slowly extracted as if from a bed of India rubber. There was no violent rush of blood from the erectile tissues, but a slow, continued discharge as from a large vein. This was controlled by means of a sponge and bandage. A gradual suppuration, with apparent elimination of the sac, formed around or pushed before the foreign body, followed, and the patient is now recovering in the most satisfactory manner. The case is interesting from its rarity and for the practical facts which it teaches in regard to the danger from interference with the erectile tissue, which at first would appear likely to be more considerable." There were other instances of balls lodging in the penis, and removed by excision; but these were cases of primary extraction: Case 1000.—Acting Assistant Surgeon W. J. C. Duhamel records the case of a "soldier wounded at the second battle of Bull Run, August 30, 1862, by a heavy conoidal ball, which entered the gluteal muscles, passed along the perineum, and lodged in the root of the penis, whence it was extracted through an incision by Dr. Duhamel, assisted by Surgeon C. McMillen, U. S. Vv at the field hospital at Fairfax Station. The case was lost sight of and the result of the injury remains unknown." The missile (FlG. 279), which weighed Hl>8 grains and presented fig. 279.—Ball excised from the a very trivial derangement of form, was contributed by the operator to the Army Medical Museum. Pems- *Pec- ■ • r. Case 1001.—Private J. Brainard, Co. C, 18th Massachusetts, aged 28 years, was wounded at Cold Harbor, June 3, 1864. He was treated on the field, at Alexandria, and afterward at McDougall Hospital, where Assistant Surgeon H. M. Sprague, U. S. A., reported: "A gunshot wound of the right thigh and of the penis. The missile, a conoidal musket ball, remained in the cavernous portion of the penis for fifty-two hours, when it was excised at the First Division Hospital of the Fifth Corps. He was furloughed July 7, 1864, and, failing to report, was recorded as a deserter August 6, 1864." The report of the Adjutant General of Massachusetts states that this man was transferred to Co. B, of the 32d regiment, and discharged June 29, 1865.''' 1 Case of Corporal Vf. J. U-----, Co. F, 7th New Hampshire, wounded at Deep Bottom, October 27, 1864. Death, November 21. 1864. 2 Gnoss (S. W.), Interesting Cases of Gunshot Wounds, in Am. Med. Times, 18G4, Vol. VIII, Case II, p. 137; compare, also, Circular 3, S. G. O., 1865, p. 29. Wauben (J. M.), Ext. from Rec. of Boston Soc. for Med. Improvement, in Boston Med. and Surg. Jour., 1862, Vol. LXVI, p. 476, and in Surgical Observations, with Cases, 1867, p. 552. 3 NeudOrfer (Handbuch der Kriegschirurgie, 1837, S. 799) is rather incredulous regarding the encystinent of foreign bodies in the penis, but cites the case reported by Dr. GROSS as proof of the possibility of such an occurrence. 44 346 INJURIES OF THE PELVIS. (HAP. VII. Fio. 2S0.—Diagram of the course of a ball excised from the penis. In a third case, a musket ball was excised from the corpus cavernosum after travers- ing tlie right buttock. The particulars of this case are mainly derived from the report of the pension examining surgeon, who furnished a drawing, which is copied in the wood-cut (Fid. 280), to illustrate the course of the ball: Cask 1002.—Private J. II. A------, Co. H, 1st New Jersey, was wounded at Salem Creek, May 3, 1863, and was reported missing in action. Assistant Surgeon A. Hartsuff, U. S. A., reported, however, that lie was brought to Judiciary Square Hospital on May 8th, and transferred to Christian Street Hospital, in Philadelphia. Here Surgeon J. J. Reese, U. S. V., records that tbe patient had "a shot wound of the right buttock, the ball having been excised from the dorsum of the penis." The patient was again transferred on September 23d, and, on June 2, 1864, mustered into the Veteran Reserve Corps, and finally discharged and pensioned. Examiner J. Ii. Coleman, of Trenton, reported, March 20, 1868: "Ball entered a little to the outside of the ischium, passed inward, upward, and forward, through the gluteus magntis, quadratus femoris, and the inner edge of the long adductor muscles, back of the spermatic cord, and lodged in the corpora cavernosa of the penis, from which point it was extracted by incision. The shock to the sciatic nerve caused the right hip to be weak, and impaired its motions to the extent of fully one-half or even entire disability." With his report, Dr. Coleman transmitted a diagrammatic drawing of the course of the ball, which is faithfully copied in the wood-cut (FlG. 280). This pensioner was paid to September 4, 1872. The five foregoing are the only instances reported in which balls were found lodged in the penis. It may be inferred that such a lesion will be seldom observed. Except in a virile organ of extraordinary dimensions,1 the corpora cavernosa scarcely afford space for the encysting of a large musket ball. Their strong fibrous envelope is likely to deflect a projectile, and if the latter penetrate, it will probably lacerate the tissues and pass on. Few of the reported cases of shot wounds of the penis present any circumstances of interest. The following may serve as illustrations of this class of reports: Case 1003. —Private R. C------, Co. 13, 24th Michigan, aged 31 years, was wounded at Gettysburg, July 2, 1863. At York, on the 10th, Surgeon H. Palmer, U. S. V., noted: "Gunshot wound of the scrotum and penis; simple dressings; furloughed August 19th; readmitted September 13th, and returned to duty October 14, 1863." This soldier was discharged June 28, 1S65, and pensioned. Examiner J. A. Brown, of Detroit, reported, September 17, 1868: " Ball entered at the root of the penis, passed to the left, through the hip, back of the head of the femur. The result is lameness in the thigh or groin, attended with much pain and tenderness in the groin. Disability is one-half and permanent." Surgeons J. A. Brown, X. W. Webber, and J. F. Noyes, the Detroit Examining Board,, report, September 5, 1873: "A ball struck the dorsum of the penis, wounding it, and, passing to the left, wounded the left thigh in its upper third. There is slight difficulty in voiding urine, and lameness of the left thigh. His disability is one-half." This pensioner was paid September 4, 1873. Case 1004.—Corporal P. Reynolds, Co. I, lU'ith Ohio, aged 42 year*, was wounded at Chickamauga, September 19, 1863. 1 le was treated in the following hospitals: Field hospital, Fourteenth Corps, No. 14, Nashville, and No. 15 and Taylor, Louisville, being returned to duty, from the latter, February 15, 1864. The injury had been noted as a gunshot wound of "privates," "scrotum," and "external genitals," respectively. He was admitted to hospital at Camp Chase ou May 23, 1864, with "gunshot wound of the left hip, with injury to the joint," and was discharged May 30, 1864. Surgeon S. S. Schultz, U. S. V., certified: '• The ball entered the penis on the left side one inch from the root, and escaped three inches to the left of the anus; the entire left lower extremity is slightly paralyzed; he has also incontinence of urine, at times quite troublesome. Both difficulties, paralysis and enuresis, have not improved for four months, but are becoming rather aggravated. He is not fit for the Veteran Reserve Corps. Disability three-fourths." Examiner W. Wiley, Fond-du-Lac, reported, October 14,1873: " Ball entered at the root ofthe penis, and passed out three inches external to the coccyx. There is considerable adhesion of the muscles; disability three-fourths." This pensioner was paid on September 4, 1873. 1 Among extraordinary examples of development ofthe penis maybe mentioned the instance adduced by GIBBON (The History of the Decline and Fall of the Roman Empire, Chapt. L), who alludes to the preternatural gift of Mahomet, and adopts the style of St. GKEGOKY Naziaxzex (cva0\evu>v 'HpaxAeos rpio-KaiSeKarov a6\ov, Orat. Ill, p. 108) in stating that the apostle might rival the thirteenth labor of Hercules. The testimony of Mauacci (Prodromus Alcoran. IV, p. 5") is quoted, "sibi robur ad generationem, quantum triginta viri habent inesse jactaret: ita ut unica. hora posset undecim tieminis satisfacere."—and the exclamation of Ali, who washed the prophet's body after death, is cited from Albufeda: "O propheta, certe penis suus coplum versus erectus est."—(In Vita Mohammed, p. 140.) HOUXER was accustomed to exhibit a large injected penis from the Wistar Museum collec- tion, with the remark that it formerly pertained to a South Sea Islander; and that the missionary who obtained it stated that when the organ became turgid, the derivation of blood from the systemic circulation was so great as to induce syncope. Though there are many exact series of measurements of the urethra, few anatomists give definite statements of the normal dimensions of the penis. SriGELIUS (Op. omn., Amsterdami, 1645, L. I, Chap. X) sn-s. "in an adult man the penis, when erect, should be six inches long and four inches in circumference." Two injected preparations in the Army Medical Museum i Sect. IV, Xos. JO, :21) divested of integument, measure in length, respectively, from the meatus to the pubis, six and a half inches and five and a half inches; from the extremity to the termination of either crus, nine and three-quarters and eight and three-quarters inches ; in circumference, varying less than two lines in any pail, the measurements are: four and three-quarters, and four and one-quarter inches. Paullixis (C. F.) (Ephem. sect, in.] WOUNDS OF THE PKNIS. 347 Erections arc a great hindrance to the healing of wounds of the penis, especially of those that implicate the cavernous tissue. They tend to induce haemorrhage, and necessarily break up incipient adhesions and retard reunion. Hence everything promoting sexual excitement must he sedulously avoided in these cases. The parts should be lightly dressed; the patient should lie on a hard bed, and have a spare regimen, and should be exhorted to shun lascivious thoughts. Cam- phor, in pill or enema, may be often advan- tageously employed: Case 1005.—Private J. Q. Erwin, Co. H, 27th Massa- chusetts, aged 19 years, was wounded near Petersburg, May (>, 18,i4. He was sent to Hampton Hospital, where the injury was recorded as a ''gunshot wound of the penis and scrotum.'' Jul v 17th, the patient was transferred to Filbert Street Hospital; October 28th, returned to duty, and discharged and pensioned June 15. 1S,'>5. Examiner G. C. Lawrence, of North Adams, reported, May 15, IStili: "A mini6 ball entered at the root of the penis on the right side, passing downward and backward, and was extracted from the posterior part of the thigh. The wound is healed, leaving a hernia which escapes into the scrotum near the base of the penis. His disability is one-half and perma- . „ rri_- • -i T ',,.., mi i FIG. 281.—The pubic arch and root of the penis. The right corpus nent. Ihis pensioner was paid on June 4, 1-/.1. The remarks cavernosum is divided transversely, showing the dorsal artery, nerve, and on the coincidence of hernia and shot wounds, on page 13, may vein, the corpus spongiosum and urethra, and the urethral muscles and , , r^ • ligaments. [After HENLK.] be compared. Case 1006.—Private J. M------, Co. B, 7th Maine, aged 19 years, was wounded at the Wilderness. May 5, 18G4. and was treated on the field, in* a Sixth Corps hospital, for a " gunshot wound of the left thigh and testicles." On May 8th, he was admitted into Emory Hospital, where the injury was noted, by Surgeon N. E. Moseley, U. S. V., as a "gunshot wound of the testicle and penis.'' and was thence transferred to New York, to Grant Hospital, July 21st. Surgeon A. H. Thurston, I*. S. V., recorded " wound of the testicle and penis ; furloughed September 30th, readmitted October 30th. and returned to duty December 30, 1834." This man was discharged the service May 14, 183". On the certificate of disability, signed by Assistant Surgeon A. S. Packard, 1st Maine, appears "shot wound through the upper third of the left thigh, involving the testicle and sciatic nerve." On application for pension, M------alleges that he received a gunshot fracture of the femur, that spiculae of bone were discharged from the wound, and that he was confined and treated for eleven months in Emory and Willett's Point hospitals; but he makes no mention of any injury to the geuito-urinary organs, nor does any of the examining surgeons allude to such injury. Examiner B. Bussey, jr., of Houlton, Maine, reports, March 7, 183S : "Compound fracture ofthe left thigh by a shot. His leg is weak, and there is loss of power in the flexor muscles in the patient's foot, and his toes drag on the ground in walking. His disability has increased from one-third to three-fourths by reason of progressive atrophy of muscles of the leg from the knee down." But few examples were reported of amputation of the penis for shot injury: Case 1007.—Private Lyman N. C------, Co. B, 53d Illinois, aged "24 years, was wounded at Atlanta, July 21, 18(54. Surgeon W. W. Welch, 53d Illinois, reported "a lacerated shell wound of the penis and scrotum." The patient was sent to the general field hospital of the Seventeenth Corps, where Surgeon J. G. Miller, 11th Iowa, made a similar entry, and noted the patient's transfer to Rome, October ^Oth. On December 3, 1834, he was admitted to hospital at Jeffersonville, and Surgeon M. Goldsmith, U. S. V., reported: "Gunshot wound of penis; amputation of penis July 21. 18;>4. Ssnt to Provost Marshal for insubordination March 29, 1865." This soldier was returned to his regiment April 21, 1815; admitted to Foster Hospital, New Nat. Cur., Norimbergae, lfii-T, Dec. II, An. V,'App.. p. 51, Obs. I.X.W'II) relates that his father saw, at Spires, a country youth with a truly monstrous penis "two spans in length," ■' mentula duas robusti viri spithamas longa " .' BLAW (J. F.) (in a paper de monstrosa penis magnitudine, in the contin- uation of the Ephemerides, 1712, Cent. I, p. 338) relates, among others, the case of a Salzburg soldier named Herbst, examined by a jury of surgeons. This man's pendulous penis extended to the knee, and equalled in size the turgid penis of a stallion: " quam veretrum equi turgidum." DlEMEUUROECK (I. c, p. 123), discussing at length the dimensions of the penis, only recapitulates vulgar traditions on the subject: " Vulgo brevioris staturae viri nee non qui a Venere abstemii vivunt, item nasuti seu magno nasu praediti (hinc ex nasi magnitudine de magnitudine_penis, ut etiam ex oris magnitudine in mulieribus, de earum pudendi magnitudine judicari posse, sibi persuadere solent salaciores viri et mulieres, secundum hos versiculos: 'Adformam naris noscetur mentula maris: Ad formamque oris noscetur res muliebris.) Ut et stolidi, stupidique, ac fatui, majore pene donati traduntur." Hann.kus (D. G.) (Ephem. Nat Cur., Dec. II, An. VIII, 1(589, Obs. CXIV, p. 251), remarking that Nature is sometimes prodigal and again niggardly in the distribution of her gifts, relates that he once saw two sons of Mars " satellites Veneris sedulos, quos Lampsacenum deum ad sui imaginem finxissc crederes. Horum alter veretrum habet, tarn longum et laeertosum, ut ipsum Priapum in ruborem daret; sed scrotum modicum. Alteri est carta virgae supellex ; sed scroti apparatus tantus, ut huic reeipiendo vix par sit pileus." Peteoxics (A. F.) (a chaplain of Pope Ghegoky XIII, in his work De morbo Gallico, 1565, L. Jf, Cap. 15) taught that the size of the penis was an index of mental endowment: "magnum penem dieit indieare ingenium durum et stolidum, asinino simile." Spigelius (Opera qux extant omnia, Amsterdam, 1645, Lib. I, Cap. X, p. 19) considered a great development of the virile organ as disadvantageous in the function of fecundation: "major mentula," inquit, " vutvam potius replet magnitudine, quam uterum foecundo seraine. Est etiam ineptior ad Venerem, quam neque animose aggreditur, nee diu sustenet, victis pondere musculis, qui rigidam hastam tenent. Parva contra, et salacior est, et faecundior, quia titillando cervicem uteri, magis prolectat foeminarum semen, et diutissime' pugnam perfert." 3-1S INJURIES OF THE PELVIS. Berne, April 26th; transferred to Mower Hospital. Philadelphia, May 8th, and returned to duty May 18,1865. He was mustered out of service July 22, 1865, having been promoted first sergeant, and reduced at his own request. His name does not appear on the Pension List. In lacerations of the integuments of the penis, if close apposition of the divided parts is effected, owing to the vascularity and looseness of the tissues, union is rapidly accomplished, if inflammatory action is kept within bounds. In some instances, as in the following, sutures are requisite, even in shot lacerations, to ensure adequate approximation: Case 1008.—Private J. M-----, Co. A, 54th Ohio, was wounded at Dallas, May 26, 1864, and was taken to a hospital of the Fifteenth Corps. Surgeon J. M. Woodworth, 1st Illinois Artillery, reported "a lacerated gun- shot wound of the integuments of the penis and scrotum; the wounds had been united on the field by Surgeon I. N. Barnes, 116th Illinois." This patient was subsequently treated at Ackworth, and at Rome, Georgia. Surgeon J. B. Potter, 30th Ohio, reported that there was a shot flesh wound of the left thigh in addition to the wounds of the genital organs. The patient recovered, and was mustered out with his regiment, August 15, 1865. His name does not appear on the Pension List. In illustration of this class of injuries, Professor F. H. Hamilton1 adduces the interesting case of a soldier of the 94th New York, with three buckshot perforations of the penis, implicating the urethra. FIG. 282.—Profile view of the root of the penis, the integ- <-n ill • j. j_l • n j t • uments removed to show the disposition of the ligaments, Some examples belonging to tins group are collected in muscles, arteries, and veins. [After Henle.] J. . i • i • i i l the next subsection, which indeed comprises the major portion of the notable cases of wounds of the penis. Dr. Smiley has published2 the histories of two cases of shot perforations of the penis without lesions of the urethra, though complicated by other graver injuries. Boyer3 has •discussed the limits within which reunion of wounds of the penis may be anticipated, and his discouraging conclusions are adopted by most systematic writers. Baudens4 treats fully of this subject, citing several valuable observations, and, in adverting to those deformities of the penis liable to ensue after shot-wounds with much loss of substance, describes an operation by which he rectified the axis of the organ, in a case of lateral distortion, by cutting out a wedge- shaped piece from the opposite cavernous tissue. There will be occasion to revert to plastic operations in this region in the next subsection. Even when there is no lesion of the urethra, the use of the catheter is of essential importance in wounds of the penis, the inflammatory swelling often causing retention unless this precaution is observed. Several pension examining surgeons remark upon the liability of cicatrices of shot wounds of the penis to inflame from slight causes of irritation. M. Toulmouche, who has written an elaborate Fig. 283.—Longitudinal median section ofthe distal extremity ofthe penis, showing tho corpus cavernosum glandis and fossa navicularis, the commencements of the corpus cavernosum and corpus spongiosum and urethra, and the duplicatures of integ- ument. [After HEXI.K.j \, 1 Hamilton (P. H.), Gunshot Wounds ofthe Penis, in the Am. Med. Times, 1864, Vol. IX, p. 61. * Smile v (T. T.), Twenty Cases of Gunshot Wounds, in the Boston Med. and Surg. Jour., 1863, Vol. LXVIII, p. 416: Cases of Private C. Idall, Co. F, 47th Pennsylvania, and of Leitzinger, Co. A, 55th Pennsylvania. 3BOYER (Traiti des mat chir., 5e ed., 1849, T. VI, p. 794) states that he once saw a man, whose wife, in a paroxysm of jealous fury, had mutilated him by cutting off his penis while asleep, and who suffered greatly from constriction of the divided extremity of the urethra. This eminent surgeon held that if two-thirds of the cavernous bodies were divided, it would be hopeless to attempt reunion, and that the proper course would be to complete the amputation, an opinion reproduced by BEEAED (Diet de Mid., 1843, T. XXIII, p. 430), VlDAL (Traiti de path, ext, 5e 6d., 1861,1'. V, p. 2G0i, and Xelatox (£lim. depath. chir., 1859, T. V, p. G68). But VEDUEXXE (Considerations ginirales sur les lisions traumatiques dupinis, in the Rec. des Mem. de mid., de chir. el de phar. mil., 1860, 3" sene, T. Ill, p. 209) relates an instance in which the child-wife of a young Arab was so cruelly importuned by her husband that she attempted to amputate his penis with a razor, dividing more than two-thirds of the transverse diameter of tho organ, including a partial division of the spongy portion and urethra. Nevertheless reunion took place, and the functions of the penis were not seriously impaired. 41! \l hens (M. L.), Clinique des ])laies d'armes a feu, 1836, p. 406. sf.ct.iii.] WOUNDS OF THE URETHRA. -') 19 paper on the medico-legal relations of wounds of the genital organs,1 remarks that the subject is dealt with cursorily in systematic treatises on his specialty. So far as it relates to wounds of the penis, this observation is applicable to treatises on military surgery also. Hennen and Guthrie barely allude to these injuries, and Larrey's long chapter on lesions of the generative organs is mainly devoted to injuries of the testes.2 In truth, when lesions of the urethra and plastic operations are separated from this category, little remains to be commented on.3 Contusions or ruptures of the cavernous bodies and strangulations of the penis are rarely observed in military practice.4 Amputations of the penis should be restricted to cases of cancer. Even in the most hopeless cases of injury, there is little risk in awaiting what the reparative powers of nature may accomplish ; and it is needless to sacrifice anv tissue by the knife. In amputation for malignant disease, Mr. Hilton's modification of dividing the urethra and spongy body a little in front of the division of the corpora cavernosa, and then slitting up the urethra, and stitching the flaps to the integument, is an improvement on the old " clean sweep," which was often followed by contraction of the urethral orifice. Mr. Bryant5 has found the galvanic cautery the most eligible instrument for ablation of the penis. "Wounds of the Urethra.—The cases of this category were of much interest, involving the important complications of traumatic stricture, false routes, urinary fistules, l Toulmouche (A.) (E'ude viedico-iegale des blessures interessant les organes genitaux chez Vhomme, in Annates d'Hygiene, 1868, 2e serie, T. XXX, p. 110). Devergie (A.) (Mid. legale thiorique et pratique, 2" 6d., 1840, T. II, p. 2'>:>) devotes but a page and a half to the subject; BECK 'Elem. of Med. Jurisprudence, 5th ed., 1835, Vol. II, p. 220) dismisses it in two lines. It is curious to note that Celscs, in the twenty-third chapter of the sixth book, de obscenarum partium vitiis et curationibus, speaks of the vocabulary of the Greeks on this subject as tolerable, while that of the Romans was gross : " Neque tamen ea res a scribendo deterrere me debuit," he adds. So the vernacular terms in every language seem more indelicate than foreign expressions of precisely similar import. 2HENXEX (J.) (Princ. Mil. Surg., 3d ed., 182!), p. 450); GuTimiE (G. J.) (Commentaries, etc , 0th ed., 1855, p. 594); Laurey (D. J.) (Clin. Chir., 1829, T. Ill, p. 57). Brief observations en the subject may be found in Dupuytrex (Lecons Orales, 1839, 2e 6d., T. VI, p. 509). Mexie;:e (L'Holel-. Die.it en 1830, p. 308) cites four cases of shot wounds of the penis. Al'PlA (P. L.) (The Ambulance Surgeon, 18G2, p. 1C8) relates a surprising case of longitudinal transit of a ball along the corpus cavernosum. Demme (Studien, B. II, S. 100, Schusswunden der Ruthe) details five cases t.f shot wounds of the penis. Emmert (Lehrbuch der Chir., 1862, B. II, S. 704), SOCIN (Kriegschir. Erfahr., 1872, S. 100), and Neudorfer (Handbuch der Kriegs chir., 18G7, S. 7i/8) each devote several pages to the subject. Cole (J. J.) (Mil. Surg., 1852, p. 84) gives a case of mutilation of the penis by a cannon shot, with some sensible reflections on injuries of this group. Faxo (Traiti Hem. de chir., 1869, T. II, p. 1004, Blessures du penis) satisfactorily summarizes what is known on the subject. Gillette (Blessures des part, genital., in Arch. Gin., 1873, Vol. XXI, p. 322) gives four cases from Metz. 3Four cases of complicated shot wound* cf the penis have already been cited in the two preceding sections: Cases 706, p. 213; 712, p. 245; 702, p. 259; and 791, p. 207. Xokris (I.) (Case of Gunshot Wound of the Penis, in the Am. Jour. Med. Sci., 1867, Vol. XLVII, p. 281) has recorded the case of Private J. L. Williams, Co. D, 96th Pennsylvania, wounded at Chancellorsville, who recovered, with little deformity, from a severe shot laceration of the penis. Tilton (II. R.) (Gunshot Wound of the Penis, with the Results, in the Med. and Surg. Reporter, 1860, Vol. IV, p. 517) relates the history of Hugh C----, accidentally shot through the penis by a pistol ball. The bleeding is said to have demanded two ligatures; recovery took place with traumatic hypospadias. AXXAN (S.) (Cases of Gunshot Wounds, with Remarks, in DUXGLISON'S Am. Med. Intelligencer. 1839, Vol. II, p. 3) describes, among cases observed in the Baltimore riot of August, 1835, a severe shot wound of the penis advantageously treated by sutures. The subject is alluded to with extreme brevity at pages 11, 13, 21, and 264 of the Appended Documents to the First Part of this history. Bertherand (Gazette des Hopitaux, 1861, No. 10, p. 38) relates that a large dog bit off and swallowed the penis and scrotum of a French Zouave in Algiers; a portion of the penis was found in the dog's stomach. STUOMEYElt (Maximen der Kriegsheilkuu.it, 18.35, S. 667) cites the case of an artillerist, who, while washing himself, was bitten by a horse, the integument of the entire periphery of the pendulous portion of the penis being torn off, except near the corona, where a slight attachment remained. The surgeon first called in stitched on the glove-finger cf skin wrong end behind, when the surgeon in charge cf the hospital arrived and replaced the integument properly; but, though carefully approximated by sutures, the part perished. A similar ease is reported by Ekiciisex (Science and Art of Surgery, 6th ed., 1872, Vol. I, p. 515). On the anatomy of the penis consult: MULLElt (Med. Zeitung des Vereins fiir Heilkunde in Preussen, No. 48); KrausE (HeCKER'S Annalen, February, 1834) ; WILSON (E.) (Cyclop. Anat. and Phys., Vol. Ill, p. H09); Steix (A. W.) (The Histology and Physiology ofthe Penis, in New York Med. Jour., 1872, Vol. XV, p. 595). 4 Cases of rupture or laceration of the corpora cavernosa, with excessive infiltration of blood, occasionally result from malicious violence inflicted on the erect organ, or from the accident described as " missing the mark " in coition. Professor P. F. Eve (Remarkable Cases in Surgery, 1857, p. 373 et seq.) has industriously collected a series of extraordinary examples of this nature, including the two instances reported by V. MOTT (Trans. New York Acad, of Med., 1851, Vol. 1), G. C. Blackmax's cases (Cincinnati Jour, of Med., 1866, Vol. I, p. 316), and Dr. Peter Parker's case, reported by Dr. W. S. W. RusCHEXBEUGER (Am. Jour. Med. Sci., 1840, Vol. XVII, p. 410). But the exhaustive monograph on this subject is by DEMARQUAY and Parmextier (Des lisions dupinis determinies par le coit, Paris. 18(H). Tryis (C. B.) (Med. Communications, 1790, Vol. II, p. 158, Case of Rupture of the Corpora Cavernosa Penis) details an instance that exemplifies the impropriety of making incisions to liberate the effused blood in these cases. IIUGUIER (Bulletin de la Sociiti de CJiir., T. Ill, p. 514) narrates a case, complicated with rupture of the urethra, which proved fatal from urinary infiltration. Professor Eve (op. cit, p. 376 et seq.) has also collected a variety of examples of strangulation ofthe penis by rings, bottles, etc. bBryaxt (T.) (The Practice of Surgery, 1672, p. 59!)). ZIELEWICZ (J.) (Ueber die Amputation des Penis mit der galvanocaustischen Schneide- schlinge, in Laxgenbeck's Archiv, 1870, B. XII, S. 580) has an elaborate paper on this subject. Compare also PlllLirrEAUX (Traitipratique de la cauterisation, 1850, p. 470). VELPEAU (A. L. M.) (Nouv. £lim. de mid. operat, 2° 6d, 1839, T. IV., p. 340) says: "Je ne puis terminer sans faire observer que, toute simple qu'elle est, l'amputation de la verge manque neanmoins rarement d'avoir des suites assez fdcheuses. Si les malades qui s'y soumettent gufirissent il peu pr6s constatnment au bout de quinze, vingt, trente jours, bon nombre d'entre eux ne tardent pas a, etre tourmentes par les idees les plus sombres, un fond de tristesse dont rien ne peut les tirer; de telle sorte que les uns finissent par se d^truire, que d'autres succombent assez souvent a leur accablement moral, au moment ou on pouvait le moins s'y attendre." P>oO INJURIES OE THE PELVIS. [CTTAP. VII. foreign bodies, and delicate operations of catheterization, urethroraphv, urethroplasty, and the extraction of foreign bodies. The danger of injuries of this group varies according to their seat in the penile, scrotal, membranous, or prostatic portions of the urethra, increasing with the distance from the urethral meatus. As the bladder is approached, the urethra acquires additional investments and the risk ^L of urinary infiltration augments. Under the ^^ —f^_ fossa navicularis the canal of the urethra is covered only by its proper membranes, and frequent operations for enlarging the meatus Fig. 2f:4.—Sir Astley Cooper's urethra forceps. [After FERGU6SON. ] -i . . . -i •. /> i r» , 1 • demonstrate the innocuity ot wounds 01 this locality. Further on, in the pendulous portion, the urethra is invested by spongy erectile tissue, a loose connective tissue, and the skin ; then, it is in relation with the scrotum ; then, traversing the triangular ligament and middle perineal aponeurosis, and, passing between the latter and the upper perineal fascia, it reaches the prostate. The practical consequences of lesions of the prostatic portion of the urethra have already been exem- plified. They were due mainly to contact of the urine with the wound and its infiltration in neighboring parts. These accidents are less frequent and less grave in wounds of the membranous and penile portions of the urethra, in which the urine can usually be retained, and its contact with the wound can be avoided by the judicious use of the catheter ; or, at all events, such contact need only take place at comparatively remote intervals. If infiltration occurs, it is located in a cellular tissue widely separated from the peritoneum by numerous layers of fascia, whereas in wounds of the neck of the bladder or the prostate the great serous membrane is in dangerous proximity. The difficulty of "reuniting wounds of the urethra, inversely to their danger, augments with the distance from the bladder, fistules near the distal extremity of the pendulous part being especially intractable. The remark at the commencement of this Chapter (p. 209), that the injuries of the pelvis to be examined, with the exception of a few operations for non-traumatic affections and a single case of bayonet wound, were examples of shot wounds exclusively, was too unqualified. Cases 930, 977, and 997 were examples of bayonet wounds, and Case 978 was an instance of puncture by a knife-blade ; in this subsection a case of sabre-wound occurs, and examples of rupture of the urethra from violence not inflicted by shot.1 Systematic writers commonly subdivide wounds of the urethra into those from without inward, and those from within outward. The military surgeon is chiefly concerned with those of the first group; but some examples of the second will be encountered ; for, apart from the accidents of catheterization, the frequency of wounds inflicted with a therapeutic purpose, by internal urethrotomy or by forced dilatation, has, of late years, rapidly increased. In examining first the shot wounds, and subsequently those produced by other causes, there will be occasion to exemplify the complications of traumatic stric- ture, foreign bodies, false routes, urinary fistules, and the operations of catheterization, suprapubic, perineal, and rectal puncture of the bladder, urethrotomy, urethroraphy, and urethroplasty. Shot Wounds.—These were attended by complete or partial division of the canal <>r the urethra, and varied in their character according to the portion of the urethra interested 1 The remark was really applicable to the cases of the first section only. It was based upon the reiterated assurances of the clerk in charge of the assorted documents, who thought the inquiry applied to the papers belonging to the section and nctf to those of the chapter. The editor, doubting this as-rtion, made repeated searches for other cases of incised and punctured wounds ; but the memoranda were not brought to light until it was too late to suppress the erroneous statement here corrected, and for which this apology is made. SECT. III.] WOUNDS OF THE URETHRA. 351 and the extent of the attendant complications; for they were rarely uncomplicated. There were a hundred and five cases in this category, of which twenty-two were fatal. Abstracts of seven of these cases have been already recorded.1 The fifteen remaining fatal cases were attended by grave complications. Tho proximate causes of death are indicated in the foot-note;2 and we may proceed with an examination of the different varieties of cases of recovery from shot wounds of the urethra, noticing first the cases of Traumatic Stricture: Cask 1009.—Private .1. Smith, Co. G, 101st Indiana, was wounded at Chattanooga, September 22, 1863, and was treated in afield hospital and afterward at Cumberland Hospital, Nashville, where the case was noted as a "gunshot wound of tlie bladder and testicle." lie was furloughed December 25th, and admitted to hospital at Madison, March 11, 1864. Acting Assistant Surgeon D. W. Flora then reported that "he was accidentally wounded while lying flat upon his face, the ball entering the perineum and perforating the bladder near tho neck, passing out in the left inguinal region, lie states that the urine was discharged from both wounds for some time after the reception of the injury. He was discharged the service on April 9, 1854, his general health being fair and his wounds healed." Examiner 13. S. Woodworth, of Fort Wayne, reported, November 3, 1865, that "the ball entered the perineum midway between the anus and scrotum, striking the ramus of the pubis on the left side, and penetrated the bladder. There is a slight stricture, the wound probably having affected the urethra. Disability is three-fourths." This soldier was pensioned, and paid to June 4, 1873. Case 1010.—Private O. H. Moore, Co. A, 2d New York Cavalry, aged 25 years, was wounded at Campti, April 4, 1864, and was treated in the University Hospital, New Orleans, and Ira Harris Hospital, at Albany. Assistant Surgeon J. H. Armsby, U. S. V., states that he was "admitted, September 21, 1864, with a gunshot wound of tbe abdomen and bladder; there was a profuse discharge of glairy pus from the sinuses, and the patient was weak and irritable. On January 22,1855, Acting Assistant Surgeon E. II. Ferris made an incision two inches in length through the gluteal muscles and extracted the ball." The patient was "discharged for disability, July G, 1865, his general health being good, and he being able to earn partial subsistence." Examiner W. H. Miller, of Sandy Hill, reported, July 19, 1865: " The ball entered the left buttock, passing through to the other, and was removed from near the anus in January, 1865. The place from which the ball was extracted is yet unhealed and discharges; the wound will probably heal; he complains that it affects his urinary organs." Examining Board of Surgeons R. B. Bontecou, W. H. Craig, and C. H. Porter, of Albany, reported, October 2, 1863: "The ball entered the middle of the left gluteal region and passed through the pelvis and neck of the bladder, lodging in the right side of the perineum, against the ramus ofthe right ischium, from whence it was removed. The proximity of the track of the wound to the membranous portion of the urethra has caused stricture, and obliged him to resort to frequent dilatations of the urethra to void his urine. Disability continues at total." His pension was last paid him June 4, 1873. Cask 1011.—Private Peter Lins, Co. B, 9th Pennsylvania Reserves, was wounded at Antietam, September 17, 1862, and was treated in hospitals at Frederick, Philadelphia, and Pittsburg until December 1, 1863, when he was transferred to the Veteran Reserve Corps. He was subsequently discharged and pensioned, and Examiner W. M. Herron, of Allegheny City, reported, January 15,1837, that "the ball penetrated the right hip over the tuberosity ofthe ischium, fracturing it, aud escaping through the upper part of the left thigh. The urinary organs were so injured by the passage of the ball that he cannot urinate without the use of the catheter." October 19, 1867, Examiner G. McCook, of Pittsburg, reported to the same effect, and, on September 9, 1873, Pension Examining Board A. G McCandless, J. W. AVishart, and W. J. Gilmore, of Pittsburg, reported that "the ball entered the right buttock and passed across to the left side, opening the urethra, and coming out on the inner side of the left thigh. He is obliged to use a catheter continually. His disability continues at total." This pensioner was last paid to June 4, 1873. ■1. Case 690, Private H. C----, Co. H, 15th New York Artillery, p. 238; 2. CASK 823, Private D. P. Grubb, Co. B, 48th Ohio, p. 287; 3. Case 850, Private Fleming P----, Co. K, 6th Georgia, p. 291; 4. Case 855, Private W. B. Waite, Co. K, 108th New York, p. 293; 5. Case 867, Sergeant H. Ford, Co. P, 67th New York, p. 304; 6. Case 868, Private Charles C----, Co. A, 3'Jth Iowa, p. 304 ; 7. Case 938, Private Henry M—-, Co. B, 8th New York Cavalry, p. 325. *1. Corporal A. J. Hartmann, Co. K, 97th Pennsylvania, aged 25, wounded at Milford, May 20th; ball traversed perineum and urethra; died June 3, 1864, from urinary infiltration. 2. Private J. Meyer, Co. E, 32d Indiana, wounded at Nose's Creek, Georgia, June 17th, in penis and perineum ; died July 21, 1864, from septicaemia. 3. Sergeant J. Miuturn, Co. H, 67th Ohio, wounded at Fort Wagner, July 18th, in left thigh and perineum, the urethra being divided; died August 11, 1863, from exhaustive suppuration. 4. Private G. Cummings, Co. H, 86th New York, aged 31, wounded at Spottsylvania, May 10th, oblique shot perforation from right natis to left testis, lacerating the urethra; died May 19, 1864, from tetanus. 5. Private A. G. Stinwalt, Co. G, 5th North Carolina, wounded and captured at Spottsylvania, May 12th ; shot fracture of right'femur and division of the urethra by the same ball; died June 4, 1864, from surgical fever and shock. 6. Corporal J. Moran, Co. E, 39th Massachusetts, wounded at Southside Railroad, March 31st, shot fracture of left femur, the urethra severed by the same ball; died August 7, 1865, exhausted ; an attack of pleuropneumonia gave the coup de grace. 7. Private C. Griner, Co. I, 3d Delaware, wounded at Petersburg, April 1st, shot fracture of femur and laceration of scrotum and urethra; chills, delirium ; death, April 19, 1865, " exhaustion." 8. I'rivate M. Smith, Co. F, 38th Virginia, wounded at Spottsylvania, fracture of upper third of left femur by a conoidal ball, which passed through both thighs and lacerated the urethra; excision of head of left femur; death May 13, 1864 (compare Case XLV, p. 43, Circular 2, S. G. O., 1869, and Spec. 5500, Sect. I, A. M. M ). 9. Corporal J. Bishop, Co. B, 23d Alabama, wounded at Chickamauga, September 19th, shot fracture of right femur, the ball traversing the bulbous part ofthe urethra and tho soft parts ofthe left thigh ; died October 8, 1863 (vide Confed. Slates Med. and Surg. Jour., 1864, Vol. I, p. 77). 10. Private E. C. Hoff, Co. A, 1st Minnesota, wounded at second Manassas, August 31st, shot fractures of both femurs with wound ofthe perineum and injury to the membranous part of the urethra; death, October 12, 1852, from "exhaustion." 11. Corporal P. K. Price, Co. D, 32d Colored Troops, wounded at Pocotaligo, December 6th, shot perforation of peuilo portion of urethra and wound of left thigh; death, December 31, 1864, from urinary infiltration. 12. Private II. Strauss, Co. F, 145rh New York, wounded at Chancellorsville, May 3d, shot perforation of the pelvis from the left buttock to the left side of the scrotum, dividing the urethra; phlebitis and dry gangrene ensued, and termi- nated fatally, July 24, 1863. The three fatal cases, of English, Bobbit, and Stewart, will be related in detail. :>•)!' INJURIES OF THE PELVIS. icil.uwii. Ordinarily the introduction and maintenance of a catheter constitutes the most important part of the treatment of a shot wound interesting the urethra; but it often happens that, after a certain stage, of variable duration, the presence of a catheter is prejudicial to the process of cicatrization.1 It is possible that in such a case as that following, it would have been practicable to have avoided the entrance of the catheter into the wound-track by employing M. Mercier's ingenious plan (Fig. 285) of passing Fir:. 285.—Mercier's instrument for avoid- ii . -i . .1 -i n . • ,i i -n . it ing false passages, it is a silver catheter, a small gum catheter through a fenestra m the hollow metallic hollow up to the dotted line; beyond this . _ _ . is a solid portion which enters the false instrument first introduced. The false passage being filled bv passage. A small gum catheter is passed loo J S'in ufrc'vitylo^ra^e {£ the metallic sound, the gum catheter projecting laterally might urethra beyond the false passasre occupied i • t "I • 1 11 j l "ll c • l i i i • ■ l by the extremity of the instrument, [After be guided into the true canal, and when tairly lodged in the Thompson.] *. 1 i i -1 i it i ^ 1 ^ ■ 1 i bladder the metallic catheter could be withdrawn. Case 1012.—Private J. N. Fugate, Co. F, 55th Illinois, aged 21 years, was wouuded at Kenesaw Mountain, June 27,1S64. Surgeon J. B. Potter, 30th Ohio, at one of the Fifteenth Corps field hospitals, reported "a gunshot wound of both thighs and scrotum." Acting Assistant Surgeon M. M. Shearer made the following report of the case from the hospital at Barton Iron Works: '"'The patient having been removed from an erysipelas ward, where he had been suffering from erysipelatous inflam- mation of the wound for fourteen days, it was found that the ball had entered on the anterior surface of the left thigh, imme- diately over the upper third of the sartorius muscle, live and a half inches below the origin of the muscle and two and a half inches below the centre of Poupart's ligaments, ranging inward, upward, and backward, passing beneath the tendons of the pectineus and the adductors and deep perineal fascia, piercing, in its course, the corpus spongiosum of the penis and partly severing the membranous portion ofthe urethra; from this point the missile ranged downward, outward, and backward through the right thigh, passing posterior to the femur, and lodged beneath the integuments, whence it was extracted. The urine discharged copiously through the entrance wound at every attempt to micturate, none escaping through point of exit. Tlie wound suppurated freely. Ordered simple cerate dressing to the wounds, and muriated tincture of iron and milk punch to be administered thrice daily. July 8th, patient's general condition excellent; appetite good. July 9th, urine still discharges through the wound in right thigh; wound in left thigh healing kindly. A metallic catheter was introduced and the urine was drawn off morning and evening. But little urine passed through the wound daring the day. July 10th, entrance wound nearly closed; exit wound healing kindly. A gum-elastic catheter was introduced and left permanently in the bladder." For the next four days the catheter was maintained in the bladder, being removed and cleansed every twenty-four hours; during this period no urine escaped by the entrance wound. On July 14th, there was difficulty in replacing the catheter. Even after chloroform was administered it was impracticable to reach the bladder, the extremity of the instrument passing into the wound-canal notwithstanding the utmost care and caution in manipulation. Urine again passed through the wound, causing great pain. There was but little constitutional disturbance. Repeated unsuccessful attempts were made, during the next few days, to conduct a catheter into the distal portion of the urethra. On July 18th, a small abscess pointed behind the scrotum, and, on incision, a small piece of cloth was found and extracted. On July 27th, the urine passed wholly by the urethra; the general health of the patient was good, and he was furloughed by Surgeon A. Goslin, 48th Illinois. He entered the hospital at Quincy, November 11, 1864, and Surgeon D. G. Brinton, U. S. V., recorded that "a conical ball had entered the sartorius muscle anteriorly, and passed through the urethra and right gluteal muscles. He has some difficulty in voiding his urine. Transferred to Veteran Reserve Corps. February 13, 1865." He was on duty, in the 34th company, at Mound City Hospital, when Acting Assistant Surgeon J. A C. McCoy reported that he was discharged, August 14, 1865, being unfit for service on account of a urinary fistula. He was pensioned, and Examiner T. J. Caldwell, of Adel, Iowa, reported, September 4, 1873, that "the ball took effect a little below the left groin, passed through the bladder, and came out on the opposite thigh about two inches below the hip joint. He suffers from pain in the region of the bladder, and has difficulty in passing his urine, and has resorted to a catheter twice in the last few months. He is unfit to perform any severe manual labor. Disability third grade." Case 1013.—Private M. S. Clark, Co. I, 1st Iowa Cavalry, was wounded at Chalk Bluffs, Missouri, May 2, 1863, and was admitted to the regimental hospital at Lake Springs. Assistant Surgeon C. H. Lothrop, 1st Iowa Cavalry, recorded: '"gunshot wound in the penis, the ball passing near the spermatic cord and wounding the urethra, thence passed into the right thigh." This soldier was transferred, on May 5th, to Post Hospital, Cape Girardeau, whence Surgeon H. A. Martin, U. S. V., reported as follows: "Shot wound of scrotum and left testis, involving the urethra. There was an immense extravasation of blood and urine, for which free incisions were successfully made; for two weeks urine passed by the Avound only, but the wound then closed fully and urine passed entirely through the urethra. He was returned to duty twenty-nine days after the reception of the injury." Clark is not a pensioner. 1 DiU'UYTKLX (Lecons orales, 1839, T. VI. p. 514) taught that shot wounds of the urethra should ordinarily be treated by the introduction and maintenance of a catheter, the external surface of the wound being covered by compresses covered with simple cerate. Hut he adds: "II ne faut pas croire cependant que la sonde a demeure dans la vessie soit toujours un moyen infallible de guenson. A une oertaine 6poque, il arrive quelquefois qu'elle nuit plus qu'elle ne sert. on voit la cicatrisation s'arreter. et en 1 otaut, celle-ci se fait tres-rapidement. In individu recut dans les journ6es de juillet un coup de feu qui lui ouvrit l'uretre a la racine de la verge. 11 fut recju a lTIotel-Dieu dans la service de JI. BltESCHET; on lui mit une sonde 4 demeure dans la vessie ; il la conserva pendant son sejour a l'Hotel-Dieu et a la maison de convalescence de Saint-Cloud pendant pins de trois mois. A cette 6puquc il n'6tait pas encore gueri, car la plaie de l'uretre subsistait encore. I'ensant alors que ce malade 6tait du nombre de ceux auxquels la sonde nuit dans ces cas-ld plus qu'elle ne sert, je lotai, et en peu de jours la guerison se tit." SOCIX (Kriegschir. Erfahrungen, 187-2, S. 100), in his description of the wounded after the engagements befre Jletz, observes: 'There were four cases of shot wounds of the urethra. * * The urinary fistules closed in from five to seven weeks without use of the catheter. Extensive infiltration did not occur."' SECT. III.] WOUNDS OF THE URETHRA. 353 In shot wounds of the penile portion of the urethra the diagnosis is obvious. Lesions of the deeper part are suggested by the escape of blood from the meatus, by the passage of sanguinolent urine from the meatus and the wound, by scalding pain in the wound and canal following a shot penetration in the course of the urethra, and by indications derived from the employment of tho catheter. Tho latter signs also discriminate solutions of continuity in the deep parts of the urethra from those in the bladder. Moreover, the escape of urine by the wound-track is intermittent in lesions of the urethra, except in cases of incontinence; whereas, in penetrations of the bladder, the urine dribbles constantly away. Micturition is usually easy immediately after a laceration of the urethra; but, through inflammatory swelling and spasmodic contraction, the excretion of urine soon becomes difficult, and often impossible. Infiltrations of blood and urine, which are reckoned among the early accidents of lacerations of the urethra, are peculiarly liable to be followed by retention, though in shot wounds attended with much loss of substance such infiltrations are less common than in other varieties of rupture. In the cases treated without incisions, it is difficult to estimate the extent of loss of substance involved in the urethral laceration; and the degree of contraction in many of the cases of traumatic stricture is left to conjecture, from the omission from the reports of reference to the size of instruments that could be passed through the constricted part: Case 1014.—Captain B. Q. A. G------, Co. B, 10th Indiana Cavalry, wounded at Chancellorsville, May, 1863, was treated in a cavalry corps hospital near Aquia Creek. Assistant Surgeon J. II. Knight, 3d Indiana Cavalry, reported: "The ball entered at the right side of the scrotum, and, injuring the right testis, passed through the left thigh. He is recovering rapidly." Captain G------ was promoted lieutenant colonel of 10th Indiana Cavalry, January 7, 1864, and was reported wounded at Florence, South Carolina, September 13th. He was admitted, October 13, 1864, to No. G, New Albany, with an " injury to the right testis and urethra," and returned to duty November 20th. In April, 1835, he was sent to Grant Hospital, Cincinnati, for examination, and was discharged the service April 25, 1865, and pensioned. Examiner E. R. Hawn, of Leavenworth, reported, September 11, 1871: "Gunshot wound of both testes. The ball entered the right testis near the centre, passing through it and cutting the under side of the penis, opening the urethra, and entering the left testicle at the upper part, and passing through it. The wound involves the spermatic cord and causes pain. The wound of the urethra causes stricture at the point of the wound. He is at times subject to incontinence of urine from the effects of the wound; disability total." This pensioner was paid to September 4, 1873. Case 1015.—Sergeant T. Parker, Co. K, 69th New York, aged 26 years, was wounded at Deep Bottom, August 16,1864. He was taken from the field aud admitted into Satterlee Hospital, Philadelphia, on the 20th. Assistant Surgeon D. Bache, U. S. A., reported the following particulars in the case: "Wounded by a minie ball, which entered the perineum anterior to the anus, and, passing forward, made its exit near the middle of the upper third of the right thigh, passing external to the femoral artery, and producing a wound of the bulb of the urethra. He passes his urine through the posterior wound and some through the anterior wound, but none through the urethra. The private parts are very much congested. By August 30th, the wound was cleaning finely, though suppurating profusely. On October 3d, the wound being nearly closed, a catheter was placed in the urethra, with some difficulty because of stricture. The treatment had consisted, throughout, of water dressing and nourishing diet." The patient recovered, and was discharged June 6, 1865, and pensioned. Examiner J. L. Hodge, in a report of June 7, 1885, says: "A shot wound of the right thigh, scrotum, and urethra has impaired the usefulness of the thigh and left him with a bad stricture of the urethra." Examiners C. Phelps, J. T. Ferguson, and M. K. Hogan, on June 22, 1870, reported: "Ball entered the right thigh, upper and anterior aspect, passed through the perineum, and emerged before the opposite side. He has traumatic stricture and incontinence of urine." The same Board reports, September 9, 1873, that this pensioner "is much troubled with incontinence of urine and seminal emissions; disability three-fourths." Case 1016.—Private C. W------, 34th Massachusetts, aged 35 years, was wounded at Cedar Creek, October 13, 1864. He was sent to Winchester, and, on the 18th, transferred to Camden Street Hospital, Baltimore, where Surgeon Z. E. Bliss, U. S. V., noted "a gunshot wound of the left testis and urethra." Thence, February 17, 1865, this soldier was sent to Dale Hospital. Surgeon C. N. Chamberlain, U. S. V., reported "gunshot wound of the left testis—severe; testis removed October 14, 1864," and, on the certificate of disability, "gunshot wound of perineum and scrotum, injuring the urethra and left testicle; wound not healed." Examiner 0. Martin, of Worcester, reported, November 12, 1838: "A ball hit inside of the right buttock just above the anus, passed through the lower portion of the pelvis, cut through the penis, severing the urethra, and carried away the left testicle; venereal powers weakened; freedom of motion of the body impaired from adhesions; disability total and permanent." Examiner G. M. Morse, on September 6, 1873, reported : " Ball passed through the right natis, coming out at the root of the penis, rupturing the urethra, and carrying away the left testicle; he had urinary fistula for four months; now there is pain in the back and region of the wound; pain and tingling on passing urine; and pain in the abdomen when he works. He cannot do any work that requires him to stoop. There is stricture of the urethra, caused by the ball having passed through the scrotum; disability total." This pensioner was paid to September 4, 1873. 45 35-1 INJURIES OF THE PELVIS. [Chap. vu. Contraction of the canal necessarily attends the cicatrization of shot wounds of the urethra in a degree commensurate with the loss of substance, unless the narrowing is O ' o resisted by the presence or frequent passage of unyielding tubes. Even then the tendency to contract remains. It is different with traumatic stricture due to inflammation of the contiguous tissues, when the integrity of the canal has not been destroyed. The super- vention of stricture, after an interval of five years, in the first of the following cases, is remarkable: Case 1017.—Lieutenant H. C. P------, Co. H, 21st Pennsylvania Cavalry, was wounded at the engagement at Hatcher's Run, CK-tober 27, 1864, and sent to the Second Division Hospital, Cavalry Corps. Assistant Surgeon E. J. Marsh, U. S. A., recorded a "flesh wound of the left thigh." The patient was transferred to hospital at City Point, and furloughed November 7th. On December 5, 1864, he was registered with wounded volunteer officers at Washington. Acting Assistant Surgeon F. S. Barbarin notes the injury as "a gunshot flesh wound of the scrotum and left thigh;" and adds that this officer was "discharged February 8, 1885, readmitted March 4th, and discharged the service April 9, 1865."—S. O. 62, § 19, A. G. 0. Dr. H. W. Sawtelle, of the Revenue Marine Service, states that in this case the sciatic nerve was injured, and that there was for a long time pain and sensitiveness in the course of this nerve. He adds that during the treatment an abscess formed in the scrotum, requiring evacuation by a trocar, and that after retirement from service this officer experienced no inconvenience from the injury until the spring of 1870, when scalding on micturition, and a diminution in the size of the stream of urine was observed. Catheterization thrice weekly was employed for nearly a twelve-month, with great benefit. In January, 1873, Dr. Sawtelle examined this pensioner, and detected "a slight stricture corresponding with the exit ofthe ball. A system of gradual dilatation by bougies was advised, and under this treatment steady improvement took place." Dr. W. P. Johnson and Examiner J. O. Stanton, of Washington, certified that the stricture was, in their opinions, of traumatic origin. Case 1018.—Corporal B. II. Wood, Co. B, 154th New York, aged 24 years, was wounded at Chancellorsville, May 3, 1863. He was sent from an Eleventh Corps hospital, on the transport Mary Washington, to Stanton Hospital, where Surgeon J. A. Lidell, U. S. V., reported a "gunshot wound resulting in urinary fistula." On June 20th, the patient was removed to Carver Hospital, where Surgeon O. A. Judson, II. S. V., recorded a "shot wound of the urethra." At De Camp Hospital, November 21, 1834, Assistant Surgeon Warren Webster, U. S. A., reported this man as "returned to duty." On April 29,1865, this soldier was sent from a Twentieth Corps hospital, by the hospital steamer S. R. Spaulding, to McDougall Hospital, New York, and Assistant Surgeon S. II. Orton, U. S. A., reported that he was discharged for traumatic stricture ofthe urethra, June 12, 1855, and pensioned. Examiner O. A. Tompkins, of Randolph, reported, May 1, 1872: "The ball entered at the right side of the root of the penis, passed backward and inward through the urethra, and emerged at the centre of the left natis three inches from the anus. There now remains permanent stricture of the urethra." An increase of pension was recommended. Case 1019.—Private J. Metzler, Co. A, 44th Illinois, aged 32 years, was wounded at Resaca, May 14, 1864, and was treated in hospitals at Chattanooga, Nashville, and Louisville; again in No. 8, Nashville, from October 27th; and transferred to,Brown Hospital, November 30th, where a wound of the penis was first reported; thence to Jefferson Barracks, where Assistant Surgeon H. R. Tilton, U. S. A., noted a "stricture of urethra from gunshot wound." This soldier was transferred to the Veteran Reserve Corps, January 11, 1865; discharged October 17, 1865, and pensioned. Examiner S. Wagonseller, of Pekin, reported, April 30, 1867: " One wound in the wrist, ball entering the back part of the hand, passing through the wrist joint, fracturing the bones; he has not full control of the motion of the joint. In the other wound, the ball struck the penis on the left side in front of the scrotum, passing out from the right gluteal muscles. He urinates with great difficulty, water dripping away slowly ; disability one-half and permanent." This pensioner was paid to the date of his death, July 31, 1871. Case 1020.—Captain John M------, 79th New York Militia, aged 38 years, was wounded at Bull Run, July 21, 1861, and again August 30, 1862. On the last occasion he was taken prisoner and remained in the hands ofthe enemy for eight days. He was paroled and rejoined his regiment, and was promoted major November 17, 18.52, and lieutenant-colonel February 17, 186:?. He was mustered out at the expiration of his term of service, May 31, 1384, and pensioned. Surgeon J. E. MacDonald, U. S. V., formerly of the 79th New York, July 5, 1865, makes the following statement: "At the battle of Bull Run, July 21, 1861, Mr. M------received a very serious wound from a musket ball, which perforated the apex of the left chest and lung and fractured the left scapula. He made a rapid recovery, however, from so severe a wound, and reported for duty in an extremely short time." * * "At the second battle of Bull Run, August 30, 1862, Mr. M----received a wound from a minie ball,which passed through the right natis, the scrotum, and the urethra. On this occasion, the nature of the wound did not permit him to escape from the field, and he remained eight days in the hands of the enemy. Much to the surprise of many surgeons, myself among the number, he survived to be removed to Washington, and again to be of service to his regiment. I have carefully examined his condition recently, and find that he is still obliged to make frequent use of the catheter to relieve his bladder, and often suft'ers from both incontinence and retention of urine. It is my opinion that he will never cease to be subject to temporary difficulties of like nature." Examiner T. F. Smith reported, January 30, 1868: "A ball perforated the apex of the left lung, fracturing the left scapula, in consequence of which he has not full power of the left arm; disability from this, one-fourth. Another ball passed through the right natis, scrotum, and urethra. He is obliged to use a catheter continually in order to draw off the urine. Wlienever he performs hard labor the wound breaks open. He is unable to walk but a short distance. Disability from this, three-fourths.'' The same examiner, September 17, P-73. reports: "Ball entered over middle third ofthe left clavicle and made exit over the inner border of the middle third of the left scapula; no disability. Ball entered to the left of the scrotum in the groin, cutting the urethra, and made its exit from the right natis. He is obliged to use a catheter to draw off the mine; locomotion considerably interfered with; disability total." This pensioner was paid December 4, 1*73. SECT. III.] WOUNDS OF THE URETHRA. 355 Continuing the examinations of traumatic stricture consequent on shot wounds of the urethra,1 there will be next noted four examples of stricture of the penile portion of the canal, and one in which the seat of contraction is indefinitely indicated: Case 1021.— Private S. D------, Co. I, '23th Pennsylvania, aged 4r> years, was wounded at Spottsylvania, May 12, 18 il. He was sent to Emory Hospital on the 25th, and tho injury was recorded as a "wound of the left testis and penis by a minie ball." On Jtme 11th he was transferred to Camden Street Hospital, and mustered out June 18, 1864. Examiner II. E. Good- man reported, October 8, lSlD : " The wound of the applicant lias resulted in the loss of the left testis and slight wound of the end of the penis. The cicatrix of the scrotum is well marked, and tho testis is entirely absent. The meatus of the urethra is contracted by reason of the cicatrix, causing, however, little trouble. He states that before the loss of the testis he had one child, and has had none since: his wife is healthy, lie has the same desire as formerly for sexual intercourse; the discharge is thin, watery, and of very slight amount. I was under the impression that the spermatic cord of the right testis was obliter- ated, and I examined the semen eight hours after copulation, and found it of very slight amount, thin, and watery as stated, and having live spermatozoa but fewer in number than in ordinary semen. He states that he has pains when lifting or doing heavy work." This pensioner was paid September 4, 1873. Case 1022.—Private W. Kahlman, Co. C, 21th Wisconsin, aged 49 years, was wounded at Adairsville, May 17, 1831, and treated in a Fourth Corps hospital. Surgeon W. P. Pierce, 88th Illinois, reported a " gunshot flesh wound of the left hip and scrotum."' The patient was sent to Chattanooga on the 23d, and thence to Nashville, Louisville, and Jefferson Barracks, and to Keokuk on December 4th, where Surgeon il. K. 'Taylor, U. S. V., reported: "Gunshot wound of the left thigh, the ball entering on the ou'er posterior aspect, three inches below Poupart's ligament, piercing the upper part of the scrotum, and occasioning a severe abraded wound of the penis an inch posterior totheglans." This soldier was discharged June 10, 1835. Examiner G. W. Perrine, of Milwaukee, reported, February 7, 1836: "He received a flesh wound from a rifle ball which entered the fold of the left natis. passed through behind the bone, emerged on the inside of the thigh, thence through the scrotum and penis; all of which wounds are healed and have been for over a year." October 24, 1833, Dr. Perrine continues: "Tlie increased disability is caused, I should think, by an injury to the sciatic nerve. At times he is very lame, and can lift but very little, and often has cramps. Of this I have satisfactory evidence from others, as well as from Rahlman himself. He did not represent himself, at the first examination, as bad as he was." Examiners E. Kramer, I. II. Stearns, and R. B. Brown reported, November 12. 18T3, that "the leg is lame, and there is a stricture ofthe urethra, caused by a wound." Case 1023.—Private E. W. Knapp, Co. E, 157th New York, aged 44 years, was wounded at Gettysburg, July 1. 1833. The case was recorded at Camp Letterman as a " wound of the genitals by a minie ball." The patient was sent, July 24th, to Harewood Hospital. Acting Assistant Surgeon J. Carrier reported: "Ball entered at the posterior part of tlie head of the penis and passed upward, making its exit at the anterior part. The wound healed, and this soldier was returned to duty September 22. 1833." He was discharged July 6, 1865, and pensioned. Examiner P. B. Havens, of Hamilton, reported, November 2li. 1^37: "Gunshot wound through penis, producing constant irritation of the kidneys, liver, and heart, through irritation of the spinal cord and weakness of the spine, the urine passing off seven or eight times during the night. He is unable to do common labor; disability permanent." Examiner D. D. Chase, of Monisvillo, September (i, 1873, reported: " Wound of the penis ; the ball penetrated just posterior to the glans. Tliere is slight contraction of the urethra, and painful and difficult micturition." Case 1024.—Private E. Bobbins. Co. I, ]0th Illinois, aged '26 years, was wounded at Windsor's Farm, North Carolina, March 1(5, 1865. Surgeon E. Batwell, 14th Michigan, reported, from a hospital of the Fourteenth Corps, " a gunshot wound of the penis and pubes." The patient was sent to New Berne, where Surgeon C. A. Cowgill, U. S. V., reported, April 5th, " a shot wound ofthe penis and scrotum." On April 13th the patient was sent to McDougall Hospital, whence he was discharged, May 31, 1835, for " shot fracture of symphysis pubis, the ball having passed through the penis and scrotum," according to the certificate of Assistant Surgeon S. II. Orton, U. S. A. This soldier was pensioned, Examiner S. X. Pierce, of Iowa, reporting, December 15, 1871 : '■ An ounce musket ball entered directly at the symphysis pubis, and, passing backward around the thigh, lodged on the posterior of the left thigh, where it remained two years. Some exfoliation from the femur resulted. The applicant suffers much from difficulty in passing urine, and frequently requires to use a catheter. There is pain, referred to the neck of the bladder, and some atrophy ofthe left thigh. The strength of this extremity is reduced." This pensioner was paid March 4, 1873. Case 1025.—Private J. O'Brien, Co. D, 7th New York Artillery, aged 18 years, was wounded at Tolopotomy Creek iu June, 1834. He was sent to Douglas Hospital ou June 12th. The injury was recorded as a "gunshot wound of the tipper third ofthe thigh and ofthe penis—severe." The patient was furloughed August 23d, readmitted, and discharged June 3, 1835, and pensioned. Examiner J. A. Dockstader. of Sharon Spa, reported, June 22, 1833: " The ball nearly cut his penis off, so that it hung by a fragment of skin; but, after a good deal of trouble, the organ was saved." Examiner J. J. Swart reported, December 2, 1873 : " Gunshot wound of the left thigh and penis. The ball passed through the penis just above the glans, then passed through the thigh, while in a standing position, severed the sartorius, grazed the femoral artery, injuring the nerves, and struck the bone, producing enlargement ofthe bone." This pensioner was paid December 13, 1873. 1 Histories of several cases of shot wounds of the urethra have appeared in the medical journals. It will suffice to refer to them without recapitulating the details: 1. Parry (J. L.) (Gunshot wound, involving the membranous portion of the urethra, in the Phil. Med. and Surg. Reporter, 1806, Vol. XIV, p. (i) ; case of J. Y----, aged :i2, wounded at the second battle of Manassas, successfully treated by the catheter a demeure. 2. Se.mmes (A. J.) (Gunshot wound of the gluteal region and of the urethra, in New Orleans Med. and Surg. Jour., Vol. XIX, 1863-CT, p. fiJ); case of Private W. McC-----, 5:d North Carolina, wounded May 3, 1863; the urethra was lacerated in front of the triangular ligament; when inflammation had subsided, a catheter was maintained in the urethra; rapid convalescence. 3. SIUSCROlT (C. S.) (Gunshot wound of the urethra—Removal of a broken cat.'ieler, in the Am. Med. Times, 180'3, Vol. VII, p. 181). 356 INJURIES OF THE PELVIS. [CHAP. VII. Doubtless, when pensioners made no complaint of dysuria, the existence of traumatic stricture was sometimes overlooked by the pension examiners; and, often, less stress was laid upon this cause of disability than would be anticipated from the nature of the antecedent injuries: Case 1026.—Private M. McCarthy, Co. D, 83d Pennsylvania, was wounded at Gaines's Mill, June 27, 1862. He was taken prisoner, and subsequently paroled and sent north, and was admitted into Broad and Cherry Streets Hospital, Philadelphia. Surgeon John Neill, U. S. V., reported: "A ball entered on the left side, on a line with the penis, below the arch of the pubes, and, passing obliquely backward, made its exit in the right of the buttock, immediately behind the great trochanter. When admitted, July 31st, his general condition was pretty good; whenever an attempt was made to evacuate the bladder, the urine passed freely from the wound iu front; some also passing from the urethra. No catheter was employed in the treatment of the case;' a warm-water dressing was applied to the wounds and a good diet ordered. The wound of exit healed rapidly with very little discharge; that of entrance of the ball granulated slowly, and urine continued to flow until October 1st, at which time the wound had cicatrized, and the patient was convalescent without a bad symptom." On November 12th the patient was transferred to Chester, and thence returned to duty January 23, 1863. He was discharged from service February 11, 1863, and pensioned. The certificate of disability recommends discharge by reason of " varicose veins of left leg," and the adjutant general endorsed on the same, May 22, 1673: " This man was entitled to discharge by reason of gunshot wounds." Examiner W. M. Chamberlain, March 6, 1863, reported: " The ball entered the left groin, and, passing through the scrotum, issued on the external surface of the right hip. There is, probably, some stiffness and soreness after much exertion, but it is hardly a cause of disability, in my judgment." Examiner J. L. Stewart states, January 10,1870 : " Gunshot wound through the scrotum and the root ofthe penis, from the left side, passing through the right hip, resulting in weakness and stiffness of the same." Drs. J. L. Stewart and W. M. Wallace reported, February 7, 1872: " Gunshot wound entering on surface of scrotum, immediately above the left testicle, passing out, as stated by applicant, at a small mark on the surface of the gluteal muscles of the right side, producing some abrasion and contraction at point of entrance." The same Board, with the addition of Dr. H. Strickland, September 4, 1873, reports: "Mark of gunshot wound of the left groin; ball entering the left groin on a line with the penis, passing through just below the neck of the bladder, making exit ou the right hip opposite the lower edge of the glutei muscles, producing pain upon motion of the limb ; disability three-eighths." This pensioner was paid to September 4, 1873. Case 1027.—Private A. Bordeaux, Co. F, 14th Ohio, aged 17 years, was wounded at Atlanta, August 5, 1864. lie; was treated for a gunshot wound of the scrotum in a Fourteenth Corps hospital; thence sent to No. 2, Chattanooga; thence to No. 3, Nashville ; and finally to No. 6, New Albany. Here Acting Assistant Surgeon E. S. Crosier reported the injury as a " gunshot wound of the scrotum and perineum," and that the right testicle had been removed, under chloroform, by Surgeon G. E. Sloat, 14th Ohio, on the field, on the day of injury. This soldier was discharged July 11, 1865, and pensioned. His attending physician, Dr. Joel Greene, testified as follows, May 23, 1873: "Gunshot wounds of the penis, testes, perineum, and rectum, causing the loss of the right testicle, and producing such contraction and derangement of the tissues that he is, from time to time, unable to empty his bladder without the aid of a physician." Examiners S. S. Thorn and S. H. Bergen, of Toledo, reported, August 6, 1873 : " Ball entered from the front, striking the penis, removed part ofthe glans, and, passing through the scrotum, destroyed the right testis ; theuce through the perineum, emerging at the centre of the anus. The urethra was wounded by the ball. The applicant passes water with difficulty, frequently requiring the use of a catheter. The bladder was evidently injured at the neck by the same missile; he has suffered from cystitis ever since; he evacuates the contents of the bladder frequently. Disability is three-fourths." This pensioner was paid September 4, 1873. Case 1028.—Private J. Roe, Co. C, 4th New Jersey, aged 49 years, was wounded at Gaines's Mills, June 27, 1852. He was admitted into Fourth and George Streets Hospital, Philadelphia, on July 30th, where Acting Assistant Surgeon J. B. Bowen reported: "A round ball entering the left thigh below the superior spine of the ilium, passed through the thigh, through the scrotum, right testicle, and right thigh, cutting the spermatic cord and urethra. When wounded he was taken prisoner and sent to Richmond and confined there for three weeks. When admitted to this hospital, the wound was neglected and in a bad condition, urine escaping through the opening in the urethra and the right testis protruding. The man improved from the first, and the wounds healed, with atrophy of the testis." This soldier was discharged from service December 22, 1862. Examiner C. Hodge, jr., of Trenton, reported, October 27, 1873: " Ball entered the left hip immediately in front of the joint, passing downward and inward through the thigh, entered the scrotum, destroying both testes, then entered the right thigh on the inner side, aud made its exit from the posterior surface ofthe thigh. He is not able to work at all. Disability total and, to a degree, permanent." The rarity of any notice, in the reports, of the early symptoms attending shot wounds of the urethra, must be regretted. It is impracticable to determine definitely in what ' In considering the treatment of shot wounds of the bladder, it has been seen that unanimity of opinion regarding the uniform necessity of main- taining a catheter permanently no longer prevailed. Similar doubts as to the expediency of the continued employment of the catheter in lacerations of the urethra have emanated from high authorities. The opinions of DUPUYTREN and of SOCIN have been already cited (p. 352, note). PlEOGOl'F (Grundzuge der allgemeinen Chirurgie. 1864. S. o'14) enquires: 'In traumatic ruptures of the urethra, should the catheter be introduced immediately ? I am not in favor of it, even in cases of retention. * * I make deep incisions through the infiltrated integument and subjacent cellular tissue. If a rupture of the bulbous part is detected, I split the scrotum in the raphe, separate the two testes and lay open the ruptured part." BECK (Chirurgie der Schussverletzungen, 1872, S. 5C6) sa}'s : "By the introduction of a catheter the surgeon should convince himself whether the urethra be permeable or not. If penneable, allow the pewter or rubber catheter to remain for a short time ; if impermeable, make an incision in the median line of the perineum, search for the wounded urethra, and introduce the catheter. An incision should not be feared, but the catheter should be used with the srreatcst caution.'' SECT. III.] WOUNDS OF THE URETHRA. 357 proportion of cases retention of urine occurred early, and the supervention of other primary complications are seldom mentioned. It would appear, from the silence of the reporters on the point, that primary hsemorrhage to any troublesome extent was unusual. Tliere were several instances, however, in which this accident was recorded: Case 1029.—Corporal J. Snodgrass, Co. (), 11th West Virginia, aged 32 years, was wounded at Halltown, August 26, 1864. He was admitted into hospital at Frederick, and Acting Assistant Surgeon J. II. Bartholf reported: "Shot passed through the buttock, taking the urethra in its course, from which ho had profuse hsemorrhage at the time, and recurring at intervals during three days. He was admitted here ou September 11th, and was then in very good condition; the scrotum was ecchymosed; there was no passage of urine through the wound at any time, and. apparently, there had been no infiltration of urine. He recovered rapidly, walking about by September 25th, and was furloughed October 3d, at which time the wound was healed." He was readmitted, and was transferred to Mower Hospital November 17th, and thence sent to duty on the 28th. He was discharged June 27, 1885, and pensioned. Examiner S. A. Walker, of West Union, reported, June 1, 1868: "Ball entered right thigh, through head of adductor longus, passed through the perineum, rupturing the urethray and out a little below the left tuber ischium; for awhile urine passed through the wound; his back is so weak that he cannot work; disability total and permanent." Examiner E. D. Safford reported, February 15, 1869, that * * "he is a constant sufferer from vesica] irritation." Dr. M. S. Hall certifies, August 6, ISO'.): "The ball entered the right groin, or a little below it, and passed upward, backward, and transversely, so that it came out a little back of the left trochanter; in its course it passed near the neck of the bladder, partly cutting off the urethra and some of its blood-vessels. I think the pudic artery must have been cut. He passed his water, for the first three days, from the opening made by the ball—this is his statement to me. But the effects of this wound at the present time are: Great irritation of the neck of the bladder, producing severe incontinence of urine; great pain in the back and perineum, so that if he rides on horseback, or walks, or stands on his feet, it is aggravated to great suffering; and inability to labor. Since he has been wounded he has constantly had rheumatism of the back (lumbago), to such an extent at times that he is helpless. This is often his condition when it is cold and damp. Last June he had an abscess in the gluteal region of the left hip, and I was of the opinion that it was from the effects of the wound. * * Disability total." This pensioner was paid September 4. 1873. Case 1030.—Private J. L. Williams, Co. D, 93th Pennsylvania, aged 35 years, was wounded at Chancellorsville, May 3, 1863, and admitted into Mount Pleasant Hospital on the 8th. Assistant Surgeon C. A. McCall, U. S. A., reported a "gunshot wound of the penis and scrotum, the ball laying open the urethra two inches in front ofthe external meatus, passing out below, and entered the left groin below Poupart's ligament, making its final exit to the left of the coccyx. On May 15th and 16th, haemorrhage occurred from the artery of the corpus cavernosum to the amount of two ounces, and was arrested by pressure upon the artery." He recovered, and was transferred to Philadelphia on June 22d, and admitted into McClellan Hospital,1 whence he was finally discharged the service. On the certificate of disability Acting Assistant Surgeon J. G. Murphy states: "A shot wound of the penis, scrotum, and back, the ball passing in at the centre of the glans just above the urtehra, and out one inch beyond, entered the scrotum, and, after running around the pelvis, at last emerged an inch above the anus. He has also incontinence of urine." Examiner J. G. Koehler, of Schuylkill Haven, reported, September 12, 1863: "Ball entered at the glans penis, passed through a portion of the urethra, lacerating it, through the scrotum, and then through the muscles of the lower part of the abdomen, making its exit at the upper part of the sacrum. At present, there is partial anchylosis of tbe knee joint and stiffness of the leg at the groin; pain over the lower spine; incontinence of urine, and total inability to labor. The disability is rated total and permanent." This pensioner was paid June 4, 1871. Another instance of primary hsemorrhage after a shot wound of the urethra will be found with the instances of urinary fistula of the penile portion of the urethra. It is hardly necessary to call attention to the frequent association of injuries of the urethra and of the testes: Case 1031.—Private H. S. W------, Co. B, 29th Iowa, aged 25 years, was wounded at Jenkins Ferry, Arkansas, April 30, 1864. Surgeon S. H. Sawyers, 36th Iowa, reported that this soldier "received a gunshot wound of the penis and scrotum, and fell into the hands ofthe enemy." Assistant Surgeon W. L. Nicholson, 29th Iowa, who appears to have remained with the captured wounded, makes a similar entry on the register of the Camden Hospital, Arkansas, June 28, 1854, adding, "still in hospital in the hands ofthe enemy." On March 1, 1865, the patient was sent to the Marine Hospital, New Orleans, from Camp Distribution, a depot for exchanged soldiers. Surgeon J. Bockee, U. S. V., reported a "shot wound involving the penis and testes." This soldier was discharged May 26, 1885, and pensioned. Examiner J. N. Penn, of Des Moines, reported, June, 1866: "A ball passed through the penis and destroyed the right testicle, entered the groin, passed through the right thigh, injuring the muscles and the periosteum of the femur." Examiner J. W. Martin, of Red Oak, reported, September 4, 1873: "Gunshot wound of right thigh and testicle; the ball passed through the back part ofthe thigh, carried away the right testicle, and cut through the penis an inch and a half back of the glans. The wound in the thigh weakens it and interferes with free motion; the scrotal cicatrix is tender; there is tenderness also in the track of the spermatic cord. The injury to the penis contracts the urethra, producing stricture, so that he suffers extremely iu micturition. His general health is sensibly affected, and his sufferings are severe; disability one-half." This pensioner was paid September 4, 1873. 1 Acting Assistant Surgeon I. NOBKIS, jr., has reported this case from McClellan Hospital (Am. Jour. Med. Sci., 1864, Vol. XLVII. p. 281), stating that "a urinary fistula existed for some time, * * which, however, finally closed." 358 INJURIES OF THE PELVIS. [CHAP. VII. So little information regarding stricture resulting from shot wounds is recorded, even by writers treating specially of traumatic lesions of tho urethra,1 that it is of interest to notice all the instances reported during the War, however scanty may lie the details ascertained:2 Cask 1032.—Private G. H. Shaeffer, Co. G, 115th Pennsylvania, aged 25 years, wounded at Spottsylvania, May 12, 1864, was admitted into Washington Hall Hospital, Alexandria, on the 25th. Surgeon T. Rush Spencer, U. S. V., reported "gunshot wound of the testicles by a conoidal ball." The patient was furloughed on June 6th, and, on July 2d, was received into Filbert Street Hospital, Philadelphia, convalescent, whence he was returned to duty July 10th. He was discharged July 27, 1864, and was pensioned March 31, 1871. Dr. A. G. B. Hinkle, of Philadelphia, certified, March 16, 1872, that he had removed a minie' hall from the scrotum of this invalid, June 19, 1864." Examiner E. A. Smith reported, April 3, 1872: "The ball struck the penis about the middle, and, passing downward, was extracted from between the testes. He now suffers from stricture of the urethra, painful erections, etc. The disability has not increased on account of wounds, but the applicant is suffering from phthisis pulmonalis in its second stage, as shown by general emaciation. He formerly weighed 159 pounds. He has haemorrhage, night-sweats, prostration, cough, etc., and there is a cavity in the left lung; and it would appear as if a recent general deposit of tubercle had taken place. He is unable to entirely wait upon himself, and has done no work since December, 1871, having been confined to his room. Disability total." This pensioner was paid September 4, 1873. Case 1033.—Private G. E. Douglass, Co. E, 157th New York, aged 29 years, was wounded at Chancellorsville, May 3, 1863, and was sent to Washington to St. Aloysius Hospital. He was transferred, October 17th, to Harewood Hospital. Acting Assistant Surgeon C. F. Trautman reported from Harewood: "A minie ball entered near the left os pubis, and, passing directly backward, wounding in its course the urethra, made its exit through the right buttock about an inch and a half from the anus. When admitted the wound was healed, but the patient had difficulty in voiding urine, and was not able to walk any distance without causing inflammation of the parts injured." He was discharged for gunshot wound of the urethra, disability three-fourths, and was pensioned. Examiner T. B. Smith, Washington, reported, December 28, 1863: "Ball entered the root ofthe penis to the left ofthe symphysis pubis, and passed through the pelvis, wounding the urethra. Catheterism was rendered necessary for about four months; some constriction of the canal remains, as he frequently has dysuria, and dull pains through the pelvis. A stricture may ultimately result from the injury and entitle him to an increased pension." On March 12, 1865, Examiner H. C. Gazlay reported: * * "The wound has healed externally, but abscesses gather and break as often as once in six weeks, discharging bloody matter from the urethra, accompanied by severe pains. This pensioner has also soreness and tenderness ofthe left testis, and much pain, at times, extending along the spermatic cord to the abdomen; also heat and swelling of the testis during each occasion of the formation of pus. At these times micturition is difficult and painful." Examiner J. W. Lawrence, September 30, 1869, states that the bulb of the urethra and the prostate gland were wounded, and that there is constant and increasing inflammation in the prostate, which will suppurate and then discharge every month or two, but is never entirely well. The last report of this case is from Examiner C. H. Evans, and is dated September 11, 1873: "The wounded man is unable to assume a standing position for a long time without severe pain in the urethra. He has an occasional attack of retention of urine and is obliged to use the catheter. His urine frequently contains pus." Case 1034.—Private L. W. Bailey, Co. K, 38th Massachusetts, aged 27 years, was wounded at Opequan, September 19, 1864. Surgeon E. S. Hoffman, 90th New York, reported that "a minie" ball struck the hip and severely lacerated the urethra." Surgeon L. P. Wagner, 114th New York, reported that this patient was transferred from the Nineteenth Corps Depot Hospital to Frederick, October 12th. Assistant Surgeon R. F. Weir, U. S. A., recorded the patient's admission at that date, with a "shot perforation from the left buttock to the right groin, involving the urethra, and resulting in traumatic stricture. The urethra was fully dilated, and the wound healed, April 27, 1885, and the soldier was returned to his regiment," and discharged June 27, 1865.:i No record of application for pension, December 4, 1873. Case 1035.—Private J. B. Milner, Co. C, 17th Indiana, aged 23 years, was wounded at Selma, April 7, 1885; was admitted into Kennedy Hospital, Mobile, with a "gunshot wound ofthe abdomen," on May 4th. He was transferred to hospital at Mound City, May 21st. Surgeon H. Wardner, U. S. V., noted: "Wound of pelvis, ball entering at the left crus penis, passing obliquely back and to the right, severing the urethra, then, grazing the tuberosity of the ischium, it emerged in the right posterior gluteal region. When he was admitted the wound was healed." This patient was sent to Madison and admitted into hospital No. 3, June 9th, and registered as having received a "gunshot wound of the abdomen and perineum." He was returned to duty July 17, 1865. It does not appear that he has applied for a pension. 1 Thus, Dr. C. PHILLIPS, the fourth chapter of whose Traiti des maladies des voies urinaires, Paris, 18b'0, p. 226, treats Des lisions traumatiques de I'urithre, alludes to shot lacerations only by saying that DUPUi'THEN (Lemons orales, 2e 6d., 1839, T. VI, p. 514) "has given one example of partial destruction of the urethra by a projectile." Fiianc (J.) (Observations sur les lisions de I'urithre par cause traumatique, Paris, 1810), Beaney (J. (1.) (Traumatic Stricture of the Urethra, Chapt. VIII, of Orig. Contrib. to the Pract. of Operat. Surgery, Melbourne, 1859, p. 77), and VOILLEMIEK (Lesions traumatiques de I'urithre, Chap. X. de sa Traiti des mat des voies urinaires, 1868, p. 464) almost equally ignore traumatism from shot. 2 A few instances of shot wounds of the urethra are detailed in various reports from the Franco-German War of 1870. Thus, ScuOllek (AI.) (Kriegschir. Skizzen aus dem deutsch-franzosischen Kriege 1870-71, Hannover, 1871, S. 32) remarks: "A small shot wound of the fleshy parts, across the perineum, past the root of the penis, healed with a urethral fistula." BECK (B.) (Chir. der Schussverletzungen, 1872, S. 566) cites two cases of shot wounds of the urethra, in which urinary fistulas remained for a long time, but external urethrotomy was not considered necessary. Beuthold (E.) (Statistik der durch den Feldzug, 187U-7J, invalide gewordencn Mannschaften des 10 Armee-Corps, in Deutsche Militairdrztliche Zeitschr., Jahrg. I, S. 466) mentions two cases of wounds of the urethra. In one of the latter the urinary fistula in the urethra remained open nearly a year; a stricture remained which would not admit of the finest catheter; only by strong muscular effort a very fine jet of urine escaped. Lossen (II.) (Kriegschir. Erf. aus den Barackenlazarethen zu Mannheim, Heidelberg und Karlsruhe, 1870 und 1871, in Deutsche Zeitsehrift fiir Chir., 1871, B. II, S. 20) cites three cases of shot wounds of the urethra. 5 Adjutant General's Uep.irt of Massachusetts for 18G4-5, Vol. II, p. 898. SECT. Ill] WOUNDS OF THE URETHRA. 359 There were a few instances in which the existence of shot laceration of the urethra1 was incontestable demonstrated, and yet complete reparation was reported to have taken place at an early period." It may be questioned, however, if the results would appear as satisfactory could the ulterior histories of these cases be traced: Cask 1036.—Private J. Ii------, a Confederate soldier, aged 1- years, was wounded at Pea Ridge, March 10, 1862. Surgeon W. C. Otterson, U. S. V., reports that "a round musket ball entered the perineum midway between the scrotum and the anus, and passed forward and upward, dividing the urethra, and coming out above the symphysis pubis. Urine passed by the wounds for five days, and afterward by the urethra, and in three weeks the wound was almost healed." Cask 1037.—Private .S. C. Jarris, Co. C, 5th Kentucky Cavalry, aged 25 years, was wounded at Shiloh. April C, 1862, and was admitted into City Hospital, St. Louis, April 19th. Surgeon J. T. Hodgen, U. 8. V., reported: "Wounded bya pistol ball, which struck the root ofthe penis, passing in an outward and downward direction, coming out behind the trochanter of the ritrlit leg. When admitted, he was in good condition ; appetite fair; bowels regular; much pain in the wound; scrotum and penis swollen, and urine passed from the wound at the root of the penis. The wound was cleansed and wet cloths applied. April 25th : Wound in the same condition ; urine passing from the wound, causing much pain; urethra examined with a probe and found partially closed with granulations. A small catheter was applied, and from this date the wounds were dressed with a solution of tannin into which fresh lint was dropped, and applied to the wound every hour. Iron and quinine were given interuallv. June 2d: Wound entirely closed since middle of May; penis somewhat swollen." This prisoner-of-war was sent to the Provost Marshal August 20, 1862. Case 103S—Private M. O------, Co. D, 17th Illinois, aged 21 years, was wounded at Shiloh, April 6, 1862. and received treatment in hospital at Savannah, aud, subsequently, at (Quincy. Illinois, where Surgeon K. Nicholls. U. S. V., reported: "Gunshot wound; the ball entered two inches in front and half an inch above the left trochanter major, traversed both thighs. and, dividing the urethra iu its course, made its exit one inch behind the right trochanter major. September 12th: Wound healed, but he complains of pain at the origin of the right adductor muscles, and is unable fully to straighten the right thigh. The left thigh is painful when fully flexed, but has improved in this respect considerably." He was discharged the service September 22. 1862. It does not appear that he ever applied for a pension. Case 10:39.—Private A. Drake, Co. A. 77th Xew York, was wounded at Antietam, September 17, 1862. He was sent to Satterlee Hospital. Acting Assistant Surgeon X. Hickman and W. F. Atlee made the following report: "He was admitted into this hospital on September 26th, suffering from a wound produced by a minte ball, which penetrated the right natis near the tuberosity of the ischium, and, passing forward and inward, traversed the whole length of the perineum, cutting, in its course, the urethra at its membranous portion, and finally lodged in the epididymis of the right side, whence it was extracted, on October 5th, by an incision from below, extending upward. The patient stated that, immediately after he was wounded, he was sent to a temporary hospital, where he received no attention save the occasional introduction of a catheter into the bladder.3 Upon bis arrival at this hospital he was at once put in a horizontal position, and a metallic catheter was inserted into the bladder and allowed to remain about a fortnight, when it was found that the urine flowed naturally through the urethra. The wound, of course, was dressed by the usual mode. About a week subsequently, a severe inflammation set up in the testes aud scrotum, which was combatted by the constant application of cloths wet with ice-water. All the concomitant symptoms, such as pain, want of sleep, costiveness, etc., were relieved by the usual remedies. On October 25th, the left testis was diminishing in bulk, and the patient's urine continued to drop from him; he received no treatment. On the 30th, two drops of tincture of nux vomica were ordered three times a day. A catheter was introduced into the bladder without difficulty ou December 2d, and by the 4th both wounds were healing; there was considerable atrophy of the left testis, and incontinence of urine when he made any effort, but he retains it when at rest. He had pain in his testicles when he walked, and also when voiding bis urine; his health was good. On December 8th, this patient left the hospital without permission and enlisted iu the 2d Cavalry." He has never applied for a pension. Case 1040.—Private A. MurrUon. Co. H. Gist Alabama, was wounded and captured at Smithfield, August 29, 1864. At West's Buildings, Baltimore, Surgeon A. Chapel. U. S. V., reported "a slight gunshot wound of the urethra." This soldier was transferred, cured, to Fort McHenry for exchange, November 19, 18 >4. Case 1041.—Corporal C. R. Jackson, Co. I!. 6th Kansas Cavalry, was wounded at Mazzard's Prairie, July 27. 1864. Surgeon J. S. Redfield, of his regiment, reported a "shot wound of the pelvis," and the patient's transfer to Fort Smith, where Surgeon C. E. Swasey. U. S. V., recorded "a gunshot wound of tbe left thigh aud scrotum." This soldier was discharged November 18,1*04. In applying for pension he attested, under oath, that "a ball entered the left buttock and passed under the pubes, coming out near the end of the penis, destroying the urethra," a statement substantially corroborated by the company commander. 1 Neale (H. St. J.) (Chirurgical Institutes, 1805, p. 218) must have met with numerous examples of wounds of the urethra during the War of the American Revolution. He says: " If the end of the penis has been shot off, we must put a canula into the beginning of the urinary canal, of a con- venient length and thickness to prevent not only the orifice from being contracted in its diameter, but also to hinder it shrinking up and concealing itself amidst the fleshy parts, as I have seen happen, in three instances, during the campaigns in America." 2 BECK (B,) (Chir. der Schussverletzungen, 1872, S. 565): " In wounds of the penile portion of the urethra, where there is neither infiltration nor involuntary escape of urine, it depends on the extent of the injury whether a complete cure is possible, or whether a fistula remains. Repeatedly I have noticed complete recoveries." 3 The editor, seeking, as far as practicable, to give the hospital reports textually, does not exclude passages of criticism, even when obviously unjust. In the case under consideration, one might enquire, if the field surgeons were so skilful or fortunate as to introduce a catheter through a ruptured urethra, what further "mti*riti..n" in the way of primary treatment was demanded? 360 INJURIES OF THE PELVIS. [CHAP. VII. In other instances, like the following, of alleged speedy recovery after shot wound of the urethra, it is not clear that the canal was in reality lacerated. As Herr Beck observes,1 the urethra is endowed with a resiliency analogous to that of the arteries, and may escape serious injury though lying in the apparent course of a ball: Case 1042.—Private J. Jones, Co. F, 6th Alabama, aged 22 years, was wounded at Fisher's Hill, September 25, 1864, and captured. Surgeon W. A. Barry, 98th Pennsylvania, reported "a wound in the testicles by a minie" ball." Surgeon A. Chapel, U. S. V., reported that this patient was admitted to West's Buildings Hospital, October 13th, with a "gunshot wound of the scrotum and urethra, involving the loss of the left testis. The wounds healed kindly, and the soldier was transferred for exchange, cured, to Fort McHenry, December 9, 1864." An example of a traumatic stricture consequent on a sabre wound will be recorded under the head of Urethroraphy; and other instances, resulting from other causes than shot wounds, will be noted in subsequent subdivisions. Many illustrations of traumatic stricture from shot wounds will appear in the following subsections, and general observa- tions on the treatment and results of this affection will be deferred until after the presentation of these cases: Urethral Fistules.—A large number of shot lacerations resulted in fistules that were distinguished as penile, scrotal, perineal, or recto-urinary fistulse, according to the point of outlet. The urethro-rectal fistules were the rarest, those of the penile portion of the urethra the most intractable. In connection with urethral fistules resulting from other causes than shot injury, there will be occasion to revert to this topic and to refer to their treatment under the heads of Dilatation, Cauterization, Urethrotomy, Urethroraphy, and Urethroplasty. The causes favorable to the formation of fistules after shot lacerations of the urethra are, in the first place, extensive loss of substance of the entire canal, of which this complication is perhaps an inevitable consequence; secondly, partial loss of substance with urinary infiltration; thirdly, ulceration, promoted sometimes by the injudiciously protracted maintenance of an instrument in the urethra; fourthly, the lodgement of foreign bodies; fifthly, the obstruction of the canal anteriorly to the wound by traumatic stricture. There is commonly little trouble in the diagnosis of such fistules. Escape of urine demon- strates their presence, and a probe introduced through the fistulous track reveals its extent and direction; and, if a sound can be carried through the urethra and brought in contact with the probe, the relations of the artificial canal are readily recognized. There is usually but one opening into the urethra, but the cutaneous outlet of the fistule is frequently multiple. Numerous and varied examples were reported. Case 1043.—Private H. Siegfried, Co. L, 7th Pennsylvania Cavalry, aged 33 years, was wounded at Dallas, May 26, 1864, and was treated in a cavalry corps field hospital for a "gunshot wound of the hip, scrotum, and penis," and, on June 7th, was sent to Chattanooga, and thence transferred to hospital No. 19, Nashville, June 18th, returned to duty December 3, 1864, and discharged May 6, 1865, and pensioned. Examiners W. Blackwood and W. R. Grove, of Lancaster, reported, September 24, 1873: "The ball entered the right natis and passed out two inches below the groin, wounding the penis. There is an open- ing near the glans penis, through which the urine escapes; also paralysis of the foot. Disability total and permanent." This pensioner was paid June 4, 1873. Case 1044.—Private C. H. Terry, Co. A, 12th New Jersey, aged 29 years, was wounded at Petersburg, June 16, 1864. He was treated in a field hospital of the Second Corps, and, on the 26th, was admitted to Lovell Hospital, Portsmouth Grove, with a "gunshot wound of the scrotum," and, on October 4th, was transferred to Ward Hospital, Newark, and thence returned to duty January 26, 1865. He was discharged June 23, 1885, and pensioned. Examiner Q. Gibbon, of Salem, reported, July 1">. 1805: * * "Fistulous opening of the urethra above, through which the urine passes in micturition; pain in the lower pelvis upon active exertion." Examiners J. B. Coleman, C. Hodge, jr., and W. W. L. Phillips, of Trenton, certified, September 6, 1873: "Musket ball passed through the lower part of the penis behind the glans, then through the middle line of the scrotum below the spermatic cord, and finally tore through the groin, lacerating it severely; disability total." This pensioner was paid September 4, 1873. 'Bkck (B.) (Chir. der Schussverletzungen, 1872, H. 565) remarks: "Although the urethra, on account of its elasticity, frequently eludes projectiles, solutions of its continuity occur by seton and furrowed shot wounds." SECT, ni.l WOUNDS OF THE URETHRA. 361 Like other shot wounds of the genital organs, many of those interesting the urethra were complicated, as in the following fortunate examples of fistules consequent on shot wounds of the pendulous portion of the urethra, and associated with injuries of the femur: Cask 1045.—Private T. B. Blunden, Co. II, 157th New York, aged 10 years, was wounded near Savannah, December 6, 1864. He was sent to Hilton Head on the 12th with a "gunshot wound of the penis and flesh wound ofthe thigh," and treated until February 26th, when he was granted leave of absence for a month, to report for duty at the expiration of his furlough. He was discharged December 27, 1865, and pensioned. Examiner H. C. Cazlay, of Cortland, reported, October 6, 1866: "Ball pierced the lower portion of the glans penis, carrying away a portion of the glans, and injuring the urethra, so that an artificial passage is left near the orifice. The ball then entered the inner hamstring of the right thigh, striking the femur, and making its exit at the right natis. Three pieces of bone were discharged, and the sinus is now healed; two or three buckshot passed through the scrotum, injuring the right testis, which is swollen and painful. He has constant pain during micturition. The muscles of the right hip and thigh are sore and painful, so that he walks with difficulty; any motion of the limb causes pain; disability total." This pensioner was paid September 4, 1873. Cask 1046.—Private M. M. P------, Co. K, 100th Indiana, aged 23 years, was wounded at Bcntonville, March 22,1865. He was treated at New Berne for a " gunshot wound of the penis and scrotum," and transferred to De Camp Hospital, April 27th. The hospital record is as follows: "Gunshot wound of the penis, scrotum, and left thigh. The prepuce and glans penis were perforated, and a fistulous opening into the urethra remains. On May 18, 1865, Acting Assistant Surgeon H. Sanders circum- cised the prepuce, the patient taking chloroform. The man was discharged July 26, 1805, and pensioned." Examiner D. W. Hixon, August 22. 1866, reported: "Ball entered the penis, passing through, and, playing havoc with the left testicle, fractured the left femur. [?] The muscles are, of course, contracted. His disability is one-half and permanent." Examiner J. Colby reported, September 16, 1873: "The ball entered the dorsum ofthe glans penis and passed out on the posterior surface one and a half inches above the glans, cutting the urethra, which has not united, passed through the left thigh close to the body, entering the front and inner side, and out at the lower part of the left natis. Manual labor produces pain in the leg and hip, and soon wearies the leg; disability one-half." The variety of fistula with several external orifices, rarer in the penile than in the perineal portion of the urethra, is exemplified by the following case: Case 1047.—Private W. T------, Co. B, 28th Massachusetts, was wounded at Gettysburg, July 3, 1863. No record of the treatment of this case is found prior to the patient's admission into St. Paul's Hospital, Alexandria, May 13, 1864, where he was discharged July 1, 1834. In the certificate of disability, June 21, 1864, Surgeon T. R. Spencer, U. S. V., describes a "mutilation of the penis by gunshot, followed by urethral fistula and incontinence of urine." Examiner G. S. Jones, of Boston, reported, September 12, 1866: * * "Fistulous openings now exist in the wounded parts, through which urine is ejected; tbe parts are in a bad condition." Examiners J. B. Treadwell, H. Chase, and H. Doherty reported, September 4, 1873, when this pensioner was paid: * * "The urine passes altogether from the openings caused by the wound, and not through the natural passage. * * Disability total." The following appears to have been an instance of fistula of the pendulous portion of the urethra; but the later history is wanting: Case 1048.—Private I. L------, Co. A, 17th Infantry, aged 19 years, was wounded at Gettysburg, July 3, 1863. At Seminary Hospital, on the same day, the injury was noted as a gunshot wound of the scrotum. At Camp Letterman, July 29th, Surgeon H. Janes, U. S. V., reported: "Gunshot wound of tbe glans penis; the ball severed the left spermatic cord and made its exit at the upper third ofthe right thigh." Acting Assistant Surgeon J. K. Shivers reported: "August 31st: This patient has required no treatment since he has been under my charge. The urine at times flows through the orifice, but as a general thing he draws it off by means of a catheter. He had a slight diarrhoea upon one occasion, which was relieved by the administration of a pill of opium and camphor, since which time he has been doing well. On September 2d, he was ordered a wash of subacetate of lead and tincture of opium." On September 4th, he was admitted into Sixteeuth and Filbert Streets Hospital, and was sent thence, on September 12th, to Fort Columbus, and discharged on the expiration of his term of enlistment. He has not applied for a pension. The methods employed, if any, to close penile fistules, were seldom described in detail. In Case 1051, cauterization and stitches were employed, and several examples of more methodical plastic procedures are mentioned further on. The essential prerequisite of removing all obstructions in the canal anterior to the fistulous opening appears to have been duly appreciated: Case 1049.—Private M. Keating, Co. D, 42d Pennsylvania, aged 33 years, was wounded at Bull Run, August 30, 1862. He was treated in hospitals at Washington, Baltimore, Point Lookout, and Philadelphia, entering Mower Hospital on October 1, 1853, and being discharged the service therefrom, June 21, 1864. Surgeon J. Hopkinson, U. S. V., on certificate of disability dated June 14, 1864, stated: "Necrosis of pubis, and urethral fistula, from gunshot wound. Disability one-third." Examining Surgeon H. L. Hodge, of Philadelphia, reported, June 21, 1864: " On account of gunshot wound of the pelvis bis general health had been much impaired. The anterior wound still remains open, and urine passes through it continually; disability total." There is no record of this man since September 4, 1865, when he last drew his pension. 46 3(>2 INJURIES OF THE PELVIS. [CHAP. VIT. Were it feasible, it would be desirable that the many invalids with fistules of the penile portion of the urethra should be assembled under the care of an adept in plastic surgery. Such cases as the following might admit of relief by operations judiciously planned and skilfully executed, and, if necessary, perseveringly repeated: Cask 1050.—Private C. H. Van Epps, Co. C, 26th Iowa, aged 30 years, was wounded at Chattanooga, November 27,180:',. After having received treatment iu hospital at Bridgeport, and afterward at Nashville, this soldier was transferred to the Veteran Keserve Corps, February 4, 1864. On February 24, 1886, Examiner A. B. Ireland, of Comanche, Iowa, reported: "The ball passed through the groin, penis, and thigh. The wound in the groin and thigh have healed, but the natural orifice of the penis is, I think, permanently closed, so that the urine passes out about halfway up the side ofthe penis, through a very small orifice, almost drop by drop, or in a very small stream, the pensioner requiring about ten minutes to urinate." On September 4. 1873, when this invalid was paid, Dr. Ireland added that "the wounds of the side and thigh give but little trouble; urine still discharges from the wound half way up the side of the penis, through two orifices now instead of one; disability three-fourths.'' Case 1051.—Private C. H------, Co. I, 35th Illinois, aged 24 years, was wounded at Chickamauga, September 19, 1803. He was treated in hospitals at Nashville, Evansville, and Quincy, having been admitted into the latter on December 26th. Acting Assistant Surgeon I. T. Wilson reported: "A minie ball passed through the left side of the scrotum and body of the penis, entering the latter about an inch and a half behind the glans, passing through the inferior portion of the glans. The wound healed, leaving an opening at least half an inch into the urethra, and the glans to some extent was bound down to the prepuce below by attachment to it. The urine was voided by the use of the catheter during the process of healing, and can be forced through the natural passage when closing the artificial orifice with the finger. Attempts have been made to close up this orifice—first by cauterization, and then by stitches, both proving ineffectual: the stitches having broken out in a few hours by an erection ofthe organ." The wounded man was returned to duty March 11, 1884, and, on the 23d, was admitted into Lawson Hospital, St. Louis; thence he was transferred to Jefferson Barracks, and again admitted into hospital at Quincy on July 9th. Dr. Wilson further noted that "the wounds are healed, but an orifice is left on the under side of the penis, communicating with the urethra." This soldier was mustered out September 3, 1854. He is not a pensioner. The great difficulty in closing wounds of the urethra with loss of substance, when situated in the penile portion of the canal, already adverted to, is further exemplified in the following cases, and under the head of Urethroplasty: Case 1052.—Captain O. M. F------, Co. B, 60th New York, was wounded at Atlanta, August 1, 1884, and was treated in a Twentieth Corps hospital, where Surgeon H. E. Goodman, U. S. V., recorded a "gunshot wound of the left hand and flesh wound of the testicle." At the Officers' Hospital, Nashville, and the Grant Hospital, Cincinnati, the case was registered as a "gunshot wound of the penis and of the left hand." This officer was discharged the service November 29, 1854, and pensioned. Examiner C. C. Bates, of Potsdam, reported, July 17, 1867: "Was wounded by a ball in the index finger, causing its ampu- tation at the middle of the first phalanx. A ball also wounded the penis, opening the urethra just posterior to the corona glandis and just to the right of the frsenum. The opening is like a button-hole in shape, one-third of an inch in length, and allows the escape of half the urine during micturition. The ball also wounded the left testis, causing its immediate removal. General health good." Examiner B. F. Sherman, of Ogdensburg, reported, September 6, 1873: "Fistulous opening back of glans, through which urine and secretions pass; disability one-half." This officer's pension was paid to September 4. 1873. Case 1053.—Corporal T. Garvin, Co. H, 94th New York, aged 4;? years, was wounded at Hatcher's Run, February 7, 1885, and was treated in a Fifth Corps hospital for a severe gunshot wound of the genitals," and transferred to Newton University Hospital, Baltimore, on the 11th, where the following was noted: -"Gunshot wound of the penis, right testicle, and right thigh, the ball emerging from the gluteal region, lower parts, fracturing the femur." The wound was dressed with cold water, and the right lower extremity was placed in Buck's apparatus, and counter-extension was made by pulley and weights, with favorable results. The patient was removed to Jarvis Hospital May 23d. Assistant Surgeon D. C. Peters, U. S. A., recorded a "gunshot wound of the penis, right testicle, and right thigh, involving the femur," and stated on the certificate of disability, "gunshot wound of penis, right testicle, and upper third of femur; urine escapes through the lower opening of the penis; he has some union of limb, but about three inches shortening; disability total." This invalid was discharged June 11, 1865, and pensioned. Examiner Geo. W. Cook, of Syracuse, reported, April 25, 1863: "Bullet struck the glans penis, passing downward and backward through the urethra, producing hypospadias, through which the urine is voided; thence into the right thigh, fracturing the same. About four inches of the femur has been resected."(!) The attending physician, Dr. A. Welch, states, August 16, 1869, iu an affidavit, that, to the time of his death, "Garvin was laboring under severe pain and difficulty from a wound which he received in the right hip, passing through the joint and through the testicle, destroying the hip joint, producing a shortening of the limb and an open wound, from which pus and splinters of the bone and joint were discharging to the time of his death," January 3, 1869. Case 1054.—Private Ernest S------, Co. E, 2d New Jersey, aged 36 years, was wounded at South Mountain, September 14. 1862. Assistant Surgeon H. A. DuBois reported, from the hospital at Birkettsville: "A musket ball penetrated the penis, testis, and thigh. By the end of September the patient was convalescent." He was discharged from Ward Hospital, Newark, November 10, 1865, and pensioned. November 21, 18 18. Examiner I. Q. Stearns, of Elizabeth, reported: "A ball passed through the penis just back of the glans and destroyed the left testis. The hole through the body of the penis remains open and the urine passes involuntarily at the artificial orifice." The Trenton Examining Board, September 5, 1873, gives substan- tially the same statement as that of Dr. Stearns. SECT. III.] WOUNDS OF THE URETHRA. 363 When a shot perforation of tho urethra results in a fistula at the corona, or but a few lines posterior to it, and attempts to close the artificial opening fail, it may be proper to produce artificial epispadias or hypospadias by connecting the meatus and fistula by an incision.1 Cask 1055.—Private S. W. Sinierl, Co. B, 21st Missouri, aged 27 years, was wounded at Pleasant Hill, Louisiana, April 9, 1864. He was sent from a hospital of the Sixteenth Corps on May 3d, on the steamer R. C. Wood, to Adams Hospital, Memphis. Surgeon J. (J. Keenon, U. S. V., reported a "gunshot wound; ball entering the glans penis and passing through the scrotum and right thigh." This soldier was returned to duty September 20, 1864, and discharged and pensioned April 10, 1806. Examiners W. Jones and A. S. Long, of St. Joseph, reported, November 2, 1S70 : " Gunshot wound of the right testis and right thigh, the shot having passed through the glans and prepuce, causing deformity of the glans. The urethra remains open from the meatus to the posterior portion of the fossa navicularis. The missile passed through the right testis, which is atrophied and adheres to the scrotum, and entered the right thigh, passing through obliquely, and producing excessive muscular injury. Tliere is a deep adherent cicatrix both at the entrance and exit of the shot, with partial contraction of the injured muscles, resulting in imperfect use of the right leg; disability total and permanent." Examiner G. R. Baldwin, of Fort Scott, September 8, 1873, writes that " the urethra is split open to the corona and its surfaces are inflamed. The scrotum becomes excoriated, in warm weather, at tbe seat of the cicatrix." This pensioner was paid September 4, 1873. Fistules were ascribed, in some instances, to the prolonged use of sounds. The dangers to be apprehended from this cause, once underestimated, are now adequately appreciated. The cautions expressed by Dupuytren, and Drs. Pirogoff, Socin, and Beck, have been cited in the notes to pages 352 and 356. Dr. Gouley has, more recently, adduced illustrations of the ill effects of the protracted retention of catheters.2 Cask 1056.—Colonel Joshua L. C------, 20th Maine, was wounded at Petersburg, June 17, 1854, and taken to the hospital ofthe 1st division, Fifth Corps. Surgeon W. R. DeWitt, jr., U. S. V., reported that "a conoidal ball penetrated both hips, and was extracted," and that Surgeon M. W. Townsend, 44th New York, was detailed to accompany the patient to City Point, when, by direction of Surgeon E. B. Dalton, U. S. V., he was placed on the hospital transport Connecticut and conveyed to Annapolis, and promoted Brigadier-General of Volunteers and Brevet Major-General. Surgeon B. A. Vanderkieft, U. S. V., reported that be "reached the hospital at that place very com- fortably on June 20, 1864, with a shot wound involving both buttocks and the urethra." The progress and treatment do not appear on the hospital case-books, but in a letter to Surgeon J. II. Brinton, U. S. V., September 4, 1864. Dr. Vanderkieft states: " I send you a catheter used by Brigadier- General J. L. C------, U. S. V. As you will perceive, it is covered by a calculous deposit. This catheter was but five days in the bladder, and was repeatedly covered in the same way. I think it a very important specimen, illustrating the necessity of often renewing catheters when they are to be used a demeure. The history you shall get when the patient is discharged." The specimen referred to is accurately represented, of half-size, in the wood-cut (FlG. 286). The patient was furloughed September 20, 1864, and mustered out January 15, 1866, and pensioned. The promised report of the case was not received. From Pension Examiner A. Mitchell's report, September IS, 187:!, it appears that " the ball entered the right hip in front of and a little below the right trochanter major, passed diagonally backward, aud made exit above and posteriorly to the left great trochanter. The bladder was involved in the wound at some portion, as the subsequent history of escape of urine from the track of the wound and its extravasation testified. He very often suffers severe pain in the pelvic region. The chief disability resulting indirectly from the wound is the existence of a fistulous opening of the urethra, half an inch or more in length, just anterior to the scrotum; this often becomes inflamed. The greater part of the urine is voided through the fistula, the fistula itself resulting from the too long or too continuous wearing of a catheter. No change has resulted since the last examination ; disability crusted bv phosphates! total." This invalid was paid to June 4, 1873, at $30 a month. lay 6, 1H04. He was treated in a field hospital for a " gunshot wound of the testicle," and was transferred, on the 20th, to Armory Square, where Surgeon D. W. Bliss, U. 8. V., described the injury as a gunshot wound of the perineum and urethra." Subsequently, this officer was transferred to the hospital at Camac Woods. Acting Assistant Surgeon W. Camac reported: "Admitted on May 22d, having been wounded by a round ball, which entered to the left of the left cord of the testicle, passed across and struck the urethra, opened it, and passed down behind the scrotum, outward to the right side of the perineum, and down and out over the tuberosity of the right ischium. Tbe left testicle was carried away; the right, uninjured ; the urethra was opened for at least two inches of its length. The wound was then granulating. About half of the urine escaped through the opening; the other half passed in a good stream from the natural channel. Tim parts were so irritable as to preclude the use of a catheter, and the cure was entrusted to granulation, as after lithotomy, a watch being kept for any constriction. 'Ihe parts were greatly swollen ; the general condition of the patient's system was good ; pulse fair. Milk- punch was given lightly, with full diet; poultices were applied, and the patient kept quiet. On the 24th, he was doing well; on the 26th, his bowels were opened by an enema, and the rectum seemed clear. There was much pus from the perineum, it having been opened by incision, but there was no sign of infiltration. The ligature on the cord had not then come away; the pus was healthy and suppurating in the whole track ofthe wound very freely. On the 29th, an abscess opened on the left side of the scrotum; a cataplasm was placed over the whole wounded surface. For a day or two lotions of lime water had been used. A weak solution of permanganate of potash was thrown iuto the cavities. The urethra was granulating finely; no instrument was used; the stream of urine from the end of the penis was very good, and the flow from the fistulous opening was diminishing. May 31st: He was doing very well, but was not a good patient. There was still much pus from the perineum ; the ligature was still on the whole cord, and, therefore, was not expected to come away soon. On June 5th, the urine was dribbling from the fistulous opening to about one-tenth the whole amount. He was doing well on the 7th, and the pus was diminishing in quantity and was healthy; there was no trouble in micturition. An enema was used. The ligature came away on the 8th, and there was a decided general improvement in the last two days. On the 13th, the wound in the perineum was nearly healed; the scrotal wound was healed; the urethra was granulating finely, and the escape of urine was diminishing. The dressing consisted of lime water; extra diet was ordered, aud the patient"s general health was excellent. The fistule continued to granulate finely; on the 21st, only a few drops of urine escaped from it, and there was a full stream through the natural channel; the patient walked about comfortably. July 1st: While the patient urinates, a drop or two, now and then, comes out at the junction of the scrotum and penis. From this point down, about one inch and a half of the urethra has been carried away, and there is no defined canal; but a passage to the bladder is pervious and the stream natural. It was impracticable to get a bougie into the bladder, as the canal starting from the glans penis goes to tbe junction of tbe scrotum and penis, and then into tbe cavity opening into the scrotum formerly occupied by the left testicle. The general health was good; the officer walked everywhere; apparently, he could perform full duty, and there was no tendency to further contraction : therefore it was decided not to interfere unless some inconvenience should arise. When the risk of contraction is over caustic might close the fistulous orifice." This officer was transferred to Annapolis on July 31st, and mustered out August 24, 1864. Examiner J. H. Gallagher, of Philadelphia, reported, January 16,1800, that, " Cutting away a portion of the prepuce, the ball entered the body of the penis, passed into the urethra and out, and was extracted through the natis. There is a fistulous opening through the urethra from which there is constant oozing of urine, the bladder being involved in the injury, causing weakness. The pensioner has lost the scrotum and left testicle. He states that the right testis frequently becomes swollen and painful, producing a serous discharge from the fistule; be complains of general lassitude and weakness." Examiners H. E. Goodman, T. H. Sherwood, and J. Collins, September 4. 1873, reported: "Loss of left testicle, and urethral fistula, and one of the perineum on the right side. Urine and spermatic fluid are discharged. The disability continues total." This pensioner was paid September 4, 1873. To the thirteen foregoing examples of scrotal or perineal urethral fistules from shot injury, should be added Case 831, an instance of multiple scrotal fistules, and three cases recorded under the head of Urethrotomy. Of sixteen cases of vesico-cutaneous fistules recorded,1 only six opened in the perineum. Urethro-rectal Fistules.—The rarest variety of urethral fistules is constituted by those communicating with the rectum.2 In the subsections on wounds of the bladder and of the rectum, thirteen examples3 were adduced of persistent vesico-rectal fistules resulting from shot injury. Urethro-rectal fistules from this cause were less frequent and less obstinate. The anatomical relations of the urethra to the intestine involve less liability of the establishment of intercommunication between the canals, and should they be 1 Cases 781-2-3-4, on page 265; 785-6-7, on page 266 ; 797, p. 271; 808, 810, p. 279; 8J6-7, p. '-88; 856, p. 294; 858-9, p. 295; 869, p. :104. 'Voiu.EMIER (Traiti des mal. des voies urinaires, 1868, p. 423), in treating of urethral urinary fistules, observes: 'Les fistules qui s'6tendent de 1 urethre au rectum sont plus rares; elles torment une espece toute particuliere qu'on n'observe guere qu'a la suite de la taille p6rin6ale." The Professor had occasion to modify this opinion during the siege of Paris in 1670-71, as indicated by the observation cited from M. Gillette, on the next page. 3 Cases 788, 789, 790, 791, on pages 206, £07; 823, p. 287; 825, 828, p. i88 ; 860, p. 296; 876, p. 307 ; 885-6, p. 309; 887, p. 310; 899, p. 313. 47 :>7< > INJURIES OF THE PELVIS. IdlAiwii. connected by a ball track, there is not the constant dribbling of urine which opposes the closure of recto-vesical fistules, and faeces intrude less readily than into the bladder. The five cases reported during the War that may possibly be referred to this category illustrate these remarks. In Case 1072, the urethro-rectal fistula appears to have closed spon- taneously a year after the injury. In the next case, pus without urine passed by the fistules; the communication between the urethra and rectum was not incontestable. In the three cases on page 371 the fistules were recurrent rather than permanent:1 Case 1072.—Private James Dervin, Co. H, 4th Rhode Island, aged 25 years, was wounded at Antietam, September 17, 1862, and sent to the Ninth Corps Hospital at Locust Springs. Surgeon T. II. Squire, 89th New York, states that " a musket ball entered the skin about two inches back of the tuberosity of the left ischium and one and a half inches from the median line, and, passing forward across the perineum, came out at the lower part ofthe scrotum, half an inch to the right ofthe raphe. At present (December 8th?), the posterior wound is discharging laudable pus, and the anterior is healed; but tliere are two consecutive openings still higher, on the side of the scrotum, which originally gave vent to the matter consequent on active inflammation ofthe testis or of some other tissue contained in that side of the scrotum. This man was taken from the field the second day after the fight, and having had no discharge from the bladder, and because a catheter could not be introduced, the bladder was punctured through tbe rectum by Surgeon M. Storrs, 8th Connecticut, and the urine has been passing through that puncture, more or less, ever since, especially if a catheter is not introduced frequently, as it has been as a general thing. The gum catheter is now to be left in the canal, and I am in hopes that the recto-vesical fistula will heal. Occasionally of late, duriug a movement of the bowels, the urine has been expelled voluntarily by the urethra. The patient now is improving, but he has not stood upon his feet since the injury, and he complains that his limbs are stiff' and sore, and unable to support him in the erect posture. By further investigation, I discovered that the urethra, near the bulb, was laid open by the ball, and that urine escaped through the scrotum through this wound for many days. December 8th : When the patient makes water, the greater portion of it comes by the anus, probably by a communication between the membranous portion of the urethra and the rectum, either made primarily by the ball or consecutively by infiltrative inflammation and ulceration. I must send for a rectum speculum and a special catheter, and endeavor to heal this urethro-rectal fistula." * * In a second case-book, Dr. Squire continues the report ofthe case, probably in January, 1833: " For nine weeks past a secondary fistulous opening has existed at the point ofthe buttock, communicating, by a tortuous sinus behind the rectum, with the ball route; thus the case is complicated by a fistula in ano behind and a recto-urethral fistula in front, both kept open by the excretions of the kidneys and of the bowels. Heartily sick of this temporizing treatment I have been pursuing fruitlessly, I administered chloroform, and, passing in the grooved staff at the entrance wound and out at the fistulous orifice in the natis, I laid open the intervening tissues by an incision five inches long and an inch and a half deep. Then, passing the staff from this cut into the rectum, through the track of the ball, and out at the anus, I also laid open the intervening tissues here. It is my intention to use the knife in the recto- urethral fistula by and by, iu hopes of obtaining union from tho bottom, and thus making a complete cure of this disgreeable case. In the meantime, the patient must wear a catheter or have one introduced every twelve hours." The patient was transferred to No. 1 hospital, Frederick, January 20, 1883, when Assistant Surgeon R. F. Weir, U. S. A., recorded the existence of a urinary fistula, without comment, and the man's transfer to Jarvis Hospital, June 13,1833. Assistant Surgeon D. C. Peters, U. S. A., transferred the patient to Hammond Hospital, July 3,1833. Acting Assistant Surgeon M. A. Booth reported : "Gunshot wound of the perineum; ball lodged in the scrotum, injuring the testis, and was extracted at the Frederick Hospital, February 14. 1883, by Dr. North. There is a fistulous opening in the urethra. August 21st: Catheter dispensed with; fistula closed. August 25th : Has taken cold from lying on damp ground; has fever and dysuria, with soreness over the region ofthe bladder; urine is somewhat bloody. August 30th : Cystitis improving; the urine is nearly free from mucus and albumen ; there is some phosphatic deposition. September 15th : The urine is alkaline, aud there is a superabundance of triple phosphates ; reaction alkaline. September 22d: Improvement continued; recommended for discharge." The patient was sent to duty January 1G, 1834, and, on February 8,1834, was admitted into Mount Pleasant Hospital from Camp Convalescent. He was furloughed and readmitted, and returned to duty May 24, 1854, and discharged October 15, 1834, and pensioned. Examiner H. W. Rivers, of Providence, reported, May 30, 1838, that " the ball entered the left buttock about three inches to the left of the anus, passed through the urethra, and came out at the scrotum, wounding the right testis. The injury causes incontinence of urine and severe pain on exercise." This pensioner was paid on June 4, 1873. Case 1073.—Private D. Emms, Co. D, 8th Ohio, aged 21 years, was wounded at Cold Harbor, June 3, 1884, and was admitted to Armory Square Hospital on the 8th, the injury being rated as a " gunshot wound of the scrotum." He was returned to duty June 29th, and discharged the service July 13, 1864, and pensioned. Examining Surgeon A. IT. Agard, of Sandusky, reported, June 1. 188(5: " Was wounded by a ball in the left of the scrotum, passing backward and wounding the testis, urethra, and rectum. He now suffers some pain along the track of the ball, and has occasional discharges of matter from the urethra and rectum." Dr. Agard reports, November 15, 1871: "His increase of disability results from a numbness and pain in the left thigh, resulting from the •wounding of nerves, I think a reflex action in the sciatic nerve or branches; disability total." Examiner J. Ii. Ford reported, on examination for increased pension, December 21,1871: " Right testis gone; ball passed into the upper part ofthe left hip or thigh, whence it was extracted after fifteen months. The left thigh is weak and motion impeded, and he is unable to be much on his feet; disability total." The pension was increased, and paid to September 4, 1873. 1 GILLETTE (Remarques sur les blessures par armes d. feu observies pendant le siige de Metz (1870) et celui de Paris, 1871, in Arch, gin., 1873, T, XXI, p. 322) cites a case of shot wound of the perineum with recto-urethral fistula. The penis was tumefied; vesical catheterization impossible; there was infiltration with emphysema ofthe perineum, scrotum, and penis ; numerous deep incisions were made; death. SECT, mi WOUNDS OF THE URETHRA. 371 In two of the three following examples of urethrorectal fistules,1 the abnormal canal closed early; the third is persistent, apparently requiring operative interference: Case 1074.—Private O. Hitt, Co. E. 105th Ohio, was wounded at Penyville, October 8, 18G2, and was admitted into Antioch Church Hospital on the same day. Assistant Surgeon C. N. Fowler, 103th Ohio, noted " a gunshot wound of the perineum and urethra, urine passing from the wound." The patient was transferred to hospital No. 12, Louisville, December 1st, where Surgeon 1\. L. Stanford, U. S. V, reported "gunshot wound through the right hip, injuring the urethra." This soldier was discharged December 11, 18G2, Dr. Stanford recording on the certificate of disability "gunshot wound an inch to the right of the coccyx, the ball passing through the rectum into the bladder, making a fistula through which the urine passes in large quantities." Examiner C. D. Griswold, of Cleveland, December 9, 1833, reported: "Gunshot wound, the ball entering posteriorly between the nates near the os coccygis, passing forward and injuring the bladder and rectum, resulting in irritability of the bladder and pain from locomotion." Examiner J. W. Falley, March G, 1873, reported: "Three or four times a year the parts inflame, suppurate, and discbarge by the rectum; while that is going on he is laid up." Dr. Falley, in reporting the biennial examination, December 22, 187!', says: "The fjrees and urine are now voided regularly; the parts are well healed; his general health has much improved; disability total." This pensioner was paid to December 4, 1873. Case 1075.—Acting Assistant Surgeon John Neill, in charge at Broad and Cherry Streets Hospital, Philadelphia, reported that "Private W. H. Disbrow, Co. D, 5th New York, aged 19 years, was wounded at Gaines's Mills, June 27, 1«62, and taken prisoner, and subsequently paroled and sent North. He was admitted, on July 29th, with a gunshot wound of the bladder and intestines, the ball having penetrated the abdomen in front just above the pubes, and remained in the body. At the time of admission, urine dribbled from the wound. He stated that for several days after the injury his urine poured from the wound in a stream, and that occasionally a small quantity of itvees also passed. His general condition was good. He was discharged the service August 7. 1862." Examiner T. Franklin Smith, of New York City, reported, September 20, 1873: "Ball entered the right groin and was removed from the perineum, involving the urethra. Locomotion is affected in consequence of tenderness and pain in both legs and testicles. Disability continues at one-half." This pensioner was paid in July, 1873. Case 107(5.—Private K. E. B------, Co. F, 0th New Jersey, aged 2G years, was Avounded at Williamsburg, May 5,1832, and treated at Mill Creek till sent to the Filbert Street Hospital, Philadelphia. October 14th, Acting Assistant Surgeon E. L. Duer reported : "He received a ball from behind, entering about one inch to the left of the anus and the same distance from the point of the coccyx. The missile traversed the urethra from its membranous portion to near the base of the glans, completely disorganizing the parts, and emerging on the right side of the urethra. Haemorrhage ensued to exhaustion, but, by reason of a good constitution and fortunate conveyance, he rallied, and was placed in hospital. The urine passed mostly through the posterior wound for several weeks. The case came under my care about two months subsequently, when the urine merely trickled out after being at stool or after voiding it by the natural channel, which, by the way, he experienced no trouble in effecting. The posterior wound at its orifice had nearly healed. I passed a large-sized catheter sufficiently well into the bladder to draw off the urine, but could not bring down the shaft of the instrument to the axis of the body, nor could the patient retain it comfortably for more than a few minutes. The point of resistance seemed beyond the wound, though the patient states that he had never had anything like stricture previously. The treatment consisted in enlarging the posterior wound, and injecting dilute iodine and weak solutions of nitrate of silver, at the same time that a tent was kept introduced into the posterior wound and a catheter introduced occasionally. The edges of the anterior wound rapidly contracted under the stimulus of nitrate of silver. The perineal wound in the urethra has evidently nearly closed from the fact of there being but an occasional drop passing posteriorly, but yet the fistulous disposition of the wound is still remaining. Pure iodine has been injected and a drainage tube kept in for a short time, by which it is hoped to accomplish a cure. November 20th: Under the treatment detailed, the posterior wound has closed up, and, with the exception of the fistula behind the glans, the patient seems quite cured. The missile was supposed to be a mini6 ball, fired from a distance of only twenty yards. The sensation was that of having a red-hot iron poked through the wound. The fistula will be treated by operation in a few days. January 21, 1833: There has never been any disposition to erection of the penis since the reception of the wound." This soldier was discharged March 16, 1863, and pensioned. Examiner W. Jewell reported, March 24, 1863: " Musket ball in the left hip, passing through the penis, entering the urethra, and coming out on the right side of the virile member. The wound is healed iu part, leaving an opening or fistula into the urethra, which gives rise to incontinence of urine; disability total;" and on September 7, 1865, he again reported, "The improve- ment warrants a reduction of disability to one-half." Examiner P. Leidy, August 29, 1838, stated: * * "There is a fistulous opening communicating with the urethra from without at the point of exit ofthe ball, through which the urine passes in voiding, constituting hypospadias, which has increased, as also the pain and tenderness of the whole region included between the point of entrance and exit of the ball. His general health is fair; disability total." In October, 1887, Examiner J. M. Adler gave a similar description of this soldier's wound and result, and added: "The posterior wound becomes inflamed, at times suppurates and opens, and the urine escapes through it. The consequent irritation from the urine interferes greatly with locomotion and manual labor, and tbe deformity is great and probably incurable." Examiners E. A. Smith, T. S. Harper, and G. C. Harlan reported, February 1, 1871: "Ball entered the left buttock about an inch to the left of the coccyx, and, ranging forward, passed through the soft parts, slightly wounding the neck of the bladder, and made its exit through the side of the penis. Discharge still continues from both entrance and exit wounds. When urinating, a portion passes through the wound in the side of the penis, and if attempts to micturate in erect position be made, a portion of the urine passes from both wounds." September 24, l'-S73, Examiners T. II. Sherwood, H. E. Goodman, and James Collins reported: "Shot wound of right groin and left hip, resulting in urinary fistula from the penis and anus. The pensioner is practically emasculated, and the discharge is offensive. The disability is equivalent to the loss of a limb in consequence of the disgusting nature of the complaint." 1 Urethrorectal fistules consequent on shot wounds are not referred to in the writings on military surgery the editor has consulted. Concerning such fistules due to other traumatic causes, the reader may compare: Joukdax (Art. Fistule, Diet. des. sci. mid., 1816, T. XV, p. 627); BtiRAUD (A.) (Les fistules urithro-rectales, in Diet de Med., 2« 6d., 184G, T. XXX, p. 123); Desault (P. J.) (Traiti des mat des voies urinaires, An. VII, p. 295); Faoielski (De fistulis urinariis, lierol., 1822); Jamain (A.) (Manuel depath. et de clin. chirurgie, 2« ed., 1867-70, T. II. p. 835). 372 INJURIES OF THE PELVIS. [ciiap. vu. Fatal Shot Wounds of the Urethra.—Of the morbid anatomy of shot lesions of the urethra, scarcely anything is definitely known. The Army Medical Museum shares in the poverty of European pathological collections in respect to prepa- rations illustrating this form of injury. Nineteen of the twenty-two fatal cases in which the urethra was wounded by shot are enumerated on page 351, two others are noted on this page, and the remaining case with the operations of external perineal urethrotomy. The causes of death may be indicated, in a general way, as: hsemorrhage in three cases; urinary infiltration in eight, in two of which the signs of peri- tonitis were pronounced; surgical fever, with profuse suppuration, in nine, including three cases complicated with fracture of the femur; tetanus and phlebitis with gangrene, each in one case. There were several autopsies; but little information was derived from them, owing to the disorganized condition of the parts examined. The Museum possesses a preparation (Fig. 290) of shot perforation of the urethra, contributed by Dr. K. K. Stone, with the following memorandum: Cask: A9.—"Mr. Corn. H- Pio. 290.—Shot perforation of the penis, dividing the urethra. Sjiec. 902. -, one of two clerks, bosom friends, in Washington, in 18G2, married a charming person, and took lodgings, at which his friend was a frequent and welcome visitor. After some months, annoyed by his comrade's assiduities near his wife, Mr. H----returned unexpectedly, during office hours, to his bed-chamber, and became the unhappy witness of the infidelity of his wife, actually beholding the stylum inpyxide. He avenged himself with a Derringer pistol, aiming with such precision that the ball entered the raphe of the scrotum of the preoccupied paramour, traversed the penis forward and upward, and lodged in the pubic bone. Profuse haemor- rhage was quickly followed by hyperacute peritonitis, and the wounded man expired after thirty-six hours of agony." Occasions where the urethra is exposed to such oblique, postero-anterior, shot perfo- rations should be exceedingly rare. Scant details were reported of two fatal cases of shot laceration of the urethra, the one complicated by urinary extravasation, the other by phlegmonous abscesses near the urethra. Cask 1077.—Private C. Stewart, Co. G, 16th Pennsylvania Cavalry, aged 19 years, was wounded at Shepardstown, July 1(>, 1883. He was treated in a cavalry corps hospital until the 20th, and then sent to Camden Street Hospital. Acting Assistant Surgeon E. G. Waters reported: "A musket ball entered the dorsum of the penis near its base, passed backward and outward through the scrotum, and entered the left thigh through its anterior and inner aspect, about two inches below Poupart's ligament. His condition was reasonably good on admission, but the penis and scrotum assumed a gangrenous appearance, and, on the 23d, he was found pulseless at the morning visit, exceedingly restless, his countenance anxious and livid, thirst insatiable, and the thigh throughout its extent enormously swollen. The entire surface of the body emitted a cadaveric and offensive odor- This assemblage of symptoms, together with a slight hsemorrhage from the Avound in the thigh, occasioned apprehensions of injury to the urethra and either the femoral or profunda blood-vessels. He sank and died at ten o'clock in the evening. The next morning about half a gallon of sanious fluid was observed to have escaped from the wound in the thigh; this discharge, saturating the table on which the body lay, formed a large pool on the floor of the dead-house. The corpse was so offensive that no examination could be made." Cask 1078.—Private P. S. Bobbitt, Co. A, 47th North Carolina, was wounded at Gettysburg, July 3, 1863, and sent to Seminary Hospital, where Surgeon A. J. Ward, 2d Wisconsin, reported a "shot wound of the urethra." The patient was moved to Camp Letterman Hospital August 5th, where Acting Assistant Surgeon E. P. Townsend reported that "the ball entered to the right and above the symphysis pubis, and passed out through the muscles of the back above the pelvis, and to the left of the sacrum. The urine was discharged entirely from the posterior wound. But little was known of this patient's previous history. On admission, he had an exhausting diarrhoea with entire loss of appetite, being unable to retain the least nourishment on his stomach. Attempting to pass a catheter, a stricture was found about two lines beyond the glans penis. This being finally passed, and a gush of pus instantly filling the catheter, a second and impassable stricture was reached at the neck of the bladder. The treatment pursued was expectant. The patient failed, and died of exhaustion on October 20, 1863." Ot the eighty-three reported cases of recoveries from shot wounds of the urethra, some details have been furnished of twenty-six resulting in stricture, of thirty-eight with the superadded complication of fistula, and of seven without recorded permanent lesions SECT. 111.1 WOUNDS OF THE URETHRA. 373 of the canal. The three following cases may be added to the last-named category; in each, the effects of the urethral lesions appear to have been slight: Case 1079.—Private J. Lawler, Co. A, 9th Massachusetts, was wounded at Spottsylvania, May 12, 1834, and, after treatment on the field, was sent, on the 18th, to Douglas Hospital, the injury being noted as a "gunshot wound of the perineum, lacerating the urethra." lie was transferred, June 16th, to McDougall Hospital, New York, furloughed, and, on July 17th, was admitted into Mason Hospital, Boston, whence he was discharged July 2, 1834, and pensioned. Examiner (J. 8. Jones, of Boston, August 1, 1834, reported : "The wound was in the natis and scrotum. The ball entered the right buttock and emerged near the right external abdominal ring, injuring the bones of the pelvis and the right testis. He is now quite lame." Captain McGonnigle, late of Co. A, 9th Massachusetts, on oath attests that said Lawler was wounded "by a ball and two buckshot in his right groin and testicles." Surgeon A. N. McLaren, U. S. A., examined this man for enlistment in the 42d Veteran Reserve Corps, on July 17th, and reported: "Gunshot wound; ball entering about an inch and a half to the right of the anus; through the perineal muscles and right testicle, and impinging upon the right side of the pubic arch, escaping at this spot; the wound is healed." He was re-enlisted, receiving his pension to that date. Cask 1080.—Corporal E. Carpenter, Co. D, 10th New York Artillery, was wounded at Petersburg, July 7, 1834. Surgeon S. A. Richardson, 13th New Hampshire, reported, from an Eighteenth Corps hospital, that this man was struck " by a minie ball, which passed through the right thigh and penis, and was sent to Fort Monroe, July 13th," and transferred to Lovell Hospital, Rhode Island. Surgeon L. A. Edwards, U. S. A., recorded a "shot wound of right thigh, penis, and scrotum," and the patient's transfer to Troy. Surgeon G. H. Hubbard, U. S. V., recapitulated the foregoing diagnosis, and reported this soldier's discharge, April 18, 1833, for "disability resulting from loss of muscle from the anterior portion of the thigh, unfitting him for service in the Veteran Reserves." Examiner W. A. Anderson, of Wisconsin, reported, October 8, 1837: "A musket ball passed through the glans penis and upper third of the right thigh anterior to the femur. In hospital, gangrene destroyed much muscular tissue in the track of the wound, leaving a cicatrix involving half the circumference of the limb. There is great contraction, and the limb is slightly atrophied, and he complains of pain and weakness in the knee, which, I should think, might result from such a wound. He follows his business as a farmer." This pensioner was paid June 4, 1873. Cask 1081.—Private J. S. O------, Co. F, 115th New York, was wounded at Newmarket Heights, September 2:1, 1864. He was sent from a Tenth Corps hospital on October 2d to Hampton, where Assistant Surgeon Ely McClellan reported a "gun- shot wound of the scrotum involving the urethra,'' and the patient's transfer to Grant Hospital, New York, October 18, 1864. Surgeon A. H. Thurston, U. S. V., reported this man's transfer to the Veteran Reserves, January 25, 1865. No application for pension has been made. Urinous Infiltration and Free Incisions.—Extravasation of urine from shot lacera- tions of the urethra gives rise to two forms of accidents.1 When freely infiltrated into the perineal and scrotal tissues, there is rapid swelling with discoloration, and great constitu- tional disturbance. There is also a chronic form, when the urine slowly permeates the connective tissue, producing a brawny tension of the part and, ultimately, urinous abscesses. In both forms, free incisions,2 for the evacuation of the urine and disorganized tissues and exudations, constitute the important and essential remedy: Case 1082.—Lieutenant M. X. X------, Co. C, 47th North Carolina, aged 24 years, was wounded at Gettysburg, July 3, 1863, and was sent to De Camp Hospital on the 19th. Acting Assistant Surgeon E. W. Edwards reported that "the ball entered the posterior aspect of the right natis, passed forward and inward, wounding the urethra, and made its exit through the right upper part of the scrotum without wounding the spermatic cord or testis. The antecedent treatment had consisted of a free perineal incision, through which the urine flowed. When admitted, the patient was very feeble and much emaciated; he could control his bladder, but when the urine was voided it passed entirely through the exit wound and the fistule in the peri- neum made by tbe above-mentioned incision. The left half of the scrotum had sloughed, leaving the testicle bare. The patient was allowed a generous diet, with sherry and porter; the parts were kept clean, and the testis wrapped in a linen compress covered with simple cerate; a No. 8 steel bougie was passed every other day, with some difficulty at first, and allowed to remain for ten minutes. The patient began at once to improve, and, at the end of thirty days, the urine flowed entirely by the natural passage. The passing ofthe sound, however, was continued up to the time of his discharge. The scrotum reformed, the wounds and fistula healed kindly, and when he was transferred, on October 20, 1863, he was, to use his own words, 'as good a man as ever he was.'" On October 24th, this officer was sent to Bedloc's Island for exchange. Case 1083.—Private G Walters, 1st New York Sharpshooters, was wounded in the perineum, at Suffolk, in April, 1863. Assistant Surgeon J. W. Hasbrouck, 164th New York, reported that a musket ball entered the left buttock and penetrated the pelvic cavity; and that the patient was sent to the hospital of the 6th Massachusetts. Surgeon Walter Burnham, of that regi- ment, reported that "an incision was made into the urethra, the same as for lithotomy, to communicate with a wound of the canal in order to prevent the general infiltration of urine escaping from the wound in the hip." Death, April 16, 1863. 1 For an excellent exposition of the effects of acute and chronic extravasation of urine in traumatic injuries of the urethra, consult a clinical lecture at St. Bartholomew's Hospital hy Mr. W. S. Savory, P. It. >S., in The Lancet, January 17,1874, Vol. I, p. 79. The early use of the catheter is deprecated. 2 Matthew (T. P.) (Surg. Hist, of the British Army in the Crimea, etc., 1858, Vol. II, p. 334) records the case of J. Slothers, 21st regiment, aged 22, wounded June 18, 185."., hy a musket ball, which entered tho left side of the scrotum, divided the urethra, and passed out at tho right buttock A catheter could not be introduced. Free incision into the perineum was made, and an elastic catheter introduced into the bladder through the vesical portion of tho divided urethra. Death, June 27, 1855. 371 INJURIES OF THE PELVIS. [CIIAl'. VII. Injuries of the Urethra not caused by Shot.—Except when caused intentionally or accidentally in surgical manoeuvres, these are uncommon. Occasionally, however, they are inflicted under the inspiration of insanity, malice, jealousy, or mischief,1 of which some examples have been given in treating of wounds of the penis. A single instance of sabre wound of the urethra was reported: Case 1084.—Trumpeter J. D. Hall, 10th Ohio Cavalry, was wounded before Fort Donelson in January, 1832, by a sabre thrust through the buttock and perineum. His record for the next three years cannot be traced. Surgeon S. S. Schultz, U. S. V., reported that this soldier was admitted to the post hospital, Catnp Chase, May 2, 1*35, with traumatic stricture of the urethra, caused by a wound received three years previously. He was transferred to Tripler Hospital, at Columbus, May 5, 1833, where Surgeon J. D. Knight, U. S. V., reported: "This soldier is suffering from stricture of the urethra, produced by a wound from a sabre, received at Fort Donelson. The wound was sewed up immediately after the reception ofthe injury. Discharged May 30, 1865." The name of this soldier does not appear on the Pension List. The following remarkable example of eversion of the corpus spongiosum, obstructing the urethra by a cylindrical fleshy mass, recalls the extraordinary case that occurred to Mr. Hilton, at Guy's Hospital,2 in 1867: Case 1085.—Private J. Looney, Co. I, 2d East Tennessee, aged 22 years, was admitted into Asylum Hospital, Knoxville, May 29, 1864, with chronic diarrhoea. He was transferred, on July 25th, to Holston Hospital, and Surgeon H. L. W. Burritt, U. S. V., reported: "Traumatic stricture of the urethra, with vascular excrescence. The patient states that when he was a boy his penis was crushed by a fall between two mill-stones. The urethral canal is tortuous and will not admit the passage of the smallest catheter. There is such complete phymosis that it amounts nearly to occlusion; the probe grates along some hard obstruction and fails to detect a canal for a greater distance from the orifice than about one-fourth of an inch. He frequently urinates incompletely and painfully; his water escapes by drops; he complains of nothing but the mechanical difficulty. July 25th: Circumcision was practised to overcome the phymosis; then a portion of the under part of the glans penis was incised enough to expose a hard cartilaginous tumor, occupying and obstructing the meatus urinarius. This tumor was excised without difficulty, the patient being anaesthetized by chloroform. The opera- tion was performed by Surgeon John Shrady, 2d East Tennessee. July 30th: The catheter that had been placed in the urethra was removed; the patient urinates with natural freedom, and has, so far, had not a single untoward symptom. August 2d: No change, except that the organ is somewhat less sensitive to the contact of instruments. August 25th: No longer keeps his bed, and has been doing light duty around the hospital; the glans is marked by several sulci, radiating from the meatus as a centre; no difficulty in micturition." This soldier was returned to duty August 31, 1864. He is not a pensioner. The appearance of the cylindrical fleshy tumor, occupying an inch or more of the urethra from the fossa navicularis backward, and exposed by laying open the canal, is represented in the annexed wood-cut (FlG. 291), from a pencil sketch. Case 1086.—Private C. A. Maxon, Co. C, 130th New York, aged 23 years, was admitted into David's Island Hospital, New York Harbor, November 15,1863, with atony ofthe bladder. Acting Assistant Surgeon J. L. Van Norden reported: "The patient was below the medium size, and of healthy appearance. He stated that since his earliest recollection he had experienced at intervals a want of power in the bladder to expel its contents, and that there never was sufficient contractile power to enable him to throw his water any distance. After a march of two days, some six months since, he arrived at Yorktown in an exhausted condition; says that he first came to himself on the boat going to Washington, when he found that he had been insensible for five days. At this period his urine was drawn by catheter for the first time. Arriving in Washington, he was placed in barracks, where he had retention of urine for two days. He was then sent to Judiciary Square Hospital, where, a day after his arrival, a number of surgeons tried to relieve him by catheterization. Failing in this attempt, puncture of the bladder was advised, when the patient requested to be allowed to try the introduction of the catheter. This being granted, he forced the instrument in and drew off the contents of the bladder. Since then he has not been able to pass his water without a catheter, which he uses thrice daily. On examination, a false passage was found, but a No. 12 sound could be passed without difficulty. The urine flowed from the bladderwithout force; the passage of instruments is followed by considerable constitutional disturbance, depriving him of sleep the night following their use. On November 22d, the patient had facial erysipelas, for which tincture of iron was prescribed. Under this treatment the disease, which had surrounded and partly closed the right eye, quite disap- peared by the 26th. The urine was still passed by the catheter on November 29th." This man was discharged the service, January 29, 1864, for "stricture of the urethra and false passage." He is not a pensioner. 1 The American Indians sometimes torture their victims by ablation of the penis. For numerous and varied examples of mutilations, consult Dr. ClIEVElts (Man. of Med. Jurisprudence for India, 1870, p. 493, etc.). Dr. WILLIAMSON (Mil. Surg., 1863, p. 120), to "illustrate the tricks that soldiers play on each other," cites the case of Hussey, 18th Ilegiment, whose companions, while he was drunk, inserted a piece of cano a foot long and tied it in the urethra. Compare Note 2, on page 344 ; Devergie (Medecine ligale, 1S40, T. II, p. 300); MAIIOT (Des ruptures de I'urithre, Paris, 1838); and THIBAULT (Des plaies contuses de I'urithre, Th6se, Paris, 18f>3, No. 4). 2 In that well-known case, described and figured by Mr. BlUKETT (Inj. of the Organs of Generation, in HOLMES'S System, etc., 1870, Vol. II, p. 735) and by Mr. Bkvant (Practice of Surgery, 1872, p. COO), the subject was a man of fifty, bitten by a stallion when nineteen. A cylindrical fleshy mass, an inch and a quarter long and a third of an inch thick, projected from the meatus. Flo. 291.—Fleshy excres- cence in the fossa navicu- laris, resulting from an old laceration of the corpus spongiosum. SECT. III.] INJURIES OF THE URETHRA. 375 Other complications of injuries of the urethra and operations will now be considered, whether connected with shot or other traumatic lesions or with surgical diseases : Foreign Bodies.—The urethra may be obstructed by foreign bodies descending from the bladder, or introduced by the meatus, or driven into the canal by projectiles. Arrested in the urethra, they cause dysuria and inflammatory symptoms, and their extraction becomes imperative. The foreign bodies expelled from the bladder may be either calculi or bone fragments, as exemplified in Cases 806, 808, 817, 819, 849, 850, 856; or small projectiles, as in Case A8, page 284; or pieces of cloth, as in Cases 811, 818; or possibly of other foreign substances that have been driven into the bladder.1 In very rare cases, projectiles are arrested cither within the urethra or in such a position in the contiguous tissues as to press against and obstruct the canal,2 as in Cases 765, 867 ; and, in other instances, equally rare, fragments of clothing or other foreign bodies may be driven before the missile and lodge in the urethra, as in Case 1087. The foreign bodies introduced into the urethra by the meatus are either fragments of broken surgical implements, or of substances introduced by patients for the purpose of relieving retention, or else objects as varied as the perverted fancies of onanists. The Army Medical Museum contains many illustrations of the several varieties of foreign bodies that obstruct the male urethra. Among them are seventeen specimens of calculi,3 expelled or extracted from the canal after detention for periods of varied duration,—splinters of bone impacted in the urethra, as repre- pm~ sented in the fifth figure of Plate VIII, and by wood-cut 242,—a l^ J pistol ball, extracted by delicate forceps, and delineated of natural size by Figure 231,—several fragments of catheters, bougies, and other instruments, of which one illustration is given on the next page,—bits of twigs, straws, and wires, employed in futile attempts to relieve hunteb's retention of urine,—melon-seeds, hair-pins, crochet-needles, and sundry orHALES's . ' ) r ' . . forceps. other objects introduced into the urethra in order to excite erotic sen- sations.4 For a detailed description of these, reference must be made to a future edition of the Catalogue of the Surgical Section of the Museum; but one or two examples of each 1 Four instances of projectiles engaged in the urethra are enumerated in Note 1, p. 2C8, and five instances of similar obstruction by bone frag- ments are mentioned in Note 2, on the same page. In Note 3, p. 2S5, four eases of obstruction of the urethra by pieces of cloth are cited. The follow- ing references may be added: HUSSEY (E. L.) (Obstruction of the Urethra, a Piece of Bone impacted, ten Years after Injury of the Pelvis, in the British Med. Jour., March 28, 1863, Vol. I, p. 318) ; Paget (J.) (Separation by direct Violence of a Portion of Bone from the Arch of the Pubes, and its impaction in the anterior Wall of the Urethra, giving rise to Retention of Urine and other Symptoms of Stricture, in the Med. Times and Gaz., 1865, Vol. II, p. 442). A piece of bone, two-thirds of an inch long, partially encrusted with phosphates, was removed by perineal section from the urethra of a middle-aged man, whose pelvis had beeu injured by a mass of falling earth. 2 EVE (P. F.) (A Pistol-ball shot into the Urethra and extracted by Incision, in the Nashville Jour, of Med. and Surg., 1867, Vol. II, p. 222) relates an interesting observation of a bullet lodged beyond the membranous portion of the urethra, near the prostate; perineal section on a grooved staff was practised, the foreign body was removed, and the patient, a negro, recovered without a bad symptom. 3 Specimens £87, 4G67, 4830,. 4983-4-5-6-7-8, 5407, 5476-7, 5522-3, 5562, 0868, 6200. ()f these specimens, nine consist mainly of uric acid or urates, six of oxalate of lime, and two of carbonate of lime. Several of the specimens comprise from two to six separate concretions. Specimen 4850, constituted by one hundred and fourteen hemp-seed and uric acid calculi, passed by tho urethra without becoming impacted, is not included in this series. 4 On foreign bodies in the male urethra, consult the various treatises on calculous disorders, and ou the extraction of foreign bodies, and, also, Gross (S. D.) (Foreign Bodies in the Urethra, Chapt. VIII of his Pract. Treat, on Dis. Inj. and Malform. of the Urin. Bladder, Prost Gland, and Urethra, 1855, p. 828); LEE (C. C.) (Remarks on the Path, and Treatment of Urethral Calculi and of Foreign Bodies in the Urethra, in the New York Med. Jour., 1867, Vol. VI, p. 97); Lr.sriNE (L. B.) (Sur les corps etrangers quiprennent naissance dans les voies urinaires, These de Paris, 1815); George (V. P. M.) (Des diverses voies par lesquelles les corps etrangers peuvent pinitrer dans les organs urinaires, These de Paris, 1838, No. 368); BOURDON (It.) (Quelques considerations sur les corps itrangers des organs ginito-urinaires, These de Fails, 1871, No. 195); LEROY d'Etiolles (Sur I'extraction des corps itrangers solides autres que les calculs, Paris, 1843); GiJNTNER (Chir. Beobachtungen, Fremde Kocrper in der Harnrohre, in Memo- rabilien, 1869, B. XIV, 7, S. 158); Foucheh (Sur les corps itrangers introduits dans I'urithre et dans la vessie, in Bull. gin. de thirapeut, 1860, T. LIX, p. 493); Paili.et (Des corps itrangers de la vessie et de I'urethre, These do Paris, 1852, No. 186); Demarquay et Parme.ntier (Des corps etrangers Fig. 293.— VlDAl'8 curette. INJURIES OF THE PELVIS. [CHAP. VII. FIG. 294.-Two mulberry calculi passed by the urethra: a. Spec. 0562; b, Sp. 4830. variety raav be briefly alluded to here. The particulars of a case which furnished two of the specimens of urethral calculi, on account of the eminent position of the subject of it, possess extrinsic interest: ( 'ase A10.—President Andrew Johnson, iu August and September, 1857, suffered intensely from the frequent recurrence of paroxysms of lumbar pain, dysuria, and other symptoms of nephritic colic,—symptoms which his physician, Dr. I .axil Norris, U. S. A., ascribed to the passage of a renal calculus. After a few weeks' intermission, about the middle of October, another attack of difficult micturition, with tenesmus and great pain, announced that the calculus had entered the vesical end of the urethra. The pain was mitigated by the use of hypodermic injections of sulphate of morphia. On the second day of the paroxysm, the calculus could be felt in the scrotal portion of the canal, and Dr. Norris proposed to attempt its extraction by the iTid of a curette or forceps; but the patient objected to operative interference; and, as micturition, though difficult and painful, was still accomplished sufficiently to avert any dangerous vesical accumulation, the expectant and anodyne treatment was continued. During the night the calculus was expelled, and, at the morning visit, the patient handed the concretion (Fig. 2114 b) to his attendant, remarking that he might exclaim with the old Greek philosopher: JZvprjKa ! The urethral irritation at once subsided, and, on the same day, the President undertook a journey to Boston. The calculus, weighing six grains Troy, was a hard tuberculated ovoid concretion, consisting almost wholly of oxalate of lime. In the spring of 1869, after a similar train of symptoms, a second, somewhat smaller, calculus (FlG. 294 a) was spontaneously expelled. While it was engaged in the urethra, the pain was so excessive that Dr. Norris was summoned to Greenville; but, upon his arrival, March 9, 1889, the offending concretion had escaped. The patient recuperated as rapidly as on the first occasion, and has since enjoyed immunity from calculous disorder. The second concretion was similar in weight, color, and composition to the first, but of irregular form, as indicated in the wood-cut (FlG. 294 a). It is unnecessary to reproduce the illustrations of the bone-fragments and bullets voided by the urethra. They may be found on pages 284 and 294. The details of a case in which urethrotomy was resorted to, in order to extract the extremity of a large flexible catheter (Fig. 295) broken off in an. attempt at dilating a dense stricture anterior to the scrotum, will be related in the next quinquennial report of surgical cases in the Army. The incision in the pendulous portion of the urethra was closed, with difficulty, six weeks after the operation. An abstract has been already published1 of a case in which a broom-straw (Fig. 296), broken off* in the urethra in a patient's attempt to relieve a distressing attack of retention of urine, was removed through an ante- scrotal incision, by Assistant Surgeon J. H. Bartholf, U. S. A. The nature of foreign bodies that lodge in the urethra, and the positions they may occupy, are so varied, that the surgeon is often called on to improvise a plan for their removal, and it is impracticable to formulate general rules for their extraction. When impacted near the meatus, FIG. 295.— Fragment of rubber cathe- b" urethrot- it is often possible to remove them with ordinary forceps, a division of A bent probe omv 5965. Spec. the urethral orifice frequently facilitating this procedure. A Dent p will often answer the purpose when the foreign body lies near the free end of the urethra, or the body may be caught in the metallic loop, long since proposed by Marini (Fig. 297). By palpating the canal the exact position of the foreign body can be determined, and then, if it is lodged in the pendulous part, by deflecting the urethra, the loop may be slipped over the foreign substance and made to extract it, if its size and form permit. In many cases, however, such simple means will be unavailing, and it will be necessary to employ more complicated contrivances, or even, as has been seen, to have recourse to urethrotomy. introduits dans I'urithre, in Gaz. hcbdom., 1857, T. IV, p. 23); Guube (W.) (Beitrage zur Casuistik der Steine und Divertikel der mannlichen Harn- rohre, in Berliner Klin. Wochcnschrift, 1867); CUTTER (E.) (Case of Urethral Calculus, in Boston Med. and Surg. Jour., October 6,1870); PHILLIPS (C) (Des corps etrangers introduits dans I'urithre, Chap. VI, de son Traiti des mat des voies urinaires, 1860, p. 666); RELIQUET (Operat. necessities, par un gravier ou un calcul dans I'urethre, Chap. VI, de son Traiti des op. des voies urinaires, ] 871, p. 572); CUTTER (E.) Case of Urethral Calculus, in Bost Med. and Surg. Jour., October 6,1870); ANNANDALE (T.) (Case of Multiple Calculi in the Urethra, in Brit. Med. Jour., 1869, p. 399); GOXTARD (Sur des portions d'os sortis de I'urethre, in Jour, de Mid., 1757, T. VJ, p. 107); BOINET (Mem. sur un procidi nouveau, etc., pour I'extraction des corps aigus introduits dans I'urethre, in Jour, des connaissances medico-chir., 1847, T. II, p. 145). 1 In Circular 3, S. G. O., 1871, p. 255: Case of Private J. Kline, Co. C, 11th Infantry. FIG. 296.— Broom-straw removed by urethral sec- tion. Spec. 5527. SECT. 111.1 OPERATIONS ON THE URETHRA. 377 FlG. 297.—Marini's metallic urethral loop. J. [After HEISTEK, Plate XXIX, FlG. 7.] Jules Cloquet substituted for Marini's loop (Fig. 297) a silver canula and wire noose.1 Professor Voillemier regards the so-called Hunter's forceps (Fig. 292) as the best instru- ment for the extraction of calculi from the urethra.2 In some of its innumerable mod- ifications, this instrument has been largely employed in the a b removal of foreign bodies from the urethra or bladder, consti- tuting, indeed, under the des- ignation bilabe or trilabe, the essential part of the apparatus with which modern lithotrity was successfully practised at the end of the first quarter of the present century. The reliable Vidal considered his curette (Fig. 293), consisting of a flattened silver canula with a button pushed forward by a stylet, as one of the best means of extracting foreign bodies from the urethra, and I have used it successfully more than once for this purpose; but, with all the curettes, the difficulty of getting behind the foreign body is sometimes insuperable. With a view of eluding it, Ravaton3 invented a jointed curette, designed to be insinuated between the foreign body and the urethra (or the auditory canal) while straight, a button afterward being projected laterally by the movement of a slide. Leroy modified this contrivance (Fig. 299), and it has been further improved by the admirable instrument-maker Charriere.4 It is the basis of the urethral lithotrites of Dubowitzky and of Ndlaton. The varieties of urethral forceps that have been recommended are almost innumerable. The form used by Sir Astley Cooper (Fig. 284, p. 350) is celebrated rather for the success of its appli- cation by that great surgeon than as an invention; for it had been known for two centuries. The instrument has been improved by Weiss, and forms part of the armamentarium of British surgeons.5 It is more useful for the extraction of small bodies from the bladder than from the urethra. The construction of the urethral forceps of Sir Henry Thompson is beautiful; but the slender blades have a feeble grasp. The action of the lever forceps of Robert and Collin is more effective; but the latest and best instrument of this descrip- tion is probably that fabricated by M. Mathieu6 (Fig. 298). Si«* Fig. 298.—M. Mathieu's urethral forceps. Fig. 299.—Ar- ticulated curette ofLEKOY(d£ti- i. 'GiJNTiiElt (Lehre von den Blut Op., Leipzig, 1860, B. IV, S. 443) cites cases in which HANEKROTH, of Siegen, in 1841, and Diuffenbacii extracted urethral calculi by wire-loops (Drahtschlinge), HANEKROTH using a fine piano-string. DESCilAMPS (F. J.) (Traiti hist et dogmat. de la taille, 1826, T. IV, p. 222) states that he had frequently successfully used a bent probe. 2 VOILLEMIER (Traiti des mat de I'urethre, 1868, p. 509). HALES (Statical Essays, 1733, Vol. II, p. 257) believed himself the inventor of this instrument, and many surgical critics have accorded him the credit of it. Yet an almost identical apparatus was figured long before him by Fabkicius Hildanus in the De lithotomia vesicse liber, Cap. XXVII, p. 755, Francofurti, 1646 (Delineatio speculi ad extrahendos calculos e virga), and by Scri.TE- tus (Armamentarium chirurgicum, Francofurti, 1666, Tab. XVI, Fig. 3, p. 25). It is, indeed, only the simplified reproduction of the instrument employed by Franco (Traiti tris ample des hernies, Lion, 1561, p. 147) and by Andreas della CROCE (Chirurgia universale perf etta di tutti leparli pertinenti al chirurgo, Venezia, 1574) for the extraction of small calculi from the bladder. Franco spoke of the instrument as invented long before him: "Thefirst inventor," he said, "must have bad more loz than I; for, as it is commonly said, it is easier to modify advantageously an invention than to invent it." 3 Pratique moderne de la Chirurgie, Paris, 1776, T. I, p. 378, et PI. IV. 1 See a figure and description in Phillips, Traiti des maladies des voies urinaires, 1860, p. 621, Fig. 90. For details of LEUOY's instrument, compare Voillemier, op. cit, p. 508. 6Fergusson (W.), A System of Practical Surgery, 5th ed , 1870, p. 710. Weiss's Blustrated Catalogue, 1863, PI. XXIV, Fig. 7. 'Mathiel', Pince urithrale a double levier et a branches paralleled, in Bull, de I'Acad. de Med., Seance d'Otubru 10, 1871, and in Gaz. des Hopitaux, 1871, No. 114. 48 378 INJURIES OF THE PELVIS. [chap. vu. V It is more prudent to resort to incision of the urethra for the removal of foreign bodies, rather than to incur very serious danger of injuring the canal by persistent efforts at extraction; for incised longitudinal wounds of the urethra generally heal without fistules. Friable bodies too large to traverse the urethra, and especially impacted calculi, may often be advantageously treated by crushing and removal in fragments. This is a very old operation. It is described in detail by Abulkasim1 (A. D. 1100), by Franco (1591), and by Ambroise Pare', who, as is too often the case, neglects to acknowledge his indebtedness to his predecessors. Though prac- tised by Fischer, it was regarded by surgeons generally as of merely historical interest, until the invention of lithotrity recalled attention to it.2 Civiale perfected a urethral lithotrite (Fig. 300), which, in skilful hands, is sometimes very serviceable. The great difficulty consists in passing the female blade behind the concretion. This is sometimes avoided by strongly depressing this blade, and, if the foreign body is in the pendulous part of the urethra, by bending the penis abruptly (Fig. 302), as advised by Reliquet and long before by Paulus ^Egineta.3 With the most careful manipulation, however, the female blade will sometimes strike against the foreign body and press it backward. Nelaton sought to evade this obstacle by having fabricated, by M. Mathieu, a lithotrite with a jointed female blade. The objection to this instrument is that it has not sufficient strength to crush a really hard calculus; and, if such a one is seized and cannot be pulverized or disengaged, the difficulty of withdrawing the instrument may place the operator in an awkward dilemma, m!chakr[e\e" Ingenious instruments have been designed for cutting, bending, and otherwise facilitating the extraction of pins, bougie-fragments,*and pattern.] the like. Unless habituated to the use of such implements,4 the surgeon will prefer, in difficult cases, a clean longitudinal incision to the risk of lacerating the canal. FIG. 300.—Cl- viale's urethral FIG. 301.—Nk LATON's jointed urethral brise pierre. [After M. MATlIIELi'S 1 ALlJUCASIS (De Chirurgia, Oxon., 1778, cura JOHANNIS Channing, Lib. II, Sect. LX, p. 289): " Dein sumas fllum, et cum illo ligato virgam subter calculum, ne forte in vesicam calculus revertat. Deiude introinittas ferruni perforans (terebram) cum lenitate in penis foramen donee fen-um perforans ad ipsum calculum pervenerit; et terebram cum manu tua revolve in ipsum calculum paulatim, et tu conator perforationem ejus, donee ilium calculum penetraveris per alteruni latus. Equidem urina illico liberata erit. Deinde cum manu tua constringe reliquias calculi, ab exteriori parte virgae, illae etenim perforata sunt, et cum urina educentur: et sanatus erit asger; si voluerit deus excelsus." 2 Compare FRANCO (Traiti des hernies, 1561, p. 116); Pare (CEuv. compl., Liv. VIII, Chap. XLI); FISCHER (C D.) (De calculo vesicse urinaria: in urethram impulso et singulari encheiresi absque sectione cxemto, IK; 302.—Diagrams illustrating the introduction of a lithotrite and the seizure of a urethral calculus. [After REi.iyuET.] Erford, 1744); Dubowitzky (in Phillips, op. cit, p. 620), etc. 31!eliquet (Traiti des Opirations des Voies Urinaires, Paris, 1871, p. 586); Paulus JEgineta, Adams's ed., London, 1846, Book VI, Sect. LX, Vol. II, p. 356. 4GiJXTllEU (Lehre von den Blut. Operat, I860, B. IV, S. 442 ct seq.) enumerates not less than sixteen modes of elimination of foreign bodies from the urethra, citing illustrations of each from numerous authors. It will suffice cursorily to hint at the subdivisions: 1. Spontaneous (Famucius Hildanus, Civiale); 2. After suppuration (Bartholinus, Steiger); 3. By manipulation (Fr. Jacqi ks); 4. Copious drinking of diluents (Sir ClI. BELL); 5. Pushing back into the bladder (Demarquay); 6. Dilatation by bougies (Sir ClI. Bell, DELl'ECH, Aumoxt); 7. Injection of liquids (WlGAN, Schkeger); 8. Insufflation of air (Trousset); 9. Suction (FOURCEOY, ClIOl'AET); 10. Removal by special instruments (FRlliE. V. AMJION, Hunter. Weiss, Dubowitzky); 11. Curette (Tarler, Moiikeniieim); 12. Trituration by forceps and stylet (AMUSSAT); 13. Crushing (DE- MARQUAY, Muker); 14. Wire and metal loops (HANEKROTH, DlEF- EENBACIl); 15. Forceps (SEYI)EL, CIVIALE, DE LAMOTTE, SI.i.AI.AS); 16. Incisions (BROD1E, SAbATlEU, BOULU, MUKAT, DEJlAliyUAY, etc.). SECT. III.] OPERATIONS ON THE URETHRA. 379 The rarity of the complication of traumatic lesions of the urethra by foreign bodies has been pointed out on page 375, and the instances reported of foreign bodies in the urethra consequent upon wounds of the bladder are there enumerated. A rare instance of shot wound of the urethra, with a piece of cloth impacted in the canal, was recorded, and another in which Surgeon C. S. Muscrol't, 10th Ohio, successfully extracted a broken catheter from the canal with the aid of forceps ■} Case 1087.—Private T. J. Khmcar, Co. D, 13th Indiana, was wounded near Suffolk, April 13, 1863, and sent to the regimental hospital, where Surgeon A. D. (Jail, 13th Indiana, noted a "gunshot wound near the anus, wounding the urethra, produced hy a conical riilc ball, which entered on the right and a little anterior to the anus, passing upward and forward a short distance, and wounding the urethra; the ball, however, dropped out of the wound and was found in his clothing. The urine, during micturition, passes out of the wound—at first in large quantities, but considerably less now. The patient is doing well, and seems to be recovering without any other unfavorable complication. This man had also a flesh wound over the metatarsal bones of the left foot, which was quite severe, but is doing well; treatment, cold-water dressings." Surgeon T. II. Squire, 89th New York, reported: "He was wounded while skirmishing in front of the enemy; having first received a wound in the foot, he was upon his hands and knees trying to escape from his dangerous situation, when a second ball struck exactly in a line corresponding to that of the usual incision for the lateral operation of lithotomy, on the right side of the body, about two inches from the anus. The patient was conveyed in a light cart about one mile to the hospital at Suffolk, where his trousers were removed from him while he was in a sitting posture on the edge of a chair, and, while this was being done, the ball dropped on the floor. Soon after this the patient undertook to urinate, but the effort caused him so much pain that he desisted until the next day, when he was compelled to evacuate the bladder. At this time most of the urine escaped by the wound. Subse- quently, during micturition, the water escaped in both directions, about half one way and half the other; but at the present time, June 7th, only a very small portion of it escapes through the false passage, and the wound is nearly healed. About six weeks after the injury, a piece of his drawers, of cotton fabric, was forced out of the meatus by the stream of urine. A purulent discharge lias, all along, been going on from the meatus as well as from the wounds. It is probable that the urethra was wounded in the membranous portion. The catheter has not been used at any time, and, virtually, the case has been left entirely to the efforts of nature, and its progress thus far has been favorable." This man was sent to Chesapeake Hospital May 12th, aud transferred to the Veteran Reserve Corps September 1, 1863. He has not applied for a pension. Case 1088.—[An extended account ofthe early history of this case has been published3 by the attending medical officer, Assistant Surgeon B. C. Brett, 21st Wisconsin. The following memoranda are compiled from the hospital and pension records.] Corporal J. Sheets. Co. I, 101st Ohio, was wounded at Murfreesboro', December 31, 1832, aud was sent to a Eourteenth Corps hospital, in charge of Surgeon J. L. Teed, U. S. V. A musket ball had entered the right buttock and passed out at the left side of the scrotum, dividing in its passage the membranous portion of the urethra. There was great oedema of the scrotum, with interstitial extravasation of blood, extending to the inguinal and pubic regions. The urine could be voluntarily retained, but, on micturition, it escaped chiefly through the scrotal wound. A catheter was introduced into the bladder and cold lotions were applied to the wound-orifice. On January 3, 1833, two free incisions were made into the tunica vaginalis, and pus and decom- posed urine were freely discharged from the tumefied scrotum. In the next two days the walls of the scrotum sloughed anteriorly, leaving the testes bare. On January 21st, the vesical extremity of the catheter was found encrusted, and its calibre was nearly obliterated by phosphatic deposition. It was removed and cleaned, and replaced by another instrument. On January 24th, this was found similarly encrusted and clogged, and a smaller gum-elastic instrument was substituted. On January 25th, in withdrawing this instrument it broke, and about a third ofthe distal extremity remained in the urethra, where its open extremity could be felt by a probe. The ward medical officer, Assistant Surgeon B. C. Brett, 21st Wisconsin, being baffled in attempts to extract the foreign body, Surgeon C. S. Muscroft,- 10th Ohio, succeeded in grasping the end of the broken fragment with a long narrow bullet forceps, and safely extracted it. The perineal wound was drawn together by adhesive straps with a view of obliterating it. On January 27th the patient had a chill, and a large perineal abscess formed, and, on February 1st, this was incised, a vast amount of pus being liberated. He was transferred, as reported by Surgeon J. Y. Finley, 2d Kentucky Cavalry, to the general field hospital at Murfreesboro' on March 21st, and not discharged "cured," on February 2d, as published by Assistant Surgeon Brett. April 2d, this man was furloughed, and September 26, 1863, transferred to Co. A, 15th Veteran Reserves (Gen. Ord. 320, A. G. O., 1853), and discharged June 30, 1855, and pensioned. Examiner C. W. Backus, of Three Rivers, reported that "he has chronic conjunctivitis, and sclerotic inflammation, etc.," without adverting to the disability from wounds. In his application for increase of pension, the pensioner states under oath that he was "wounded by gunshot, the ball passing through the body, coming out below the left groin, severing the water passage, causing the lower part of the scrotum to slough off, and severing and injuring the muscles of the left leg so as to leave the same weak and ready to give out when standing." This pensioner was paid September 4, 1873. Complex instruments are unlikely to be required for the removal of foreign bodies connected with shot wounds of the urethra; for, if accessible, they may be extracted through the wound, and otherwise, it is better to resort to incision, for the canal will not be in a condition to permit tedious and painful manoeuvres. 1 For instances of bougies breaking in the urethra, consult: Mason (E.) (Stricture of the Urethra,- Breaking of a Bougie in the Urethra, in Am. Jour. Med. Sci., 1869, Vol. LVIII, p. 391); Bancroft (Stricture of the Urethra,- Extraction of a broken fragment of a Gutta-percha Bougie, in Bost Med. and Surg. Jour., 187.1, Vol. 10, p. :>0fi); and IIARTSIIORNE (II.) (Phila. Med. Times, 1874, Vol. IV, p. 432). 1 Brett (15. C.), Removal of broken Catheter from Bladder, in the Am. Med. Times, 1863, Vol. VII, p. 181. 3S0 INJURIES OF THE PELVIS. [C1IA1*. VII. Treatment of Wounds of the Urethra and of Traumatic Strictures and Fistules.— The immediate introduction of a catheter into the bladder, if it is possible to pass one, has long been regarded as indispensable1 in wounds of the urethra, and was the established rule of practice during the War. When this was accomplished and foreign substances were removed, the edges of wounds were approximated over the catheter by adhesive strips,2 and a compress of lint completed the dressing.3 Agreed thus far, surgeons differed widely in opinions respecting the period of retention of the instrument, or whether it should be retained at all. Some experienced practitioners advised that the catheter should be introduced only often enough to prevent repletion of the bladder, and a growing disapprobation of protracted maintenance of instruments was undeniable. A similar modification of former views is observable in the writings of cotemporaneous European military surgeons.4 On the other hand, there may be noted a greater confidence in the advantages of early and free perineal and scrotal incisions when the ball-track commu- nicating with the urethra is tortuous and deep and the danger of urinous infiltration and abscess imminent.5 The immediate introduction of a catheter after a shot laceration of the urethra will often present great difficulties to the field surgeon, pressed for time and unprovided with a variety of catheters. Nevertheless the attempt must be made, with the utmost caution and delicacy of manipulation, without waiting until the desire to urinate is urgent. M. Voillemier teaches6 that a medium-sized silver catheter is the best for the purpose, and the pocket-case always affords such an instrument. A full-sized flexible catheter, always at hand in the hospital knapsacks or field-companions, is the instrument preferred by most of our surgeons, and approved by M. Legouest.7 If the operator is foiled, attempts may be repeated with small flexible catheters; and if even a filiform instrument can be inserted, it may be used as a conductor (Fig. 303) for an instru- ment of larger calibre. Sometimes the difficulty of introducing even the smallest instru- ment is invincible, and then it is imprudent to incur the hazard of making false passages by insisting on catheterization. If there is retention of urine, and interference is imperative, 1 LARREY (D. J.) (Mim. de Chir. Mil., 1812, T. II, p. 1G4); LEGOUEST (Chir. d'Armie, 1872, p. 434); GUTHRIE (Lect, etc., 1847, Conclusion 18; Commentaries, 1855, 5th ed., p. 614); Tripler (Handbook, etc., 1861, p. 87); CHISOLM (Man. of Mil. Surg., 1864, p. 350); MATTHEW (Hist. Brit. Army in Crimea, Vol. II, p. 334); BECK (Chir. der Schussverletz., 1872, S. 566). 2Hennen (Princ. of Mil. Surg., 3d ed., 1829, p. 450) remarks: "Wounds of a most distressing nature, but fortunately not very common, occur in the perinseum, and in the organs of generation. In the first class, the elastic gum catheter is of the utmost assistance to us. In the few cases which I have met with a perfect cure was effected by its employment, together with that of small adhesive straps to bring the lips of the urethra together, and light easy dressings, particularly finely scraped dry lint, without the aid of any scarifications whatever; the latter application, with an occasional emollient poultice, has generally brought the wounds of the genitals to a healthy state." 3 THOMPSON (J.) (Report of Observations, etc., after the Battle of Waterloo, 1816, p. Ill) remarks: "We saw one case at Brussels, and another at Antwerp, in which a ball had carried away a considerable portion ofthe inferior surface ofthe urethra, with a portion, in one ofthe cases, of the anterior part of the scrotum. In both instances catheters were introduced, by which the urine was discharged, and the granulations forming on the edges of the wounds very properly drawn together by means of adhesive straps placed over these catheters." 4 See notes on pages 352, 356, and 373. STROMEYER (L.) (Maximen der Kriegsheilkunst, 1855, S. 662) observes: "Open injuries of the urethra from shot wounds heal readily, as I have several times witnessed, without leaving a fistule or requiring the maintenance of a catheter." Treating of ruptures of the urethra, Mr. J. BlRKETT (Holmes's System, etc., 1870, Vol. II, p. 727) says: "A catheter should not be secured in the bladder, for when this is done the urine may ooze along the canal, by the side of the instrument, and become extravasated into the tissues about the site of the laceration. Besides, the presence of the instrument stretches the urethra and tends to keep the divided tissues apart." 6 The treatment of urinous infiltration from shot injury of the urethra by free perineal and scrotal incisions has been approved and practised equally by the older and more modern military surgeons. Thus, BlLGUER (J. U.) (Chir. Wahrnehmungen, 1763, S. 356) cites the case of Ratsch, wounded at the battle of Prague, May 6, 1057; the ball, entering at the root of the penis, perforated the urethra and the corpora cavernosa. No urine passed for four days. The penis and scrotum were swollen and highly inflamed; urine passed through the wound on the fourth day; the scrotum was opened and a copious collection of urine and pus was allowed to escape; recovery. STROMEYER (L.) (Maximen, u. s. w., 1855, S. 663) records a case of shot laceration of the urethra observed at Hadersleben. in 1849, three days after an assault on Fridericia. The ball entered on the left side of the penis and severed the membranous portion of the urethra, dragging it from its attachments. Dr. STROMEYER made a free and deep incision to the urethra, relieving tlie infiltration, found the ball, and introduced a catheter through the vesical portion of the urethra. The patient died, fifteen days after the injury, of pyaemia. Dr. STROMEYER regrets that he had not seen the injury in its earlier stage and made a precise diagnosis. He would not, he says, have attempted to introduce a catheter. 'VOILLEMIER, Lesions traumatiques de I'urithre; loc. cit, p. 470. 7 Li:.;OUE.-T (L.) (Chirurgie d'Armee, 2e 6d., 1872, p. 434): "L'introduction d'une sonde laissee a demeure dans la vessie est la premiere indication qui se presente dans les solutions de continuit6 de I'urethre: elle a pour but d'empecher la retention d'urine et I'infiltration urineuse, et de prcvcnir les r6trecissements. La sonde doit etre de gomme elastiquc et d'un calibre aussi considerable que possible." SECT. III.] OPERATIONS ON TIIE URETHRA. 381 it is safer to have recourse to perineal section, or to puncture of the bladder, expedients to be hereafter considered. Occasionally, when it is impracticable to pass a catheter by the meatus, because of the entanglement of the extremity of the instrument in the lacerated canal, it is feasible to gain the bladder through the vesical portion of the urethra. This accomplished, the free end of the catheter may be engaged in the anterior portion of the urethra, through the wound, and carried forward through the meatus, and the continuity of the canal may thus be re-established. If it is possible to introduce a catheter2 before the bladder voluntarily or involuntarily voids itself, the dangers of inflammatory swelling and of urinary infiltration will be largely diminished.3 Unhap- pily, in war-surgery, this salutary prophylactic measure is seldom practi- cable. If the bladder happens to be distended when the urethra is torn by a ball,4 the soldier will yield to the desire to micturate, and the urine will pass through the lacerated wound. Confidence is no longer reposed in the general and local blood-letting, by which the older surgeons sought to avert the inflammatory complications incident to this form of injury, and it is the more necessary to insist on such other means of moderating inflammation as are likejy to be effective. Absolute rest should be con- joined with a severely restricted diet. Diluent mucilaginous drink should be given in moderation; for it is unwise to vex the urinary passages by inordinate secretion. Opium and camphor by the mouth or in suppository are of great advantage in allaying irritation. The bowels should be kept soluble by saline laxatives. Warm baths are grateful and useful. Assuming that a catheter has been passed to the bladder, the question arises of the duration of its retention, and this must be determined by the attendant circumstances. If the laceration of the urethra is ante-scrotal, it will be prudent to let a full-sized gum-elastic catheter remain in for twenty-four hours, and 'Gaujot et Spili-Mann, Arsenal de la Chirurgie Contemporaine, Paris, 1872, T. II, p. 693, Fig. 1367. Compare also the figure in M. MAISOX- NEUVE's article in the Gazette des Hopitaux, 1852, p. 311. 2To the circumstances under consideration the emphatic language of Civiale is especially applicable: "Le cathet6risme est une operation importante, paisqu'elle decide parfois de la vie des tnalades. " * Les difficultes dont elle est entouree, sont aussi s6rieuses que les accidents qu'elle peut produire." 3"As far as precept without practice can impart instruction on this subject, the inexperienced practitioner will find M. Voillemier a reliable guide. Treating of traumatic lesions of the urethra, the eminent surgeon of Hotel-Dicu says (op. cit, p. 470 ): 'The surgeon should sound the patient as early as possible, without waiting until the latter wishes to urinate. He will select a medium-sized silver catheter, which he can direct more surely than a flexible instrument. Having introduced it into the meatus, he will push it forward very gently, having care to make its extremity follow the upper wall of the canal, which is generally preserved even in the midst of the most serious lacerations. If he reaches the bladder safely, he may immediately replace the metallic catheter by another of caoutchouc, which the patient will more easily tolerate. But, if the catheterization has been troublesome, he will refrain from this change, for he may encounter new obstacles, and be less fortunate than in his first attempt. He will leave in the silver catheter for a day or two, to give the tissues time to mould themselves, as it were, upon it, and will then only attempt to replace it by a flexible catheter. But, however experienced one may be in practising catheterization, he cannot always introduce a silver catheter, and will he compelled to resort to flexible catheters of different forms and sizes, and trust a little to chance. After many gropings, one often succeeds in passing a very small instrument; this is already something gained. It must be left in place, its free extremity scrupulously kept open. As it does not fill the canal, and is of too small calibre to empty the bladder rapidly, the urine, if the patient has an urgent desire to urinate, will pass without it, and reach the wound. This accident is very common. A large catheter maintained in the bladder is the best means of preventing it; but this does not always obviate the difficulty; sometimes it even promotes it by irritating tho bladder and inducing contraction. When there is this vesical intolerance, a very soft catheter, which has had a proper curve given it, should be chosen, and care should be taken to insert it only just beyond the neck of the bladder, and to leave its free extremity unplugged.'" "The diversity of opinion expressed by writers on military surgery respecting the average condition of the soldier's stomach in battle (see notes to pp. 41, 57) as regards repletion or vacuity, is paralleled by their antagonistic dogmas in relation to the average state of the bladder. LARREY (D. J.) (Mim. de chir. mil. ct camp., 1817, T. IV, p. 285) behoved that the bladder would generally be found distended in action : "La chaleur de l'action ct sa dnree les detournent du soin de verser leur urine; ce liquide s'aocumule dans la vessi qui offrc alors, on remplissant lc bassin, une telle surface que lu cause vuln6rante ne peut entrer dans cette boite osseuse sans toucher ou entamcr ce viscere." Dr. CHISOLM (A Manual of Mil. Surg., 1SG4, p. 352) observes: "Fortunate it is for men going into battle that the excitement under which the troops are at that time laboring causes a continual dropping from the ranks to urinate, so that rarely does a soldier go into battle with his bladder full. In this physiological fact lies the safety of many a man, as the contracted bladder, concealed behind the pubis, in the cavity of the pelvis, often escapes injury from the passage of a ball, which, were the organ distended, would assuredly traverse it." Dr. Chisolm appears to forgot that, under the circumstances he depicts, the immunity of the bladder, the ball pursuing the same course, is purchased at the expense of a perforation of the peritoneal cavity. Fig. 303.—Improvised catheterization on a con- ductor. [After Gaujot et Spillmann.1! J. 182 INJURIES OF THE PELVIS. [CHAP. vn. then introduce such a catheter as can be passed with the least inconvenience, whenever the patient desires to urinate, until cicatrization has so far progressed that the contact of the urine is no longer irritating. The reintroduction of an instrument can rarely present serious difficulty when the laceration is in the penile portion of the canal; the irritation excited by the permanent retention of an instrument can here be safely avoided. When a shot wound involves the bulbous or membranous portions of the urethra, the problem is more complex. The dangers from protracted retention of a catheter and the difficulty of replacing it when withdrawn are alike augmented. It is generally inculcated that, in such cases, a catheter should be left in, unless its presence induces intolerable irritation, until cicatrization has fairly commenced. Yet this precept is maintained less positively than formerly,1 and is rejected by many. There is a middle course, that has not been sufficiently tested experimentally to decide on its value: It is possible to withdraw the catheter, as soon as it occasions discomfort, over a long filiform conductor,2 which might remain3 without 1 Sir Benjamin C. BRODIE, speaking of perineal fistules (Lectures on the Diseases of the Urinary Organs—Works, 1865, Vol. II, p. 441), says: "I formerly have advised the patient never to void his urine without the aid of the catheter, but 1 am now inclined to believe that the irritation thus kept up tends, on the whole, to delay rather than to expedite the cure. At other times I have kept the patient in bed for some weeks, with an elastic gum catheter constantly in the urethra and bladder; but I cannot say that, with my present experience, I have much more faith in this mode of treat- ment than in that which I have just mentioned. After a few days, the urine generally begins to flow by the side of the catheter, which docs not, therefore, answer the purpose for which it was introduced, of preventing its escape by the sinus. Then in many cases the catheter has the effect of a seton, causing an abundant suppuration of the urethra, and the purulent discharge, finding its way into the sinus, prevents it from closing as much as it would bo prevented by the contact of the urine." 2 There is rarely difficulty, as I have found by repeated experiment, when either a silver or gum catheter is introduced into the bladder, in inserting through one of the eyes a small whalebone guide-bougie, with a spiral bulbous tip, cr a filiform gum conductor, its conical tip abruptly bent. By screwing or tying the proximal end of such a guide to a straight stylet, the catheter may be withdrawn over it, leaving a guide to the bladder. 3 The use of cylindrical tubes for the relief of retention, or for exploring the bladder through the urethra, dates from remote antiquity. Thus, HIPPOCRATES (jrepl vovauiv I, 6, ed. LITTRE, T. VI, p. 150) counts a phj'sician unskilful who cannot sound the bladder: "y.no' e; Kvartv avkio-Kov KaOtivra SvvaaQai KadUvat." Termed by the Greeks catheters (KaOiraxv, I thrust in), " Grxci catheterem rocant," Galen (De locis affect, Lib. I, Cap. I, ed. Basileas, 1561, p. 5), they were designated by CELSUS (Lib. VII, Cap. 26, De urinie reddendx dijjicultate: "Ergo apneas Astute fiunte," etc.) and his contemporaries, fistulae, and were made of copper or brass, of three sizes for men, of fifteen, twelve, and nine finger-breadths in length, and of two sizes for women, of nine and six finger-breadths, respectively. Catheterism is mentioned by iETll'S (Tetrabiblos, ed. Lugduni, 1549, p. 601) and other Greeks; but none described the operation fully except Paulus ..Egineta (Lib. VI, Sect. LIX, Syd. Soc. ed., Vol. II, p. 351). By the Arabians, the instrument was called syringa or algalie. The latter term has been borrowed by the French, who apply this name and the synonyme sonde to the instrument denominated catheter by English speaking peoples, and use the term catheter for the instruments we term staffs and sounds. Antyllus (A. D. 350, cited by OlilliASIUS) and Haly Abbas (A. D. 9D4, Pract. LIX, Cap. 45, De min- gendi arte cum cathatiro, ed. Lugduni, 1523) briefly mention catheterism. Alhucasis (Chi- rurgia, Lib. II, Cap. LIX, ed. Ciianning. p. 279) commends a catheter of silver: "ex argenteo conficitur; sit vero tenue, glabrum, concavum uti pennae avis cannula." He follows the descrip- tion of Paulus as to its use. and also figures an instrument for injecting the bladder, a silver tube with the bladder of a ram attached. ItHAZF.S (A. D. 923, in his Continent, ed. Venctiis, 1506, Lib. X, p. 220) gives a fuller account of catheterism than any of the mediaeval writers. He insists on the importance of having a smooth rounded vesical extremity to the instrument, a flexible stylet, and small lateral perforations: "quum caput ipsius cannulas est laave et planum, hujus foramina in lateribus parva et multa, in quibus non poterit ingredi sanguis coagulatus neque sanies penitus ex parvitate ipsorum: et eo ut sunt multa foramina, si opilatur unum, urina ingreditur per aliud: et omnino ingreditur per aliquod ipsorum. Et si ei fuerit difficultas ex aliqua particula saniei coadunata, in cannula instrumenti habeas acum ingredientem in ipsa cannula," etc. Riiazics recommends also (Lib. X, Cap. 3, p. 220), in some cases, a flexible leaden catheter of his invention: "instrumentum urinativum confectum de plumbo ut torqueatur et involvatur ad foramen: quum evitandus est dolor." AviCENNA (A. D. 978-103(5) first mentions, as known before his time (Canon, Lib. Ill, Fen. XIX, Tract. II, Cap. 9, ed. Venet , 1564, p. 879), flexible catheters, composed of animal or vegetable tissues: "Syringarum melior est ilia quae conficitur ex levioribus corporibus et magis susceptibilibus flexionis." Though the idea of flexible instruments was not entirely abandoned, they were little used for several succeeding centuries. LASSUS (De la Midecine Opiratoire, Paris, An III (1794), T. I, p. 439, ct l'l. Ill, Fig. 1) saw at the Museum at Portici a medium-sized (mm. 4) copper catheter, with a double curve, like an italic xy^'. This instrument was taken from the ruins of Pompeii, and therefore dated A. D. 79 at least. I had copied the figure given of it by MM. Voillemier and Gau.iot (Fig. 304, a) before meeting with the drawing of Lassus, which represents tho beak with a single eye on the concavity, larger and more oval than the double lateral foramina now in vogue. Many other catheters were subsequently found in the ruins of Pompeii, and are now preserved in the Museo Borbonico, in Naples. They are of bronze, varying ia calibre and curvature; several are rectilinear. As anatomical knowledge advanced, surgeons essayed to adapt instruments to the curvature of the urethra at different ages, and catheters were designed in great variety. There were innumerable modifications in form and calibre, and iu the fenes- tration ofthe vesical extremity. Franco (Traiti des hernies, 1561. p. 113) and A.MUKOISE Fig. 304 —Patterns of metallic catheters: a, catheter found at Pompeii; b, Geiy's model; c, Heurteloup's model. SF.OT. III.] . OPERATIONS ON THE URETHRA. 383 causing irritation, to serve as a guide for the replacement of a catheter. If the lacerated urethra will tolerate the presence of such a guide, a soft rubber catheter, open at the vesical end, may be passed over it as often as is necessary to relieve the bladder; and the dangers of infiltration on the one hand, and, on the other hand, of irritation from protracted retention of a catheter, may be avoided. The gravity of the disorders consequent on urinary infiltration is such that the aid the catheter may afford in obviating them will be only relinquished with extreme reluctance. Thus far it has been assumed that a catheter has been introduced in the first instance ; but it cannot be denied that, in many shot lacerations of the urethra, the surgeon may fail to introduce a catheter, not only in his hasty attempts on the field, but under more favor- able circumstances, when provided with a variety of instruments and enabled leisurely and perseveringly to employ the most dexterous manipulation. In a very valuable paper on the treatment of contusions of the perineum attended with lacerations of the urethra, printed, in 1870, in the tenth volume of the New York Medical Journal, Dr. Stephen Rogers teaches that the passage of a catheter is impossible in cases of transverse lacerations of the urethra, but that longitudinal lacerations do not oppose an equally insurmountable Pare (loc. cit, T. II, p. 464) figure several very similar to forms now in use ; others with an orifice at the vesical extremity, which can bo closed by a bulbous stylet; others again with a single eye on the concavity, or with double lateral eyes on either side. Tolet (Traiti de la lithot, 5th ed., 1708, p. 113) approvingly describes a semi-circular catheter used by MARECHAL, identical with that reproduced in the present century by RECAMIER as a novelty. J. L. Petit (CEuvres computes, ed. Prevost, 1844, p. 779) invented an S-shapcd catheter, for use when a protracted retention of an instrument was necessary. It resembles that which Dr. Squire has latterly recommended (FlG. 252, p. 302), and was much used prior to the invention of gum-elastic catheters. Petit also used an S-shaped catheter without eyes, open at the vesical end, but provided with an obturator, a pyriform button at the end of a stylet. GARENGEOT complains that it was used everywhere in Europe except in the country of its inventor Heister (Institutiones chir., Amstelaed., 1739, T. II, p. 924, PI. XXIX, Figs. 3 et 4) used a catheter (Fig. 306) which bent backward before bending upward, a curve formerly termed pause or paunch, and figured in 1 (i81 by Tolet, very suggestive of the catheters not long since extolled by M. BENIQUE (De la ritent d'urine et d'une nouv. mithode pour intro- duire les bougies et les sondes dans la vessie, Paris, 1838). All of these catheters, save the leaden instrument of Eiiazes, were rigid, and necessarily exercised injurious pressure at some point, if long retained in the urethra. To obviate this difficulty, VAN Helmont (Opusc. med. inaudita, Colon, 1C44. Liber de Lithiasi, Cap. VII, p. 703) devised catheters of chamois leather, varnished with glue, and provided with a whalebone bougie. Richard Wiseman (Sew. Chir. Treatises, 2d ed., 1692, Vol. II, pp. 427-8) assisted Van Helmont in a difficult case, in which this instrument was used, and describes the same. Troja (Mem. sur la construzione dei cateteri flessibili, p. 2C3) substituted dog-skin covered with layers of oil of copal, polished with pumice-stone. Fahricius (ab Aquapendeute) had catheters of softened horn prepared ("at ego imaginatus sum magis flexibile corpus, et illam ex cornu paravi."—Opera chirurg., Lugduni, 1723, p. 537). These instruments were liable to speedy deterioration, especially by impregnation with calcareous salts. Solinofn (Mannale Operation der Chirurgie, etc., Amsterdam, 1(184, p. 244) designed an ingenious catheter fashioned at the vesical extremity like the ordinary catheter; but composed, from an inch from this point, of silver riband rolled spirally into a cylinder. RONCALLI (Historic morborum, Brixiie, 1741, fol., p. 59) improved this instrument, which he named the vermicular catheter, by narrowing the silver riband and covering the cylinder with waxed silk, and thus obtaining greater flexibility and smoothness. In 1708, MACQ.IER (Mem. de V Acad, des Sci., p. 209), having dissolved caoutchouc in ether, proposed to make catheters of this substance, and the jeweller Bernard carried the idea into execution. For a time he made catheters and bougies of spiral wire covered with caout- chouc ; but soon substituted for the metallic thread a frame-work of linen or silk. This was a step in advance, yet Bernard's catheters were hard and friable, and not infre- quently left a fragment in the urinary passage. Bernard sought to avoid this danger by reducing the proportion of caoutchouc. TROJA. TIIEDEN (Neue Bemerkungen und Erfahrungen, u. s. w., 1782, B. II, S. 150), and other ingenious surgeons had prepared, from caoutchouc, catheters far superior to any previously known. Nowadays, that sub- stance is no longer an ingredient in the composition of so-called gum-elastic catheters; the coating of the silken-thread frame consists of linseed oil associated in various propor- tions with resins of copal or of turpentine. The complicated processes of manufacture are clearly and minutely detailed by Vidal (Path, ext, T. IV, p. CC4). MM. FEBUltlER and LassERE have brought the fabrication of these catheters to great perfection. Gutta- percha, suggested by a physician of Singapore and commended by Dr. H. J. BIGELOW (Boston Med. and Surg. Jour., 1849, Vol. XL, p. 9), and balata (an article with properties intermediate between caoutchouc and gutta-percha, prepared from the milky juice of the YlG. 306.__HeiSTER'8 Sapota Muelleri Zeitschr. des allg. ozsterr. Apoth.- Ver., 1869, S. 525, from Sitzungsber. der catheter. J. kais. Acad, der Wiss., LIX), enjoyed a fleeting reputation as material for catheters. Instru- ments composed of them were hard and frangible, in short, inferior and dangerous. In the last few years, caoutchouc has again come in vogue, in the shape of vulcanized rubber. Catheters of this substance are far softer and more pliable than those of gum-elastic. They are very useful for persons Fig. 305 —Curved gum-elastic catheters: a, conical; b, olivary; c, cylindrical. 384 INJURIES OF THE PELVIS. [CHAP. VII. obstacle, and that all lacerations of the urethra are therefore not impassable, and that " it must be accepted as the proper practice to determine, at the earliest moment after the injury, whether the sound can be readily, or with any moderate effort, passed into the bladder." Dr. Rogers cites, in confirmation of his view, Sir Henry Thompson's remark,1 that when retention occurs from laceration of the urethra " instruments can rarely be used to relieve it, without the hazard of inflicting some additional laceration." The opinion of these eminent authorities, that a catheter can rarely pass through a lacerated urethra except by accident, while meriting the most thoughtful consideration, is yet not fully sustained by the experience acquired in shot lacerations. In a considerable proportion of these cases (in which, it is true, the extent of the lesions was not reported, and, perhaps, not ascertained, with precision) instruments were carried through the lacerated canal, apparently with gentleness, and the bladder was reached, without having recourse to forced catheterization. The passage of a catheter, with a view of averting infiltration,2 should, who have to catheterize themselves, and in cases where a catheter is to be worn for several days ; for they are retained with less inconvenience than harder and less flexible instruments, and long resist the action of the urine. These great merits are accompanied by disadvantages. The walls have to be very thick (Fig. 307) that they may not collapse on the slightest pressure and obliterate the calibre of the tube. Consequently the calibre of the tube and the eyes, or eye, for there is usually only one, must be com- ^—-——j. , . ,,, ......................,.,, ,.,w-,v.wffl^, paratively small, and obstruction by blood or mucus is easy. Such E'-^^^wn^^m -^f- j catheters are too supple to overcome the least obstacle. If a stylet is (- - :~-=jgffi"'"""'" • ;k■■■■_■ J used to give firmness, it is necessary to increase the thickness of the wall of the cul-de-sac, lest it be perforated, and then the stvlet no Fig 307.-Longitudinal section of thej vesi- j h th end of the cathetcr bnt is prcce(ied by a flexible cal extremity- ot a vulcanized rubber catheter & . 7£ mm. in diameter. appendage, deviated by the slightest obstruction, and not subject to tho surgeon's direction.—VOILLEMIER. Nevertheless, the occasions on which these catheters will be found very useful are numerous. Patients wearing them can walk about without inconve- nience and with very slight risk of inducing ulceration in the urethra; and their comparative inalterability is of great importance. The importance of the curvatures given to catheters to adapt them to the urethra at different ages and under varied diseased conditions, has been exaggerated and unduly depreciated by interested partisans. Gely, of Nantes (Moniteur des Hopitaux, 1854, T. II), Amussat (Lecons sur les ritentions d'urine, etc., 1832), Heurteloup (Fig. 304, c), and others, have made careful anatomical investigations concerning the normal curvature of the male urethra at different ages, with a view of determining the proper corresponding curve. DESCHAMl'S (Traiti hist et dogmat. de la Taille, 1826, T. I, p. 211) unjustly derided such refinements, alleging that there was little variation in the normal curvature of the urethra. The advantages of varying the form and size of catheters are now duly appreciated. For ordinary purposes, cylindrical instruments are used with a gentle curve, like that of the old Roman instrument Fig. 308.—Catheter gauge. (Fig. 304, a) or the catheters used by Desault and BOYER. In old persons, it is desirable to have a more abrupt curve. Gely commends a curvature of one-third of a circle of 12 centimetres (Fig. 304, b. The artist has failed to continue the curve quite to the beak, as should be done); HEURTELOUP (FIG. 304, c) insisted on a curve of one-fourth of a circle of 8 centimetres ; Lerov considered the fourth of a circle of 12 centimetres the proper curve. In cases of enlarged prostate, and for purposes of exploration, the abrupt curve proposed by LEROY, or the elbow-like (coudie) bend suggested by Mercier, are of great value. The form of the vesical extremity of the catheter is also advantageously varied. Ordinarily, the catheter is cylindrical, with two oval lateral eyes near the beak (Fig. 305, c); but when the canal is obstructed, the instrument may have a conical or olivary termination (FIG. 305, a, b) advantageously. For special purposes, catheters are also made open at the vesical extremity, or grooved or tunnelled, to admit of being used with a conductor. Catheterization upon a conductor will doubtless bo more generally appreciated as a resource in urethral lacerations. BUSCH (W.) (Notiz uber cine einfache Vorrichtung, welche den Wechsel des Katheters bei Harnrbhrenwunden im Damme erleichtert, in Laxgemieck'S Archiv fiir Klin. Chir., 1863, B. IV, S. 36) laid before the Association of Surgeons and Scientists at Bonn, in the fall of 1857, an apparatus similar, but, as he claims, superior to that described by JI. DEMARQUAY in VUnion mid.. Mars 4, 1858, p. 102. M. Demarquay remarks: " Comme il faut changer les sondes tous les huit ou dix jours, il importe de se servir de sondes ouvertes aux leur extremites, afin de fair penelrcr une bougie dans l'interieur de la vessie. Pour rendre cette op6ration plus facile, j'ai fait construire des bougies en baleine, comme cclles employees generale- ment par M. Guyon ; seulement je leur donnais plus de longeur. Une fois qu'une de ces bougies avait p6n6tre a travers la sonde dans la vessie, j'otais cette deraieTe toute doucement, et en la fendant de la partie superficielle vers la partie profonde." Dr. Busch continues: "My catheters have also no openings at the side, but are open at each extremity. At the vesical end, the catheter is somewhat conical, and has an orifice a little more than a line in diameter. A silver stylet is fitted as closely to the catheter as the stylet of a trocar to its canula. This strong rod should be double the length of the cathetcr, with a mark just visible at the free extremity of the catheter when the stylet is inserted through the entire length of the latter. When it is desired to change the catheter, the long stylet is inserted until the mark corresponds with the edge of the free end of the catheter, indicating that the stylet has entered the vesical orifice. The catheter is then withdrawn over the rod, more readily than by the tedious process involved by Demarquay's apparatus. The vesical portion of the catheter being slightly conical, it hugs the stylet closely, and reaches the bladder without detriment to the wounded urethra. The new catheter being placed, the stylet is withdrawn." Catheters are variously numbered, according to their calibre, by the American, English, and several French scales; indeed, almost every specialist, now-a-days, has his special gauge. It is, therefore, well to have a measure available for any scale. FIGURE 308 represents a convenient instrument, purchased from Mr. Tiemann for the Museum, under the barbarous name of " pupillometer." No doubt, korameter (nopy, cora, pupilla) would be a less hybrid appellation. The instrument, however designated, is as useful for the measurement of catheters as of pupils. 1 THOMPSON (H.), The Pathologic and Treatment of Stricture ofthe Urethra and Urinary Fistulse, 2d ed., 1858, p. 121. .'VOILLEMIER (Traiti des mal. des voies urinaires, 1868, pp. 475, 476) observes: " La gravite des plaies contuses de I'urethre git surtout dans I'infiltration d'urine. La premiere indication th6rapeutique a remplir doit done etre de prevenir cet accident en placant une sonde ii demeure dans la vessie." * * " Dans les cas, les plus simples en apparence, de plaie contuse de I'urethre, le catheterisme est encore une operation delicate. L'irregu- larite de la dechirure, le gonflement inflammatoire qui ne manque pas d'arriver quelques heures apres l'accident, la compression du canal par le sang 6panch6 dans les tissus voisins, sont autant d'obstacles qu'il n'est pas toujours facile de surmonter. Aussi faut-il prendre les plus grandes precautions si l'on veut 6viter de faire une fausse route, ou tout au moins d'agrandir la plaie." SF.CT. III.l OPERATIONS ON THE URETHRA. 385 therefore, always be the first aim of the surgeon in cases of laceration. Whether the catheter is introduced or not, it is unquestioned that, upon the first sign of the supervention of urinary infiltration, the importance of deep incisions is paramount. When it has proved impracticable to prevent the mischief, it is only by this means that its extension can be arrested. Cases 1013, 1082,1083, among others, illustrate the happy effects of opportune incisions.1 In shot lacerations of the urethra, the great variety of direction of tho ball- tracks will indicate modifica- tions in the seat and direction of the incisions. Sometimes thev may be confined to the perineum; sometimes they must extend to the scrotum and penw. and elsewhere. The surgeon must make sure that the decomposing Urine is UOwhere FIG' ™--^™*«^ «"*-™*«l '— [Reduced one-half from the author's drawing.*] confined in the cellular tissue, and should so place the incisions as to make the urethral laceration communicate with the surface as directly as practicable. The urine will then probably escape freely through the torn urethra, and no further immediate local treatment will be requisite. Should there be retention, however, it will be necessary either to guide a catheter through the lacerated urethra, or to puncture the bladder. There is variance of opinion as to the best course to adopt. Surgeon M. Storrs, 8th Connecticut, in such an emergency (Case 1072), preferred vesical puncture by the rectum.3 . This is a comparatively safe operation; but the supra-pubic puncture is more in favor, especially since the aspirating trocars have come into general use. From this cursory consideration of the treatment of recent lacerations of the urethra, it is necessary to pass to an examination of the measures required in the management of traumatic stricture, an almost uniform complication of cases that do not terminate fatally, 1 Regarding the importance of free perineal incisions in these cases, consult Dr. Stephen Rogers's article, already cited (New York Medical Journal, 1870, Vol. X, p. 370), the references to the opinions of SI. Savory and Drs. PlROGOFF, Beck, and Stromeyer, on pages 356, 373, 380, supra; and also to Charles Bell (A Treatise on the Diseases of the Urethra, etc., p. 305), to BROD1E ( Works, Hawkins's ed., I860, Vol. II, p. 421), to Guturie (Anat. and Dis. of Vie Urinary and Sexual Org., Am. ed., p. 127), and a valuable paper by Dr. W. Hunt (Traumatic Rupture of the Urethra, recent and chronic, in The Med. Times, Phila., 1870-71, Vol. I, p. 173), where eight cases of laceration are detailed, with judicious comments. 2Flur.vxt'S paper and plate may be found in POUTEAU's Milanges de Chirurgie, Lyons, 1760 (Nouvelle Mithode de pratiquer la Ponction a la Vessie, p. 503, and PI. I, Fig. 1). Lii BLANC (CEuvres Chirurgicales, 1779, T. I, p. 106) reproduces tbe description of the operation, with a different figure of the instrument. 3 The operation for the relief of the retention by recto-vesical puncture was devised and practised by Flurant, at the Charity Hospital, at Lyons, in 1750. He successfully operated on a man of sixty-two years, with impassable stricture. In 1752, he again operated, and the patient succumbed from causes foreign to the operation. In 1757, he performed a thoroughly successful vesical puncture by the rectum, in the presence of his colleague, CHARMETTON (Sahatied, Mid. opirat, ed. 1822. T. II, p. 375). Flurant used a straight trocar in his first two operations; but then had made the instrument figured in the text (FIG. 309), somewhat after the model of the trocar fur supra-pubic puncture of Frore C6me. The operation appears not to have been warmly advocated, until a century later. Le Blanc (CEuvres, etc., 1779, 'I'. I, p. 112) relates that in a desperate case of retention, in a man of sixty-three, with hiccough, the belly tense as a drum, the extremities cold, he punctured tho'rectum, "avec lo trois-quarts de M. Flurant * * en suivant les precedes presents par lui * * et le malade fut rappel6 de la mort a la vie." In the Philosophical Transactions, Vol. LXVI, 177G, Part I, p. 578, Dr. Robert Hamilton, of Edinburgh, in a letter to Sir John 1'ringle. gives an "account of a suppression of urine cured by a puncture made in the bladder through tho anus." Reid (An Enquiry into the Merits of the Operations used in obstinate Suppressions of Urine, London, 1778) and Klosse (De paracentesi vesicx urin.per intest rectum, Jena, 1791) advocated this method of vesical puncture. Frank (Decurandis homin. morb., Lib. VI, p. 542) and ScsMMERING (S. Til.) (Uber die todtlichen Krankheiten der Harnblase und Harnrohre, 1822) relate instances in which skilful surgeons attempted the operation, and it was found after death thatthe trocars had perforated the urethra without entering the bladder. These skilful surgeons must have been exceptionally awkward on the occasions referred to; for, with ordinary care, this operation, in the words of its modern advocate, Mr. Edward Cock, of Guy's Hospital, is "safe, easy of accomplishment, and without danger as to its consequences." The evidence has been very fully presented by Mr. COCKin his papers in the Medico-Chirurgical Transactions, 1852, Vol. XXXV, p. 153, and in Guy's Hospital Reports, 1866, p. 2J7. The references to the operation by Bhodie (Lect on Dis. of the Urinary Organs, London, 1849); by II. THOMPSON (Path, and Treatment of Strict, 1858, p. 333); by Charlton (Med. Times and Gaz., 1801, Vol. I, p. 27'i); hy Mr. T. Bryant (Guy's Hosp. Rep., 1862, 3d ser., Vol. VIII, p. 201, and Practice of Surgery, 1872, p. 592); and by M. PniLU'l'ART (Gaz. des Hop., I860, p. 102), will reward consultation. The objections urged against the operation are the alleged liability to suppuration between the bladder and rectum, which is unproved,—the probability of persistence of fistulous communication, which experience amply disproves,—and the possibility of injuring the seminal vesicles, with consequent trouble with the testes, a very rare accident. The operation, though seldom required, affords the inexperienced practitioner a much safer means of relieving the bladder than perineal incisions or punctures. :>sr IXJURTES OF THE PELVIC [chap. vu. and to the treatment of iistulos. As it is desired to adduce, at this point, the information furnished by the reports in regard to the treatment of ordinary organic strictures also, a digression must be allowed for that purpose, and then the principal methods of operative interference in stricture, by dilatation or incision, will be examined. Organic Stricture.—The monthly reports of sickness and mortality of tlie army, for the period of the War, recorded an aggregate of two thousand five hundred and eighty-one cases of strictures of the urethra, with eight deaths, and two hundred and forty-seven discharges for physical disability.1 It is impracticable to deter- mine whether examples of traumatic stricture were comprised in these numerical returns. The aggregates of mortality and of discharges would indicate that they were not included in any considerable proportion. Apart from mechanical injuries, and from rare malformations and malignant affec- tions, the causes of stricture are inflammation and syphilis. About one hundred thousand cases of gonorrhoea and eighty thousand cases of syphilis were returned on the sick reports3 for the period under consideration. Details of cases of organic4 stricture consequent on gonorrhoea or syphilis were rarely reported. The three following abstracts, and three that will be found with the cases of external perineal urethrotomy, are among the few exceptions: Case 1089.—Private P. Slater, Co. B, 7th U. S. C. T., was admitted to Corps d'Afrique Hospital, January 29, 1836, with syphilis. Acting Assistant Surgeon C. Lodge reported that, "on admission, the patient was very low, with cold sweats and hiccough; there was a tumor in the hypogaster, and the penis was swollen and of a purplish color, and there was phymosis, with incipient gangrene of the prepuce and glans. A director was introduced and the prepuce freely incised. A catheter passed into the urethra encoun- tered a false passage, made by previous attempts at catheterization. This being avoided, the catheter was forced through the stricture, free bleeding taking place, and a large quantity of ammoniacal urine was drawn off. The penis was enveloped in compresses wet with zinc lotion, and subsequently with dilute nitric acid lotion and charcoal poultices; a generous diet was ordered, with anodynes. For a few days the patient was semi-delirious and almost collapsed, his urine dribbling away involuntarily. Some time after admission, an abscess formed in the groin and opened spontaneously, leaving a large sloughing sore, from which, the man insisted, urine was discharged. Another abscess fonned in the perineum, from which urine unmistakably issued, yet still it passed in a small stream by the natural channel. Gangrene attacked one foot. A line of demarcation formed above the ankle, and the superficial parts above sloughed. He now contracted discrete variola. In April he was improving, the inguinal sores being healed and the ulcerated surface on the foot being nearly well. He lost by sloughing two inches of the penis. His urine passes mainly by the natural channel, but there is a fistulous opening from .the urethra at the seat of stricture, and the patient has iritis. He will probably have to undergo urethrotomy for his stricture at some future time. He was transferred, convalescent, June 25, 1836." This convalescent was sent to Sedgwick Hospital, Greenville, wliere Assistant Surgeon A. Hartsuff, U. S. A., reported that "he died, July 7, 1833, from the sequelae of small-pox." FIG.310.-BOYERS conical catheter." [From M. ClIAR- K1ERE S pattern.] J. 1 See First Medical Volume, Taisles C, p. 636, CI, p. C46, CXI, p. 710, CXII, p. 71G. 2,438 cases of stricture and 7 deaths among white, and 14:1 cases and 1 death among colored troops ; 241 discharges from white, and 6 from colored troops. 2 BOYER, Traiti des mal. chir., T. IX, p. 238. »First Medical Volume, loc. cit, pp. C36, 710: Gonorrhoea, white troops 95,833, colored 7,060= 102,893; Syphilis, white troops 73.382, colored G,207 = 79,589. Should it be assumed that the 2,C81 cases cf stricture were derived from these 182,482 venereal cases, the ratio would be nearly 1 in 75; but such an assumption would require numerous corrections. 4 It is often stated that the ancients were ignorant of strictures, and that this affection was unobserved until the prevalence of syphilis in the middle age; but Nauciie, in his excellent inaugural dissertation (Nouvelles recherches sur la ritention d'urine par ritricisscment organique de V uretre, Paris. An IX, 18U0), proves that, although Paulus tEgineta and Alijuoasis, who, of the ancients, treated most fully of urinary disorders, scarcely alluded to stricture, the disease was recognized and described by many of the old writers, as: Hiitocrates (Aph., Lib. IV, aph. 80): Alexander of Ti;.\LLI> (Op. omn., 15a>il. 1733, Lib. Ill, Cap. XXXVIII, p. 251); JF.tius (Tetrabiblos, Serin. Ill, Cap. XXI, p. C86); Pliny (Dere med., Lib. XXIII, Cap. 9. e;e ); Avicenxa (Arab. med. princ, canon medicina, Venet., 1(108, Sen. XIX, Tract. II, p. 889); and especially Riiasks (Op., Venet., 1542, Lib. XXIII, 1'jI. 240). SiTLi.ixu avers (Die rationelle Behandlung der Ilarnrbliren-Stricturen, Cassel, 187J, S. 105) that Heliodorus (a surgeon of Itonie in the time of Trajan, A. D. 96, whose fragmentary works are f.mnd in VlDUS YlDIUS. COCCIIIUS, and more fully in Oriisasius—the passages, Ilepi o-vo-o-apKu>9eio-n<; ovprjflpa.*;, are in Cardinal Mai's Vatican edition, and, still better, in the edition supervised by IJAREMUKRG and IjUssemakkr, and printed by the French Government in 1862: CEuvres d'Oribase, textegrccen grandepartieinidit, collationni sur les manuscrits, traduits pour la premiere fois en francais, pp 472. 473, 474) practised urethrotomy, writing of earnosities: "Aei ovv o-koKotti toi arcvSt ttjv adpxa iKriixveiv,'' " Then it becomes necessary with a narrow and sharp stylet to cut out the llesh." It was not until the eighteenth century that the subject was investigated in monographs and systematic treatises. The following \& a partial bibliography, many papers being designedly omitted as referred to elsewhere: Pietre (Ergo urethne ai'.gustiis nocent Kaflatpen/ca, Paris, 1614); Bsxkvoli (Nuooa proposizhne intorno alia caruncula dell urethra, Firenza, 1724); Dakan (Obs. chir. de I'urethre, Irait. suivant la noucelie mithode, Paris. 1748;; Le Dkax (M. F.) (Rec. d'obs. chir., sur les mal. de I'urethre, Avignon, 1748); ANDRE (Diss, sur les mal. de I'urethre. qui ont besoin des bougies, Paris, 1751): Goulard (T.) (Mim. sur les mal. de I'irrilhre. Montpellier, 1751); Allies (Traiti des mal. dc skvt. ill.] OPERATIONS ON TI1K URETHRA. 387 Naturally, the three cases recorded in del ail were altogether exceptional. Tlie case of syphilis with stricture and false passages, just related, was very complicated; in the next case, ante-scrotal stricture with listula was supposed to have no venereal antecedent; and, in the third case, stricture resulting from gonorrhoea was situated in the membranous part of the canal. Cash 1090.—Private T. M. Peterson. Co. 1). 32d C. T., aged -J.) years, was treated, by Surgeon C. M. Wight, 32(1 C.T., at the regimental hospital on" Morris Island, for "inilaniniation of the penis and scrotum," from July 12th to August 31, 1S1J4, and then sent to hospital No. 3. Beaufort. Surgeon J. Trenor, jr., U. S. V., recording the case as one of "'dysuria and hypospadia." December 14th, at hospital No. 2, lieaufort, Assistant Surgeon J. (J. Murphy, U. S. V., noted "inflammation of the kidneys." and the patient's ''discharge, June 5, lS;i.>, ou account of urinary fistula on posterior part of penis." This man was pensioned. Examiners Goodman, Collins, Harlan, Sherwood, Harper, and Smith reported, January 24, IS72, as follows: "lie states that on Morris Island, in 1864, he had an attack of stricture, and that there was afterward an infiltration ofthe scrotum and penis, which was lanced by the attending sur- geon. He has at this time a fistulous urethra the urine escaping from two Fig. 311.—Perreves dilatatenr.' [Reducedfrom tho inventor's drawing.] openings at the base of the penis and on either side of the raphe of the scrotum. He is compelled to wear a rubber bag on account of the constant dribbling. He alleges that he has never had gonorrhoea. Disability total and permanent." This pensioner was paid March 4, 1873. Cask 1091.—H. Boles, quartermaster's service, aged 21 years, was admitted into Post Hospital, Washington, June 4, 1S(J6. Assistant Surgeon W. Thomson. U. S. A., reported: "Double stricture of the urethra, following gonorrhoea of several months' duration ; tlie stricture existing since July, 1SG5. There was one firm and unyielding stricture in the spongy portion of the urethra, and another one, less tense, in the membranous portion; there was no discharge from the urethra; there was incontinence of urine. On June 5th, Acting Assistant Surgeon G. P. Hanawalt commenced dilating the stricture by means of silver sounds, introduced twice daily, no anaesthetic being used. Tlie patient's constitutional condition was good .at the time, and there was but little sensibility of the urethra, which had been already treated by Dr. E. K. Stone with Holt's dilator. In the evening, a No. 1 sound was introduced with slight difficulty. On the following day, a No. 2 sound was carried into the bladder, and a No. 3 into the first stricture. On the 7th, the No. 3 was passed into the bladder. On the 10th and 11th, there was traumatic urethritis from too frequent catheterism. He left hospital on the 12th, but returned on the 20th, aud was discharged from hospital June 2f>. 1S66, his treatment being continued as an out-door patient. On the 2?th, the next to the largest sound was introduced. On July 3d, the patient himself introduced a large-sized bougie without difficulty. He was cured in twenty-eight days, urinating in a full stream." I'urithre, Paris, 1755): ARSAUD (G.) (Plain and Easy Instructions on the Dis. of the Urethra, 17(J3): FOOT (J.) ICrit Inquiry into the ancient and mod. Manner of treating the Dis. of the Urethra, London, 1774); Gc'ERIN (Diss, sur les mal. de I'urethre, Paris, 1780); IIl'XTER (J.) (On Venereal Diseases, London, 17SC); CHOPART (Traiti des mal. des voies urin., 1.7'J2, T. II, p. G2G); DESAULT (Journal de Chir., 1791, T. II. p. 3CI); HOME (E.) (Pract. Obs. on the Treatment of Strictures of the Urethra, London, 1795); BERUXGIIIERI (A. V.) (Abhand. uber die Verengerungen der Harnrohre, in Hari.ess's N. Jour, der ausland. med. chir. Literatur, B. I, St. I, S. 1); LARLOXD (F.) (Rech. sur le ritrecissement chronique de I'urethre, Paris. 1805); Whatelt (An Improved Method of Treating Strictures of the Urethra, London, 1804); Lkiimaxx (G. T.) (Diss, de curandis urethrse stricluris. Lipsiae, 1810); KLEEMAXN (De curandis urethrse stricturis chronicis, Erlanga\ 1811); BELL (ClI.) (On Diseases of the Urethra, etc., London, J811); HOWSHI1' (J.) (Pract. Observat on the Diseases of the Urinary Organs, London. 1816); PETIT (A.) (Mem. sur la ritention d'urine, produit par le ritrecissement du canal de I'urethre, Paris, 1818); AbxOTT (J.) (Treatise on Stricture ofthe Urethra, London, 1819); BrxGHAM (It.) (Pract. Essays on Strictures ofthe Urethra and Disease.; of Testicles. London, 1820); Colrtray (C. I!.) (Prac. Observat on the Disease of Stricture, recommending an improved System or Treatment, London, 1822); DUCAMI- (TH.) (Traiti des retentions d'urine, causie.i par le ritrecissement de I'urethre, Paris, 1822); DU1SOUCHET (H.) (Petit Traiti des retentions d'urine, causies le plus frijuemment par un ou plusieurs retricissemens du canal de I'urethre, etc., Paris, 1823); Macilwaix (G.) (A Manual of the Treatment of Strictures in the Urethra, London, 1824); L.U.LF.MANI) (L.) (Observations sur les maladies des organes genito-urinaires, Paris. 1825); PaoUT (W.) (An Inquiry into the Nature and Treatment of Diabetes, Calculus, and other affections of the Urinary Organs, London, 1825); Scikenemanx (E. A.) (De strictura urethra-, licrol., 1820): Eckstro.m (A rs-Bcrdttelse om Stoenska Lakara-Sdllskapets Arbeten, 1825. Stockholm, 182G); Kkimer (W.) (Uber die radicate Heilung der Harnrohrenrerengerungen, etc., Aachen, 1828); Castel (J. J.) (Diss, sur les ritreeissemens du canal de Puretre, Th6se a Paris, 1828); HAMMICK (S. L.) (Pract Remarks on Amputations, Fractures, and Stricture of the Urethra, London, 1830); A lizard (C.) (Sur le. ritricisscment organique de V uretre. Those a Paris, 1831): SaclsOH.v (S.) (De urethrse stricturis, Berlin, 1833*; Cornay (J. E.) (Des retricissemens organiques de Vuretre. These a Paris. 18311); Raeiilmaxn (A.) (De urethra; virilis strictura organica. Bonnae, 1840); Kugleu (Pract. Abhandlung uber die Verengerung der. Harnrolirc, Wien, 1843); LEROY d'Etiolles (Urologie. Des angustics ou ret.reeissemens de I'urethre. Paris, 1845); IVAXCHICU (V.) (Uber die organisclie Vemigerung der Harnrohre und Hire volkommenste Behandlung, Wien, 1840); BliXIQUfi (J.) (La dilatation des retricissements de I'urethre. Paris, 184!'): Civiale (J.) (Traiti prat sur les mal. des organes ginito-urinaires, Paris, 3" 6d.. 1858,'; Sevdel (Die Stricturen der Harnrohre. Dresden, 1854); Thompson (II.) (Tlie Pathology and Treatment of Stricture of the Urethra, 2d c([ . London, I8.1S); 1SROX (F.) (Du traitement des retrerixsements de Vuretre. These a Paris, 1855); FAEIUSER (H.) (De curandis urethne stricturis, Diss, inaug., Gryphia, 1855); Pro (J.) (Anatomic pathologique des ri'recissements dc I'uretre. These a Paris, 1855); SCHMIDT (F.) (De urethne stricturis. Diss. Crvphias, 1857); Harrison (J.) (The Pathology and Treatment of Stricture of the Urethra, London, 18C8); Lll'l'ERT (II.) (Die Erkenntniss und Heilung der Harnroehr.enveriiiiejerurigeii, Frankfurt a. IM., 1859); SMITH (II.) (On Stricture of tlie Urethra, London. 1857); IIOUDART (S.) (Nouv. jimccdi de dilatation des relri'-issements du canal de I'urc'.re. These a Paris, 1860); Flavard (C.) (Consid. sur les traitement des retricissements organiques de I'urethre, Jlontpellicr, 18GG); Fra.n'CK (il.) (£iude sur les retrecissements organiques du canal de Vuretre et sur leurs modes de traitement, These u Paris, 1871). Perreve (V.), Traiti des retricissements organiques de Vur.e.thr.e (Prix d'Arg-enteuil), Paris, 1847, p. 178. :',ss INJURIES OP THE PELVIS. [CHAP. VII. FIG. 312.—Sheppard'S dilatator. Noting thus briefly the influence of gonorrhoea ami syphilis in causing organic stricture—for the general subject of venereal affections is reserved for consideration in the Third Surgical Volume—attention is recalled to the fact that in the eighty-three reported cases of recovery from shot injuries of the urethra, stricture was an almost uniform if not inevitable result. Dilatation and Divulsion.—In the treatment of all urethral strictures, not excluding those of traumatic origin, the method of gradual dilatation holds the most important place.1 It is required uniformly; the expedients of forcible dilatation and incision being subsidiary, and useless unless associated with it. In the great majority of cases of organic stricture, gradual dilatation alone suffices, a truth first fully set forth by John Hunter, through deductions from the anatomical characters of strictures, and the mode of action of bougies, ft is equally unquestionable that tliere are many cases in which gradual dilatation is inadequate; and most of the examples of traumatic stricture belong to this category. For the 1 The plan of dilating strictures by special combinations of sliding tubes appears to be a corollary of the idea of catheterism on a conductor, an expedient employed and commended by Desault, of which I find no earlier mention. Civiale, who should have known better, erroneously ascribes (Nouvelles considirations sur la ritention d'urine, 1823, p. 41) to Nauciie the credit of first introducing a catheter on a conductor. Nauche'S inaugural thesis was published Messidor, An IX (June, 1801). He does not appear to have employed this method, but substantially copies (Nouvelles recherches sur la retention d'urine, Paris, An IX, p. 59) the words of his master, Desault, in commendation of it. Desault not only advised, but put in practice, the operation, as is proved by the following citation from his lecture at IIotel-Dieu (Journal de Chirurgie, 1792, T. Ill, p. 132): "D'ailleurs, si l'on craignoit de rencontrer quelque diiliculte a passer la seconde sonde, il seroit facile d'obvier a cet inconvenient, en se servant de sondes ouvertes par les deux bouts: on introduiroit la premiere au moyen d'un stilet & bouton, et avant de la changer, on la garniroit dun stilet, long d'environ deux pieds, que Ton enfonceroit de quelques lignes dans la vessie; puis on retireroit la sonde sur le stilet, qu'on laisseroit a sa place, et sur r lequel on conduiroit ainsi, sans peine et avec surct6, une nouvelle sonde." This passage is reproduced in the Traiti des Maladies des Voies Urinaires, An VII, p. 310, and in the CEuvres chirurgicales, 3"ie 6d., par XAVIER BlCIIAT, 1813, T. Ill, p. 314. Plessmann (La Midecine puerperale et des accidents de la materniti, Paris, 1797) practised this method, acknowledging that he learned it of Desault. Piciiauzel also advocated this method, and received a prize for his paper, in 1810, from the Academy of Medicine of Bordeaux (THOMPSONS Jacksonian Prize Essay on Stricture, 1st ed., 1852, p. 199). Though useful in many emergencies besides those attending stricture, particularly in cases complicated by false routes or by lacerations, this plan appears to have been neglected for man}' years. It was revived by Amussat (Lecons sur les ritentions d'urine, 1832), who used a long fine whalebone guide. It was recommended by Rigal (De la destruction micanique de la pierre, etc., 1829, p. 22). After this, man}' surgeons, apparently quite independently of one another, adapted this principle to the dilatation cf strictures. A guide being passed, successive tubes were slid over it. In his description of his "conqiound catheter," in the London Medical Gazette, 1841, Vol. XXVII, p. 916, Dr. Buchanan, of Glasgow, figures a series of sliding tubes, which he had used since 1831, in the treatment of obstinate stricture, and which he regarded as identical with the "new surgical instrument,'' described and figured at page 051 of the same journal, by Mr. J. C. Foulkes, of Liverpool. Dr. Buchanan's instruments were made by Peter Aitkin, instrument- maker of Glasgow. The New York instrument-makers sell at the present day a very handsome series of sliding bulbous- tipped tubes, under the name of "Aiken's urethral set." Graves (System of Clinical Medicine, Dublin, 1848, Vol. I, p. 555) and Dr. Wilmot (On the Treatment of Stricture, in Dublin Quart Jour. Med. Sci., 1857, Vol. XXIII, p. 310) state that Mr. HUTTON, of the Eiclnnond Hospital, employed a similar method in 1835. it is remarkable, as Sir HENRY ITHOMrsON has frequent]}- pointed out, how often the application of this principle has been regarded as a new invention, ;! and the priority of Desault overlooked. In 1845, 31. MAISOXNEUVE read to the Paris Academy of Sciences (Compte 1 I1 rendu, Seance du Janvier 13, 1845) his Mimoire sur un moyen Ires-simple et tres-stir de pratiquer le cathilirisme dans les cas meme les plus difjiciles. The simple means consisted of a very fine supple bougie, a gum-elastic catheter open at both ends, and a silken or metallic thread to guide the catheter upon the bougie, as illustrated by Figure 303. p. 381, supra. In several successive papers (Gaz. des Hop., 1852, p. 310; Ibid., 1855, p. 295; Ibid., 1858, p. 101) M. Maison- NEUVE defended the method of catheterism on a conductor, or catheterism a la suite, as he sometimes designated it, as the easiest and surest and most generally applicable of all methods of reaching the bladder in cases of obstruction of the urethra. The value and origiuality of this plan were warmly contested, especially by MM. LENOIR and Giealues, whose criticisms may be found in the debates cf the Sociiti de Chirurgie in 1855 et seq. The fact remains that nearly all the dilators, urethrotomes, and analogous urethral instruments now fabricated by the French makers are provided with M. Malsoxneuve's conducting bougie. In 1851, Mr. T. II. WAKLEY (The Lancet, 1851, Vol. I, p. 121) presented to the Medical Society of London his "new instrument for the cure of stricture" (Fig. 313), consisting: of a small cathetcr with a removable thumb-slide, a conducting' rod to be screwed to the catheter, and a series of graduated silver and elastic tubes. Mr. Teevan states (Lancet, 1673, Vol. II, p. 5) that Solly used an elastic catheter, open at both ends, which he slid along a catgut bougie. According to Phillips (Traiti des mal. des voies urin., I860, p. 42G). Pasquier employed the same plan. Dr. (iOULEY (Dis. of the Urinary Organs, 1873, p. 54) has insisted on the superiority of capillary whale- bone bougies as conductors. AVhalebone was used for stylets by VAX HELMONT (De lithiasi., Amstelod., 1652, p. 703) and for bougies by Allies (op. cit, 1755, p. 103). The latter rejected this material as hard and liable to cause bleeding. (ll'ILLON (De la Slricturotomie intra-uritrale, 1857, p. 20, etc.) repeatedly advocated the advantages of filiform whale- bone bougies in the Gazette Medicate, February 14, 1832, the Revue Medicate, 1839, T. I, p. 311, and elsewhere. He believed that, by the assistance of these guides, forced catheterism or vesical puncture might always be avoided. F.riggh (J.) (The Treatment of Stricture of the Urethra by Mechanical Dilatation, London, 1845, p. 39), in narrow constrictions, used capillary whalebone bougies softened by warm water and curved by insertion in a catheter. M Fig. 3i::.-\Vakley's stric ture instruments. [After Weiss: Cat, PI. XXV.] SECT. III.] OPERATIONS ON THE URETHRA. 389 prevention of constrictions after injuries of the urethra, frequent mechanical dilatation of the canal is the only available prophylactic measure; but, if there is much loss of substance, the tendency to contraction will not be overcome. Traumatic strictures will therefore require, more frequently than others, recourse to incisions. The different modes of forcible dilata- tion, by conical sounds or more nnirmlpv IflnD- FIG. 314.—Dilatator or divulsor of Mallez. tations of the wedge principle, will probably be rarely found applicable to cicatricial con- strictions." No cases of traumatic stricture were reported in which this plan was adopted. But, in the treatment of ordinary strictures, many medical officers, and especially Surgeon J. R. Smith, U. S. A., approved of rapid dilatation1 and divulsion. The latter wrote: "In regard to stricture of the urethra I would like to put on record ray opinion, acquired by considerable experience, that the practice of dilating strictures of the urethra by the ordinary bougie is very and unnecessarily slow, and is not a radical cure—relapses occurring iu the majority of instances. I recommend that a Holt's dilator be issued with the personal sets of instruments." The simplest mode of mechanical dilatation of stricture is by means of large conical sounds or catheters, instruments of progressively increasing calibre being successively introduced. This plan, fiercely attacked and stigmatized as "forced catheterism," has --------------------------------------------------------------------------------------------------------------------------------------------------------------■--------7 1 Instruments susceptible of mechanical expansion after being passed through a stricture were suggested in the last century (Stilling, op. cit, p. 334); but none of them appear to have been of practical utility prior to that described by LUXMOORE (On Stricture of the Urethra, London, 1809, p. 22), a cylindrical tube, the intra-urelhral part separating into four blades, which were expanded by a screw at the outer end. It was used for very gradual dilatation. In 1831, Guthrie (Anat. and Dis. of the Urin. and Sexual Organs) used a three-bladed dilator, made by Weiss, on the principle of Sir Astley Cooper's urethral forceps (Fig. 284, ante). These instruments were inapplicable to narrow strictures. In 1847, Perreve made known (op. cit, p. 178; see Fig. 311) his ingenious instrument for the rapid dilatation and rupture of strict- V^k | E ures. In 1847 also, MlCHELENA (Des ritricissements de I'urethre, These \\ I de Paris, 1847, No. 29) and, two years later, RlGAUD (De la dilatation ^^ iL4] instantanie des ritricissements de Vuretre au moyen dun instrument \\ || nouveau. Cathiter dilatateur parallele, in Gaz. mid. de Strasbourg, 1849, \\ I I p. 32) designed urethral dilators very similar in mechanism (Figs. 315, 316). In both, the blades are separated by a series of jointed levers, and both are defective in that the valves, in opening', must slide in inverse directions. The instrument-makers greatly improved these dilators. M. Mathieu, particularly, designed a pattern (Fig. 317) in which the disten- tion of the urethra at the meatus is obviated, a pattern much imitated by the English and American makers. One of these instruments was purchased for the Museum from Tiemann & Co., under the name of "Atlee'S Dilator," and the same instrument is advertised by Gemhig (Illustrated Cat, p. 73) as "Panooast's Stricture Dilator." In the last twenty-five years, the modifications of urethral dilators have been numerous, and some of them felicitous. Professor GROSS (System, etc., 5th ed., 1872, Vol. II, p. 820) considers the instruments proposed by Holt, Voillemier, and Richardson as the best. Mr. Holt described his modification (FlG. 321) in 1852 (The Lancet, 1852, Vol. I, p. 146), and in the second edition of his monograph (On the Immediate Treatment of Stricture of the Urethra, 1862) recorded many instances in which it had been ad- rantageously employed. M. Voillemier's instrument (FIG. 320) was described in 1866 (Un nouveau dilatateur cyiindrique, Bull, de I'Acad. de Med., T. XXXII, p. 289). Mr. B. W. Richardson's " dove-tailed dilator " was described and illustrated in his article on "the instantaneous method of treating stricture of the urethra" (Dublin Quart. Jour. Med. Sci., 1868, Vol. XLVI, p. 74). Many other dilators have their advocates. Dr. Dittel, the author of the important chapter on stricture, in the Handbuch of BILLROTH and von Pitha (op. cit, 1872, B. HI, Abth. 2, S. 123), com- mends his own, which is similar to that of M. VOILLEMIER. A modifica- tion of the MlCHELENA instrument, that has been much approved, was proposed by Sir H. THOMPSON, in 1863 (Med. Times and Gaz., Vol. I, p. 461). In the same year, Mr. P. C Smyly (Dublin Quart Jour. Med. Sci., February, 1863, Vol. XXXV, p. 80) suggested the addition of the " railway catheter " principle to his modification of Perreves'S dilator. In 1866, Dr. C. O. Aspray (The Lancet, Vol. II, p. 146) printed cases in illustration of his modification. In 1868, M. Mallez (Bull, de I'Acad,., Fic,.315.-Michel£xa's dilatateur. [After the inventor's di'awing. J -J. Fig. 317. — M. Mathieu's dilatateur. [From the maker's model.J ij. etc., Gaz. des Hop., p. 495) devised an instrument (FIG. 314, supra) in which the sliding-button plan is revived. This is essentially the plan of Dr. ;,9o INJURIES OF THE PELVIS. [CHAP. VII. long retained the confidence of practical surgeons. Default, by the earnestness with which he insisted on its advantages, as it were appropriated this method. Chopart fully agreed with Desault, and Boyer (Fig. 310) systematized, so to speak, the plan of rapid dilatation. Mayor,1 of Lausanne, bv his exasperations and exclu- siveness, brought discredit on this method; yet it is approved, in our own time, by such solid authorities as Professor Gross and M. Voille- mier. The series of graduated nickel-plated sounds, issued in the army sets, is well suited to the treatment of stricture by forcible FIG. 319.—Dr. Gouley's modification of Sir H. Thompson's Expander. vi i i' n l' VI l x' dilatation. (Jontinuous dilatation, involving the patient's confinement in bed, was rarely employed in army practice;2 and the treatment of stricture by cauterization was regarded as obsolete. In the few cases in Sheppard, of Stonehouse, a grooved catheter with a metallic traveller, as figured on page 388 (FIG. 312), only the dilator of M. MALLEZ, like all the more modern instruments of this class, is provided with a conductor. Of these various forms of instruments, some are effective in stretching, expanding, or over-distending strictures, and others accomplish their rupture, splitting, or divulsion. The mechanical construction of the best of these implements has been perfected to that degree lhat the dangers of making false routes, or of pinching the mucous membrane between the valves, need not cause a skilful manipulator serious apprehension ; but the risk of constitutional disturbance, after rupture of the urethra, cannot be eliminated by any improvements in the mechanism by which the tissues are torn. It is commonly conceded that the general application of forcible ruptures to urethral strictures is an abuse. In the exceptional cases in which rupture may be of advantage, the modifications of Perheve's instrument (FIG. 311) afford the best means of effect- ing it. The modification by Mr. HOLT (FlG. 321) has enjoyed, perhaps, the widest popularity; that recommended by JI. VOILLEMIER (FIG. 320) acts with more security. 1 MAYOR (M), Sur le cathitirisme simple et force, et sur les retricissements de I'uretre et les fistules urinaires, Paris, 1836, p. 509. Three years earlier (Jour, des Connaissances mid-chir.. October, 1833), Mayor had recommended that instruments of large size should be first employed in the treatment of strictures however narrow. Rist (Theoretisch-practisches Handbuch der Chirurgie, 1835, B. XV, S. 399, Note) advocated the same error less extravagantly. Both authors erred in generalizing a fact long familiar to practical sunreons, namely, that in many cases of dysuria a catheter of medium or large calibre is more readily introduced than a small one. Fabricius Hildanus (Opera quce extant omnia, Francofurti, 1G44, De lithotomia vesicse, Cap. 3, p. 712) noted this, and explained it by the liability of small sounds to catch in the lacunae and rugosities of the urethra, which would be unfolded by the rounded extremities of large sounds: "Vidi enim aliquando, me instrumento parvo ad Vesicam pene- trare non potuisse, cum tamen magnum et crassum citra ullum impedimentum et obstaculum immissum fuerit: causa est, quia tenerum ac gracile instrumentum anfractibus ac rugis Virgae impingit: crassum vero Urethram diducit, et per se aperit." Le Dran (Traiti des Opirat. de Chir., Paris. 1742, p. 1.89) remarked that "dans les gens difficiles a sonder, une petite algalie peut percer la tunique interne de I'uretre, ct faire de fauses routes, ce que ne peut faire une plus grosse.'' Chopart also (Traiti des maladies des voies urinaires, 1792, p. 434) taught that moderately large instruments traverse the urethra more readily, with less hazard of false passages, and with less pain, than those of snio.ll diameter. Boyer and Physick and many others reiterated these precepts, but only with reference to the cathe- terism of the unobstructed urethra. 2 Much ingenuity has been expended in preparing bougies capable of expansion after introduction into .strictures. Of these, cat-gut bougies have enjoyed the most credit. They appear to have been first proposed by Ti RQUET Di: Mayerne (Op. mid., ed. J. Browne, 1703, p. 134), and were extolled by Le Dran (Traiti des operations de Chirurgie, 1742, p. 359) and by FOOT (A Critical Enquiry into the Ancient and Modern Manner of treating the Diseases of the Urethra, with an improved Method of Cure, London, 1774, p. 54). Benjamin Bell (System of Surgery, 1784, Vol. II. p. 215) refers erro- neously to William Dease. of Dublin, as the inventor. Cat-gut bougies are praised by Clossius (Uber die Lustseuche, 1797), Richter (Anfangsgriinde der Wundarzneykunst, 1802, B. IV, S. 275), and later by Jassay, Montain, Ivanciiicii, Dittel, and many others. The following papers indicate some of the materials for bougies particularly recommended in this country: McDowell (W. A.) (An Account of the Use of the Bark of the Slippery Elm Tree (Ulmusfulva) for Bougies, etc., in the Western Jour, of the Med. and Phys. Sci., 1838, Vol. XI, p. 371); Waters (W.) (Case of Stricture cured by Bougies of the Bark of the Slippery Elm Tree (Ulmus fulva), in the Am. Jour. Med. Sci.. 1839, Vol. XXV, p. 321); Bigelow (H. J.) (Employment of Gutta-percha in the Treatment of Strictures, in the Boston Med. and Surg. Jour., 1849, Vol. XL, p. 9); Cabell (P. II.( (An easy mode of constructing Bn'igiis, in the Am. Jour. Med. Sci., 1856, Vol. XXXII, p. 578); BatcheLDOR (J. P.) (History of Compressed Sponge for the Treatment of Strictures of the Urethra, in the New York Jour, of Med., 1859. Vol. VI. p. 301). Several Scotch surgeons have recommended the stems of algae, particularly of Laminaria digitata, or sea-tangle, as a material for bougies, shrinking when desiccated, yet retaining great tenacity, and readily absorbing moisture and swelling up. Dr. Sloan, of Ayr (Glasgow Med. Jour., Vol. X, p. 281), and Mr. COLLIS, of Meath Hospital (Dublin Jour. Med. Sci., 18G4, Vol. XXXIV, p. 3731. have insisted on the utility of this material for purposes of dilatation. Compare Xl'.WMAN (R.) (The Med. Record, 1872, Vol. VII, p. 270). FIG. 320.—M. VoiL- lemier's divulseur. [After VOILLEMIER.] FlG. 321. Mr. Barnard IIoi/i's dilatator. | From Weiss's pattern.] SECT. III. | OPERATIONS ON THE UR MTU It A. :YM which continuous dilatation was essayed, some ingenious efforts were made to adapt mechanical means of dilatation to the constricted portion of the urethra alone. These were substantially repetitions of the much-modified instruments of Segalas (Pig. 318), .or of Ducanrp1 (Fio. 322), and the practical results were unimportant. In short, for progressive gradual dilatation of strictures graduated elastic or metallic sounds were alone of real utility. Surgeon T. H. Squire, 89th Xew York, and Assist tint Surgeon J. \V. S. Uouley, U. S. A., devoted much attention "%fc%^>*«^ Ol to traumatic and organic strict- ures, and, since the War, have ■i-i Vi j 1 Fig. 322.— Air or water dilatator. [After DrrAMl'.l enriched our literature by important contributions on the subject.2 Surgeon J. H. Brinton, U. f\ V., often employed Mr. Holt's instrument for rapid dilatation, and had great confidence in the method in 'DUCAMP (TH.) (J Treatise on Retention of Urine .Caused by Strictures in the Urethra, translated by W. II. HERBERT, M. D., New Vork, 1827, PI. IV, Fig. 2). IDEM (Traiti des ritent. d'urine cause.es par le ritrecissement de I'urethre, Paris, 1822). Compare also COSTALLAT (Essai sur un nouveau mode de dilatation, Paris, 1834, p. 109). Sk.galas, besides his canula, divided in one portion into several elastic blades, which separated by the action of a rod governed by a screw, proposed (Traiti des retentions d'urine et des autres affection^, qui se lient aux ritricissements de I'uretre, Paris. 1828, p. K>8) dilatation by the distention of a little bag of goldbeater skin by air or water. This plan, of much older date than Segalas or Ducamp, has often been revived, only ta result in disappointment. 2 Squire ('!'. H.) (Synopsis of some Important Improvements in the Treatment of Obstinate Organic Stricture of the Urethra and Urinary Fistulse, iu The Boston Mid. and Surg. Jour., 1807. Vol. 77, p. 401) ; THE Same (Proceedings of Elmira Academy of Medicine. September, 1870); THE Same (Vertebrated Prostatic Catheter, in Am. Jour. Med.. Sci., 1871, Vol. LXII. p. 393); THE Same ( Verteb. Prost. Cath., in Am. Jour. Med. Sci., 1872, Vol. LXIV, p. 433); THE SAME (Advantages of tlie Vertebrated Catheter in Prostatic Retention, in The Medical Record, 1873, Vol. VIII, p. 4) ; GOULEV (J. W. S.) (Clinical Lectures on the Diagnosis and Treatment of Stricture of the Urethra, in The Medical Record. 1870, Vol. V, pp. 29, 54, 73, 101) ; THE Same (Diseases of the Urin- ary Organs, 8vo, Xew York. 18?:>j. Dr. GOULEY has brought very prominently before the profession the advantages of capillary whalebone bougies as conductors for catheters aiu,l sounds employed in the treatment of tortuous and eccentric strictures. The vesical extremity of the catheter is grooved or "tunnelled" (see FIG. 323, b, and FIG. 324, 3), and when the whalebone guide has passed the obstacle, its free end is slipped through the tunnel of the sound, which is then slid down to and through the contraction. This very valuable device has been adapted to urethrotomes, dilatators, staffs, and other urethral instruments. In the language of Mr. Teevan (Lancet, 1873, Vol. II, p. 5), who has adopted and modified it (Fia. 324), it must be regarded as "a beautiful and useful'' addition to surgical resources in the treatment of stricture. Mr. TEEVAN's modification consists simply in cutting out a longitudinal piece of the catheter (Fig. 324, 2) instead of grooving it, and is, therefore, inapplicable to staffs, sounds, and instruments for urethrotomy, to all of which Dr. GOULEY has extended bis plan. Acrimonious discussions have arisen respecting the priority of invention of this important improvement, some writers contending that the merit of suggesting it is due to Dr. W. H. Van BUREN. The editor would not intervene iu this controversy, "non nostrum tantas componere lites," but may state that while, as has been abundantly shown in previous references, neither catheterism on a conductor nor whalebone bougies are novelties, yet the perforation or tunnelling of the vesical extremities of urethral instruments, to adapt them to sliding on a guide, is undeniably an innovation, of which the editor, for his part, had seen no suggestion prior to the publications of Dr. GOULEY. Several of the urethral instruments devised by Dr. SQUIRE have been received with much favor. The gold or silver tubes, denominated arid nets, proposed for continuous dilatation of rebel- lious strictures of the first and second portions of the, urethra, may be worn, according to Dr. Sqi.'IBK, without discomfort. A ease is adduced of a patient who "wears it all the time, and feels no more inconvenience from it than one does from a plate of false teeth in the mouth." These instruments are figured in Dr. SQUIRES article in the Boston Medical and Surgical Journal, Vol. LXXVII, p. 402. The arid act designed for the continuous dilatation of strictures ofthe third portion of the urethra is the S -shaped catheter represented on page 302 (FIG. 252, ante), devised by Dr. SQUIRE to meet the exigencies of the case of Dervin (Case 1072, p. 370). In a letter to the Surgeon General, of January 19, 1866, Dr. Squre (recognizing the utility of a vesical siphon as early as 1862) called attention to the following advantages of this double-curved catheter: "It keeps its place in the canal itself, thus rendering unnecessary the unscientific and unsatisfactory adjuvants usually employed. It conforms exactly to the natural direction of the urethra, and imposes no restraint upon the urinary organs. Being in the form of a siphon, it empties the bladder while the patient is lying supine in bed, a thing which the silver catheter of single curve will not do." The jointed or vertebrated catheter proposed by Dr. Squire for the relief of retention of urine from enlargement of the prostate has been approved by many surgeons, particularly by Dr. L. A. Sayre (Trans. Med. Soc, State of A'eio York, 1871, p. 293), Dr. S. CARO (The Med. Record, 1871, Vol. VI, p. 535), and Dr. S. COWAN (Am. Jour. Med. Sci., 1874, Vol. LXVII, p. 359). Professor GROSS (System, etc., 5th ed., 1872, Vol. II, p. 743) and Dr. ASHHURST (Princ. and Pract. of Surg., 1871, p. 883) refer to Dr. SQUIRE'S prostatic catheter; and Professor F. II. Hamilton (The Princ. and Pract. of Surg., 1872, p. 814) states that he has "employed this instrument in a few- cases, and * * found it to answer its purpose exceedingly well," but apprehends danger from liability of the links to become detached in the bladder, and does not perceive plainly the advantages of the instrument over an ordinary flexible catheter. Fig. 323.—Dr. Gouley's tunnelled catheter. [After GOULEY.] Fig. 324.—Mr. Teevan'h modification of Dr. Gou- ley's tunnelled catheter. [After Teevan.] :v.)-2 INJURIES OF THE PELVIS. [CHAP. VII. properly selected cases. In army practice generally, recourse was seldom had to the over- distending and splitting of strictures. Indeed, a callous stricture was regarded as a disqualification for military duty, warranting a soldier's discharge. There is no record of the employment of divulsion in cases of traumatic stricture. Urethrotomy.—Although there is imperfect historical evidence that the Greeks and Arabians practised scarifications of the urethra, and that, toward the middle of the sixteenth century, the Neapolitan surgeon Alfonsus Ferri, and Ambroise Pare", and Francisco Diaz,1 employed cutting instruments to penetrate impassable obstructions in the urethra, and Allies and Vigurie performed similar operations two centuries later, and although external urethrotomy, alleged to have been first described by Aretseus, A. D. 80, was occasionally practised after Solingen's operations (circa 1673), yet it is unques- tioned that dilatation and cauterization were the only methods of enlarging strictures commonly employed until the second quarter of the present century. A familiarity with the principal varieties of this operation is essential to a correct understanding of the treatment of stricture, and the subject will be considered somewhat at length. Internal Urethrotomy.—The operations comprised under this denomination are two- fold: those of puncture or incision of urethral obstructions from before backward, or what 1 HeiT STILLING, in his exhaustive critical treatise Die Rationelle Behandlung der Harnr'ohren-Stricturen, adduces satisfactory evidence that Heliodorus (a Greek practitioner in Rome, in the first century, a contemporary of Juvenal, who mentions him in the tenth Satire) employed such scarifications of the urethra as the moderns would designate internal urethrotomy. AlBUCASIS approved of such an operation, and figured (Chirurgia, ed. Oxon., p. 112) a little scalpel suitable for its performance. Amatus Lusitanus (Curationum medicinalium, Cent. II, III, IV, Lugduni, 1565-07-80, Cur. XXIII, p. 1G8) appears to have incised the urethra by a blade concealed in a canula, in the case of a child with congenital atresia, about 1540. Ferri (De caruncula sive callo quae cervici vesicae innascitur, Lion, 1553) is perhaps the first to definitely recommend, as a general practice, the treatment of strictures by perforation by sharp or [minted stylets. Pare (Qluvres, loc. cit., T. II, p. 569) describes several instruments for internal urethrotomy, and figures two of them. He used, and even permitted patients to use, a sound roughened at the end, to rub against callous strictures, after the fashion of a file. He employed, also, a straight canula with large oblong lateral eyes, with cutting edges (Fig. 325, A). Pressed against strictures or vegetations, by a rotary movement the instrument was made to cut them away. His second instrument (FlG. 325, B) was a curved catheter, the open distal extremity closed by a button on a stylet. The instru" ment being passed down to a stricture, the button was projected, and then drawn back, with a view of dividing the stricture between the sharp edges of the canula and button. Diaz, who practised at Madrid in 1576, figures a cutting catheter " instrumento cissorio de nuestra invenzion " (FIG. 326). A pointed stylet, which was thrust out of the end of the canula., is not represented in the figure. Though he declares the instrument safe, Diaz advises that it should be used only in extreme cases: "deste instrumento tenemos de usar como de remedio estremo que no ay otro."—(Tratado nuevamentc impresso de todas las enfermidades de los rinnones y vesica, Madriti, 1588, p. 170.) In 1603, Turquet (TllEODORUS OF MAYERNE) was expelled from the Faculty of Paris, and called a "grand fourbe" by Guy Pattn, for successfully operating ou Henry IV, by perforating a callous stricture, so desperate and foolhardy was the operation considered. Mayerne, who went to England, and became surgeon to James I, records the fact with excusable exultation : " Scirpo acuto, imo ct cathaetere argenteo penetravi fcelici successu (in Rege Henrico IV, Galliae). non tamen sine dolore, sed eo tutius, quo diligentius celebrata fuerant universalia."—(Turquet DE Mayerne, Op. med., ed. Browne, London, 1703, p. 137.) The parenthesis is recorded by MAYERNE on the margin. Allies, according to his son (Traiti des mat de I'urethre, 1755, p. 72), treated urethral fistules by first relieving strictures in front of them by means of perforation. According to CHOPART (Traiti des mal. des voies urinaires, 1792, T. II, p. 328), VIGUERIE, of Toulouse, failing to relieve a trouble- some stricture by Hunter's method of cauterization, perforated the obstruction with a trocar, and cured the patient. All of these operations were of the nature of forced catheterization or of punc- ture of the urethra rather than methodical urethrotomy, and dilatation and cauterization remained the only methods of treating strictures in common use. In 1795, PHYSICK designed a lancetted catheter for the division of strictures from before backward, and in succeeding years repeatedly performed this operation with success.—(Dorsey, Elements of Surgery, 1813, Vol. II, p. 149.) He used a straight or curved canula. according to the location of the stricture. These instruments are represented by Figures A, 1 and 2, of Plate XII, copied from DORSEYS drawings. In 1819, Arnott (Treatise on Strictures, London, 1819) proposed two urethrotomes, one with a circular blade, the other with two lateral blades. Their value appears not to have been tested. In 1823, M'GHIE, a naval surgeon (Suggestions in Surgery, in Edinb. Med. and Surg. Jour., 1823, Vol. XIX, p. 361), suggested an instrument closely resembling Physick's, but having the improvement of a conical conductor in advance of the blade. In 1824, Amussat presented to the Paris Academy the first of a series of urethrotomes contrived by him. In 1827, STAFFORD presented to the Westminster Medical Society (The Lancet, 1828. Vol. I, p. 397) his lancetted catheter (Fig. 311). which attracted much attention at the time. Its uses were more fully discussed by the inventor in later publications: STAF- FORD (R. A.) (A Series of Observations on Strictures ofthe Urethra, with anAccountofa New Method of Treatment, London, 1828; and Further Observa- tions on the Use of tlie Lancetted Stilettes in the Cure of Strictures of the Urethra, with Additional Cases, 1829; and On Perforation and Division of Fig. 325.—Park's cutting sound. [After Pails; us.] SECT. III.] OPERATIONS ON THE URETHRA. 393 FlG. 327.—Anterograde urethotome of M. VOILLEMIER. is now known as anterograde urethrotomy, and incision of permeable callous strictures from behind forward, or retrograde urethrotomy. There have been few, if any, examples of the application of this method of treatment to traumatic strictures. In these, external urethrotomy was resorted to if any operative interference was attempted. In the treat- ment of old intractable organic strictures, however, internal urethotomy was regarded as a valuable resource. The ne- cessity of incisions in these difficult cases has long been recognized. The instruments Physick devised for the purpose are represented in Figure A of Plate XII, and Jame- son's urethrotome and that of Chew are shown in Figures G and D of the same plate. The rude mechanism of these instruments partly accounts for the slowness of prudent surgeons in accepting internal urethrotomy as a legitimate means of dealing with intract- able strictures. For many years, it was considered unsafe to incise strictures except in the antescrotal portion of the canal; but the instruments of precision now in use, the urethrotome of M. Voillemier (Fig. 327), and that of M. Maisonneuve (Fig. 330) partic- Permanent Strictures, London, 1836). Meanwhile the introduction of lithotrity, in 1820, necessitated the frequent enlargement of the meatus by incision, to facilitate the introduction of instruments, and sometimes the division of strictures in the fossa navicularis, and Civiale designed a sheathed knife for this purpose, and Leroy, of course, prepared a special instrument of somewhat different pattern; since when sundry surgeons have devised complex means of effecting these simple incisions, each one extolling his special "meatatome." The next real improvement in urethrotomy was by Jameson, of Baltimore, who, in 1827 (simultaneously with Stafford's publication in the London Medical and Physical Journal, October, 1827), described and figured (Am. Med. Recorder, October, 1827, Vol. XII, p. 329, Practical Observations on Strictures of the Urethra, by Horatio G. Jameson, M. D.) a urethrotome with a broad sliding blade, guarded by a sheath, analogous in principle, though inferior in construction, to the best anterograde urethrotomes now in use. A portion of Dr. JAMESON'S drawing is reproduced in PLATE XII, Fig. C. 1, 2. Already, in two essays on stricture (Am. Med. Rec, 1824, Vol. VII, pp 251, 687), Jameson had described cases in which he had successfully operated, in 1820 and 1823, on intractable strictures by internal incision. Unfortunately, these three most instructive as well as learned essays were published before the time when Edinburgh reviewers enquired, " Who reads an American book 1" and for many years escaped due recog- nition. Amussat (Arch. gen. de Mid., 1824, T. IV, pp. 31, 547), as early as 1823, presented to the Paris Academy an instrument (Fig. 329) for scarifying callous strictures. It was subsequently described by his brother-in-law, A. Petit (Lecons sur les retentions d'urine causees par les ritreeissemens, 1832, p. 143). Henceforward it is necessary, in the enumeration of urethrotomes, to distinguish between instruments designed to penetrate and divide strictures from before backward, or anterograde, those acting from behind forward, or retrograde urethrotomes, and those making slight incisions, or scarificators. Dzondi (Instrument fiir innere Urethrotomie, in Geschichte des Klin. Inst fiir Chir., Halle, 1818, Taf. II) used, in 1818, an instrument resembling PHYSICK's, for puncturing strictures, and DlEFFENISACH (HECKER'S Literar. Annalen, u. s. w., 1826, S. 165-169) later employed an ingenious instrument at once dilating and cutting; but Dieffenbach appears to have had little confidence in this plan of treatment, for he soon laid it aside. In 1826, Despiney, of Bourg, reported (Arch. gen. de Mid., T. XI, p. 146) two successful cases of strictures in the pendulous part of the urethra treated by incision. Ryan (London Med. and Surg. Jour , 1835, Vol. VIII, p. 240) states that "a lancet, covered by a catheter, was also used, about thirty years ago, by Sir Charles Bl.ICKE, of St. Bartholomew's Hospital, and by Mr. Nayler, of Gloucester." These operations, and one by Grindel, of the London Hospital, are said to have been done according to Physick's method, and with unfavorable results, especially in Mr. Nayler's case, in which there was severe haemorrhage. Dorner (Vor- sclilag eines neuen Miltels ge.gen hartndekige Ha rn riih renverengerungen, in SlEBOLD's Chiron. I) wrote upon the 'new method" of urethrotomy as early as 1806. In 1828, Dr. E. It. Chew (Description of an Instrument for dividing Strictures of the Urethra, in the North American Med. and Surg. Jour., Vol. V, p. 341) published an account of a urethrotome of his invention, with a drawing by S. G. Morton (which is copied in Figure I) of Plate XII). This instrument was used and recommended by Dr. It. Harlan (Case of Stricture of the Urethra operated upon with Mr. CHEW'S Instrument, in the North Am. Med. and Surg. Jour., Vol. V, p. 343). In 1830, Guillon (Gaz. des Hop., T. IV, No. 98, 1831, and Revue midicale, 1839, T. I, p. 299) presented to the Paris Acad- emy his urethrotome, and subsequently complained that this instrument had been copied by Leroy without acknowledgment. Reybard, in 1833, proposed the first of the many urethrotomes that bear his name (Mem. sui- tes ritricissements de I'urithre, Lyons, 1833). The instruments he finally advocated for the method, that received the Argenteuil prize in 1852, were retrograde urethrotomes, of which two patterns are represented further on (Fig. 336). Leroy (d'Etiolles), in his Traiti d'angusties, 1845, describes several urethrotomes, some of which had been presented to the Paris Academy as early as 1837. One of these instruments is represented by Figure 332. It is a canula with an olivary expansion at the terminal extremity, concealing a blade, arranged with the ingenuity in details characteristic of this inventor. In 1844, Surgeon It. J. Dodd, TJ. S. Navy, recommended (Am. Jour. Med. Sci, N. S., Vol. VII, p 374) an "improved catheter-bougie," or what is now termed an anterograde urethrotome. This instrument, adapted to scarifications rather than deep incisions, is copied from the author's drawing, in FIGURE F, Plate XII. In 1847, Dr. Martial Dutierris, of Havana (Mem. sur les ritricissements organiques de I'urethre, Paris, 1847), recalled attention to the urethrotome figured in the woodcut (Pig. 338) on page 395, which he had devised as early as 1839, while practising in New Orleans (Considerations nouvelles sur 50 FIG.328.-STAF- FORD s ure- throtome. [Ke- duced from a drawing of the author's.] Fig. 329.— A M u s S A T' S scarificator. 39 INJURIES OF THE PELVIS. [CHAP. VII. ularlv, permit the division of strictures in the sub-pubic region with as much regularity as those of the penile portion of the urethra. If, as Desault said, the simplicity of an operation is the measure of its perfection, the'division of deep strictures by the urethro- tome of M. Maisonneuve must be esteemed a felicitous solu- tion of the problem involved. In moderately skilful hands, the filiform conductor effect- ively guards against operating on false routes, and the objec- tions urged, that, this bougie is liable to curl up and present its point at the meatus, or to be cut by the knife, are not sustained by experience. There is a certain risk of wounding unconstricted portions of the urethra by the unguarded blade of this instrument, and M. Voillemier supplied his urethrotome (Fig. 327) with a shield. A limited number of these urethrotomes, manufactured (with so-called modifications) by New York and Philadelphia instrument-makers, were issued to army medical officers. No special cases of internal urethrotomy in the bulbous and membranous portion of the urethra were reported. The Fig. 330.—Urethrotome of M. Maisonneuve. le ritricisscment du canal de I'uretre et sur de nouveaux instruments de scarification, in Bull, de Therap. mid. et chir., 1839, T. XVII, p. 41). This instrument is, as the inventor designed, a scarificator only, and is adapted to the treatment of such strictures only as permit the introduction of an instrument of two and a half or three lines in diameter. Dr. Arntzenius, of Amsterdam (Ve.rhandeling over de organische Gebreken der Urethra, Ptrccht, 1840), though doubting the safety of urethrotomy in deep-seated strictures, proposed an ingenious instrument for urethral incisions from before backward. M. RATTIER (Gaz. des Hop., 1843, p 420) presented to the Paris Academy an anterograde urethrotome, which, like many others, was seldom, if ever, of prnc" tical utility. Indeed,'until many years later, all modes of puncture, scarification, or incision from before backward of urethral strictures were regarded as very hazardous unless confined to tbe pendulous portion of the urethra; but the division from behind forward of cal- lous strictures that would admit the passage of an instrument of medium size, or what is now termed retrograde urethro- tomy, was considered much surer and safer, and many instru- ments were devised for accomplishing this operation. In 184."), Petrf.QL'IN transmitted to the Acad. roy. de mid. de Belgique his memoir: " Sur Vemploid'un nouvel urethrotome dans le traitement des ritricissements de I'uretre, d'apres des recherches particulieres d'anatomie path, sur les coarctations urithrales. Petrecjuin reported five successful cases; his retrograde urethrotome was denominated quadrilateral; it did not come into general use. The urethrotome of Ivan- CHK'H, represented in the annexed wood-cut (Fig. 331), is praised by Dr. Wenzel LlNHART (Compendium der Chir. Operationslehre, Wien, 1862, p. 901), and is said to be much employed by German surgeons. It is an ingenious but com- plicated instrument. Herr Stilling (Zur Inneren Urethro- tomies, Berlin, 1866), in a severe and somewhat ungenerous criticism, undertakes to show that it is merely a derivation from Stafford's instrument. A description, with figures, of a urethrotome of Vernhes, which met with academic appro- bation, may be found in the Gazette des Hiipiteiux, 1848. p. 320. In the second edition of his treatise on operative? surgery, of 1855, Professor Sedillot (Traiti de med. op., 3me 6d., Igiiii, p. 554) intimated that ''the really useful discovery surgeons require, would be a urethrotome adapted to the division from before backward of such strictures as can be penetrated by a filiform bougie. The real practical difficulty is to pass and dilate very narrow strictures. Months, indeed, arc sometimes lost, and the greatest obstacles are encountered, before recourse can be had to the urethrotomes hitherto pro- posed, which require an opening of several millimetres, at least, for their admission. Were it possible to bring to bear on the constriction a cutting blade, using the bougie that had passed the stricture as a conductor, the patient and surgeon would be spared much time and trouble. I have made some essay- in this direction, and, notwithstanding the imperfection of my instruments, will allude to them in order to indicate the way toward which our research'^ should be directed.'' The conditions on which Professor Sedillot insisted, BONNET (De I'incision d'araut en arriere des ritricissements du canal de I'uretre. par Philipeaux, Gaz. des Hop.. 1848, p. 10s) sought to supply by a urethrotome (FIG. 334) furnished with a metallic conductor; but FIG. 331.-Urethro- tome of IVANCHICH. FIG. 332.-Urethro- tome of Leroy. Fig. 333.—Sedil- LOT'S urethrotome. A. Physick's lancetted catheters. B. Physick's coTirluclin^ bougie. C. Jameson's urethroloiue. D. Chew's lancetted catheter PLATE XII. URETHRAL INSTRUMENTS I * Hewit's tjor^et for external urethrotontv E. F. N'.Otis's dihitin$ urethrotome. F.Dodd's scarificator, G. Goulev's uretlirotome. H. Hammer's urethrotome \ !1 SIX'T. III.] OPERATIONS ON THE URETHRA. 39i "Or FlG. 335.—Urethrotome of Herr Stilling or of M. Uoinet. inferences from the general allusions to the subject are, that rupture, or divulsion, was preferred to incision in the treatment of obstinate post-scrotal strictures, being so sure and easy of execution with the improved instruments, that, in some minds, it became a question whetlier this method would not eventually ^*^---------------------------------------g^ „,%> supersede in- ternal urethro- tomy altogether. The instruments for incision and rupture of strictures very gradually attained their present excellence; and it is interesting to note that American ingenuity has been creditably illustrated in their successive improvements. In proof of this assertion, it is only necessary to call attention to the various urethral instruments figured in Plate XII, opposite. It will not be difficult to recognize, in the bougie conductor (Fig. B, 1, 2) which Physick used in 1796, an anticipation of the filiform conductors so much approved half a centmy later. In Jameson's anterograde urethrotome of 1828 (Fig. C, 1, 2) the blade is shielded in the fashion now most commended; and in Chew's instrument, also proposed in 1828, are found several of the devices subsequently held of value; while the urethral instruments of recent American invention happily combine those ingenious his instrument was not a great improvement on that proposed twenty years before by Stafford. M. Ricord (Traiti pratique des mal. viniriennes, 1838, p. 74G) employed internal urethrotomy from an early period of his practice; but very guardedly, and rather by scarification than deep incision. The instrument made for him, in 1839, by M. Ciiauuieue, is represented in the accompanying wood-cut (Fig. 337). CIVIALE (De I'urethrotomie, ou de quelques procedes peu usitis de traiter les ritricissements de I'uretre, 1849), on rare occasions, used an anterograde urethrotome of simple construction, for the division of strictures in the pendulous portion of the urethra only ; and subsequently invented the retrograde urethrotome (FIG. 339) which is commonly known by his name, having come into quite general use. To apprehend clearly the value of Reybard's urethrotomes, it is necessary to consult the voluminous report by RoliEltT (Bull, de VAcad, de Med., 1851-52, T. XVII, p. 1097) of the commission that adjudicated the Argenteuil prize in 1852. The commission decreed the prize to the dissertation of Reybakd because : " On y trouve un point de depart nouveau, bas6 tout a la fois sur l'anatomie, la physiologie pathologique et ^experimentation. Enfin, une serie de deductions conduisent. logique- ment Tauteur a rejeter les moyens de traitement connus, et a proposer une therapeutique nouvelle dont il demontre l'emcacite par des faits nombreux. M. Kevbakd a realise le perfectionnement les plus important pour la cure des retrecissements de I'uretre." In 1853, Reybard published his Traiti pratique des ritricissements du canal de I'urethre, in which are figured two of the instruments (Fig. 33b) with which he practised his deep and free incisions. These were followed by haemorrhage, or dangerous febrile attacks, or other disastrous results, often enough to raise a prejudice against internal urethrotomy in any form ; yet the view for which REYBARD contended—that incisions of strictures to be of use must be extended through the indurated tissue—was just; and he was not the first reformer to insist extravagantly upon his innovation. Subsequently, in 1.853, JI. Maisonneuve (Gaz. des Hop., 1853, p. 581) sought to put the same idea in execution by using Frere COMES lithotome as a urethrotome; but the dangers of such an application being demonstrated, M. MAISONNEUVE (Seance de I'Acad. des Sci., Jlay 14, 1855) devised the simple and effective urethrotome (Fin. 330) now in general use, suggested, as the inventor observes, by the mode of catheterism on a conductor he had proposed ten years before. The urethrotome of JI. lioiXET, with a metallic guide (FIG. 335), was an improvement on that of BONNET, but was not much used after the invention of M. M.MsOnneuve'b simpler instrument, with its filiform elastic conductor ; though Limiart (Compendium der Chir. Operationslehre, 1862, N. 895) states that a similar instrument, suggested by Herr Stilling, was recommended in (leiinany. The urethrotomes of JI. MAHylEZ (Note sur un coarctotdme, in Gaz. mid. de Strasbourg, 1856, p. 131), of Sir W. FERGU8SON (A System of Practical Surgery, 1857, 4th ed., p. 779), of JI. JlKRCIER (Recherches sur le traitement des maladies des organes ginito-urinaires consideries specialement chez les hommes dges, etc.. 1856, p. 421), of Professor Gitoss (.,1 Pract Treat on the Dis., etc., of the Urinary Bladder, the Prostate Gland, and the Urethra. 1855. p. 791), and of Dr. Liniiaut (Beschreibung eines Urethrotoms, in Verhandl.der Phys. med. Gesellschaft in WUrzburg, 1858) have had their advocates, but have not come into general use. Dr. W. F. Westmoreland, of Atlanta (Strictures of the Urethra, in the Nashville Jour, of Med. and Surgery, 1854. Vol. VI I. ]>. 91), commented favorably on the method of Reybard, and proposed a urethrotome furnished with a metallic guide, which is figured by Dr. J. F. Bumstkad (Pith, ani Treatment of Venereal Diseases, 18ii4, p. 309). M. Favrot (Gaz. des Hop., 1859, p. 5(1) submitted a three-bladed urethrotome, which is of historical interest merely. The anterograde urethrotomes of Dr. C. A. PETElts (PLATE XII, FIG. E, 3) and of Sir II. TlIOSIl'SON (Path, and Treatment of Stricture of the Urethra, 1858, p. 238, and The Value of Internal Incision in the Treatment of Obstinate Strictures of the Urethra, in Lancet. 1859,Vol.II, p. 384), on the other hand, have been Fig. 33S.—Urethrotomes of Reyiiaud. Fig. 337.— Fir.. 338.— M. RicOKD'S Scarificator of scarificator. Dr. Dui'lRURis. 396 INJURIES OF THE PELVIS. [CHAP. VII. FIG. 339.—ClVIALE'S urethrotome. modifications that later experience has approved. Borne surgeons are disposed to restrict tin1 application of anterograde internal urethotomy to strictures in the pendulous portion of the urethra, but recommend the incision from behind forward of constrictions more deeply seated. The urethrotome of Civiale (Fig. 339) is esteemed one of the most serviceable; but operators are now enabled to select from a great variety of such instruments. There is little or no evidence regarding the applicability of internal urethotomy in strictures consequent on shot injuries. Among the cases of fistules, were a number in which the urethra was nearly or completely impermeable in advance of the abnormal opening, and in some of these instances internal urethrotomy might have been the best means of restoring the calibre of the canal; but there is no evidence that the experiment, was ever tried. Dila- tation and external incision appear to have been the only modes of operative interference with traumatic stricture. External Perineal Urethrotomy.—The number of instances in which external much employed. Two other urethrotomes, that have been used, are figured below (Figs. 340 and 341) as the urethrotomes of MM. Trelat and Charrietie. Dr. BitON (Gazette med. de Lyon, 1859) disputes priority of invention in the details of these instruments, and, indeed, their proposers make no claim of originality, but have very ingeniously 3 adapted and combined the serviceable features in the instruments of other inventors, and have made urethro- tomes that may be used indifferently to divide strict- ures from before backward and from behind forward. An account of the instrument of M. TRELAT will be ' ^,e \\ found in the Gazette des Hopitaux, 1863, p. 300. Ciiarrieee's instrument was shown to the Paris Academy in November, 1852 (Gazette- midicale, 1852, p. 755). Both of these urethrotomes have, however, undergone man)7 modifications, and, as here represented (Figs. 340 and 341), are supplied with filiform guides and other recent mechanical improvements. Urethro- tomes have been continued with curved rotating blades for the excision rather than incision of strictures that permit the passage of a small* canula. The urethro- tome of M. Mallez (Fig. 342) is of this sort, and is intended for use with very narrow strictures. It is difficult to make these curved blades effective. An ingenious though complicated urethrotome with a catheter attached, invented by M. J. CllAliltlEUE (Nouvel urithrotome d, lame cahee, et porte-sonde, in Gazette des Hopitaax, 1864, p. 87), is shown in FIGURE 343. Latterly the advantages of combining incision with divulsion, in certain cases, has attracted attention, and an instrument devised for this purpose by Dr. F. N. Otis (New York Med. Jour., 1872, Vol. XV, p. 159, and Vol. XVII, p. 281) is figured on PLATE XII, Flo. E, 1, 2, 3. Already Dr. A. HAMMER, of St. Louis (Gaz. des Hop., 1854, p. 127), had sought to accomplish this by an instrument resembling the lithotome of Frere Come (Plate XII, FIG. H), and supplied with a blunt as well as a sharp concealed blade. D. C. D. Mastin, of Mobile (Report on Internal Urethrotomy, 1S71), has recommended a modification of the antero- grade urethrotome of M. Maisoxneuve, which is not unlike the urethrotome perfected by Professor Sedil- lot, represented by Figure 333. Of the retrograde urethrotomes, that of Civiale (Fig. 339), or some of its modifications, has been most employed. M. CAUDMOXT's instrument is, perhaps, the best of this class. M. HOEIOX (Des retentions d'urine, 1863), M. Beykan (De I'urithrotomie dans le traitement des ritricissements de I'uretre, in V Union mid., 1865, p. 148), and many others, have invented urethro- tomes, some of which display great ingenuity. If slight ameliorations in details, in the fabrication of urethral instruments, have sometimes been unwisely claimed as real inventions, the practical importance of many such slight improvements must, none the less, be recognized. Although in oper- ations in this region, as elsewhere, more depends upon the judgment and skill of the surgeon than upon the instruments he uses, yet nowhere, not even iu operations on the eye. is nicety of mechanism in the instruments more essential. The progress in this direction must be esteemed among the more important advances in modem surgery. Fl<:.310.—TRELAT'S urethrotome. Fig. 341.—Urethro- tome of Charriere. Fig. 342.— Urethrotome FIG. 343.—Ciiarrieiie's of M. MALLEZ. urethrotome porte-sonde. skct. m.| OPERATIONS ON TIIR URETHRA. 397 incisions1 were resorted to for the relief of stricture appears to have been small. In regard to the cases of traumatic stricture, this is the more remarkable, because so many of them were attended by fistules; there being no less than forty-eight examples of this distressing complication. Only seven operations of external perineal urethrotomy were reported, and but four of these were performed on account of consequences of shot injury. The first of this series was a division of a traumatic stricture a month subsequent to the injury: Cask 109-2.—Corporal 0. Walter, Co. D, JKith Pennsylvania, aged 39 years, was wounded at the Wilderness, May 5, 18«>4. He was admitted to the Second Division Hospital, Alexandria, on the 26th. Acting Assistant Surgeon J. Cass made the follow- ing report of the case: " Gunshot wound ofthe scrotum, dividing the urethra. The wound is healed, leaving a perm anon stricture, and in .lime, 1864. Acting Assistant Surgeon C. P. ltigelow performed the median operation for stricture by incision through the raphe, three inches in length, into the urethra. The general condition of the patient was favorable; the anaesthetic used was sulphuric ether. After the operation the catheter was introduced and allowed to remain." On October 29th, he was transferred to McClellan Hospital, Philadelphia, where he was treated for the wound, which was still open. He was discharged June 1, 1SJ.>. Surgeon L. Taylor, IT. S. A., on certificate of disability stated that ''he was wounded in the right thigh, right testicle, and uretln-Ji, the ball making its exit through the left thigh." Examiner J. Lenox Hodge reported, June 5, l>-'6.>: "The wound has impaired the usefulness of the right thigh and has left him with a tight stricture of the urethra, which obliges him to wear a catheter all the time." Examiner J. S. Crawford reported, September 17, 1H7.5: ''The projectile entered the back part of the right thigh, passed upward and outward and made its exit in the middle of the thigh, and, entering the scrotum, passed through it, cutting the urethra, and came out on the left side below the hip joint. One testicle is entirely removed, the other is atrophied. He has to wear a tube that reaches above the opening in the urethra; disability three-fourths." This pensioner was paid to September 4, 1S73. There can be little doubt, that a successful operation for perineal section, described by 1 The history of external perineal urethrotomy has been obscured by partisan discussions chiefly on the merits of Syme's operation. An immense amount of rubbish has been debited regarding the nature of the operation denominated boutonniire; the "patriotic bias" has been unbecomingly manifested; much unwarranted egotistical assumption, and much ignorant aud malignant detraction, has been displayed. Yet the historical facts remain, to be traced readily enough by the unprejudiced student. It is unquestionable that incisions in the perineum for the relief of retention of urine or of stricture, or of foreign bodies impacted in the urethra, were practised, in very early times, under the name of perineal puncture, section, urethrotomy, or boutonniire. It is equally clear that important distinctions may be pointed out between these exceptional operations, and the modern methodical operations of external perineal urethrotomy upon a grooved staff, and of external perineal urethrotomy without a conductor. Perineal urethrotomy in some shape is probably coeval with lithotomy; but the first distinct mention of it, as a separate operation, appears to be contained in AKET.EUS (De curatione acut et diutur. marborum, ed. Boerhaave, Lugduni Bat., 1735, Lib. II, p. Ill, de curatione acutorum vesicse affectuum), who, A. D. 80, speaking of calculi impacted in the urethra and causing retention, advised that they should be cut down upon and removed. '''He Se ajropo? p.ev rj 17 TmvSe 'njTpeirj, OvtJctkt) Se bSvvr}0-i iiivdpiairos, Ta/xvetl' Trjv rpt^a5a koll top tt)9 kvcjtio? TpaxfjA.oj', es re ttj^ ruv \LBu>v exnTioo-iv" (at si expediri, medieatio nequit, homoquc doloribus consuniitur, locum eum. qui sub glandc est, cervicemque vesicae incidito, ut lapis excidat). The context shows that this was a familiar operation at that time. Ten years later, HELlODOaus (loc. cit, Lib. XLV) commends a similar operation for scleroma with retention: "n-puis Se tu bo-xe^, tok vnb to a/cA^pwjLta totto^ Siaipeiv XPVi o-vvSia.ipovp.evov Ta> Trepiveui tov rpa\^\ov ttj? Kuaretos, iva Kara entT-ijSevo-iv yevrjrai pi/as" (If. on the contrary, the scleroma was situated near the scrotum, the region below the tumor should be divided, including in the incision the neck of the bladder and perineum, in the avowed purpose of leaving a urinary fistula.) OMBASIUS (Opera, cd. STEPH ixi, 1567, Synopseos, Lib. IX, cap. XXXII. p. 14G), in the fourth century (circa A. D. 3(i0), advises a similar perineal urethral incision for removal of coagula: "Spatium quod inter anum et pudendum interjacit. quod perineum dicitur. secare, quemadmodnm in vesica? ealculo consueverit, atque itagrumaseducere." In the sixth century (A. D. 550), .iEtius ('letrabiblos, Lugduni, 1549, p. 690) repeats this recommendation: "Sic vero ncque sic grumi dissolvantur, intercapedinem inter anum et pudendum, perineum Gra>cis dictam, inferne dissecare oported, quemadmodnm in calculosa vesica est praadictum, et eductis grmnis de cetero." In the following century (A. D. 650), PAULUS vEGINETA (Syd. Soc, ed. Adams, 1844, Vol. I. p. 54(5) apparently quotes this advice, though without acknowledgment: "If there be coagulated blood in the bladder [which cannot be dissolved by methods recommended, then] we must make an incision in the perineum, as in the cases of calculus, and, having removed the clots of blood, accomplish the cure in a proper manner." The same precept reappears in the writings of the Arabians. IlIIAZES, of Bagdad (A. D. 850-9:23), (Continent,ed. Venet., 1506, Cap. X, p. 215, De segrolidinibus renum et vesicse), speaking of dysuria caused by blood coagula, remarks: "Et nisi dissolvatur, aperiatur exitura cum ferro." Avicexna (Opera, Venet., 1598, Lib. Ill, cap. VI, p. 83J), after describing the use of tho catheter in cases of retention, advises no further operative interference, but says that others have adopted a perineal section: "Quando urinae fit difficultas * * est aliquis qui ingeniatur, et in eo, quod est inter anum et testioulos scissuram elficit parvain ct pouit in ca cannnlam ut eggrediatur." It was not, however, until GIOVANNI, of Cremona, and his disciple JIauiano Santo, established and popularized the operation of lithotomy by the major apparatus, that this form of urethrotomy came into common use. All of these citations refer to instances of what the old French surgeons would call la boutonniire, and henceforward minute directions were given for the operation. The patient was to be placed in the position for lithotomy. A grooved staff was to be introduced. An assistant raised the testes. The operator, taking the handle of the staff in his left hand, made the convexity of the curve of the staff to project in the perineum; then, holding his knife as a writing pen, he was to make, back of the scrotum, on the median line, or slightly to the left of the raphe, a longitudinal incision, descending nearly to the anus and interesting the urethra for the extent of an inch or an inch and a quarter. Then, laying aside the knife, he took a gorget and introduced it along the groove of the staff, through the perineal wound to the bladder, and then withdrew the staff. The gorget, in its turn, served as a guide to carry a full-sized tube into the bladder (VOLLEMIKI!, op. cit, p. 311). Many would restrict the term external urethrotomy to cases in which the operation was done with a view of dividing a stricture. Great confusion has arisen from this distinction having been observed or neglected by different writers. TllEVENTX (of Paris) does not treat specially of strictures ; but in speaking of retention of urine (CEuvres, contenant un traite des tumeurs, etc., Paris, 1658, Cap. (.'XXI p. 167) he describes this operation : " L'operateur fera une incision avec le bistouri entre I'anus ct le scrotum/' and he added an improvement; for instead of using a gorget, after dividing the urethra on a grooved staff, he glided along the groove of the catheter a stylet, which served as a conductor for the introduction of a tube into the bladder, and avoided the extension of the urethral incision toward the prostate. The remarkable operation by MOLIXS, 3')S IN.UIRIMS OF TIIK PELVIS. [Chap. VII. t the late J. Mason Warren (Surgical Observations, 15, Case OXXXIII), was performed upon the subject of the following observation, although no name is mentioned in Dr. Warren's report:1 Case 1093.—Private R. Nelson, Co. K. 29th Massachusetts, aged 20 years, was wounded at Fort Steadman, March 25, H.io. From a Ninth Corps field hospital, Assistant Surgeon >S. Adams, U. S. A., reported: "Gunshot wound of the perineum, severing the urethra; the hall entered the perineum in front of the anus, and came out through the pelvis and scrotum, dividing the urethra; the urine passed through the posterior wound: simple dressings." Dr. A. T. Fitch, April 1st: "Pulse good; much fever; tongue clean; appetite good; no sleep; not much pain." On April 3d, this patient was transferred to City Point, and, on ihe ?th. to Alexandria, whence he was discharged May 31, 18(1."). and pensioned. Examiner G. >S. Jones, of Boston, reported, .June 11*. M>5 : "Tlie hall entered the penis, passed through the right testis and neck of the bladder, and emerged from the left natis near the cleft. A fistulous opening now exists, from which hib urine escapes. The right testis is atrophied, and its functions are evidently greatly impaired. The disability is total and permanent, and biennial examinations are evidently not required." This pensioner was paid September 4, 1873. In this case, three months after the reception of the injury, the posterior portion of the urethra was found involved in a mass of cicatricial tissue, and a bougie/introduced at the meatus emerged at a fistule near the anus. Perineal section was performed, and great difficulty was experienced in finding the orifice of the urethra that led to the bladder. d he gristly mass was divided, and a large catheter was -introduced. There was immediate relief; but the ulterior result was less satisfactorv than had been anticipated. In the in 1662 (Wiseman's Chir. Treat, 1C76, Book VII, Chap. VI, p. 76), which some authors regard as the first recorded example of external urethrotomy without a conductor, will be again referred to. Surgeons were not deterred from attempting perineal section when it was impracticable to pass a grooved staff because of the contraction of the urethra. Thus COLOT (F.) (Traiti de la Taille, 1727, p. 241) relates several instances in which he incised the perineum and divided the urethra without a guide, "sans rigle et sans appui." especially a case in which he successfully operated on a notary of the parliament of Paris. In this case there were three perineal fistules, which might have facilitated the operation. Civiale (Les mal. des organes ginito- urinaires, 3m» ed., 1858, T. II, p. 323) refers this particular operation, by FltANOOis COI.OT, to June '28. 1867. In the treatise on Diseases ofthe Urinary Organs, by Dr. GOULEY, which is issued to medical officers, such an excellent historical summary is supplied of the progressive improvements made in effecting perineal incisions, whether for the relief of stricture or of retention, that it is almost a work of supererogation to recapitulate the bibliography of the subject at this period. Among the writers of the last century adduced by this author and by Professors VOILLEMIEU and STILLING may be particu- larly noted: TOLET (Traiti de la lithotomie, 1681, and the English translation by Lovell, 168:5, Cap. XXI, p. 14(1); (SOLINGEN (Mmiuale opiration de chirurgie, Amsterdam, 1(184), and the citations from the same in Stalpakt Van dek "Wiel (Obs. rar. med. anat, 1087, T. II, p. 410); PALEYX (Aunt. du corps humain, Paris, 1726, p. 174); Dio.MS (Cours d'operations de chirurgie, 4""ced., 1750. p. 19.1), and La FayE in his notes to DlONIS (op. cit. p. 211); Le I)i:.\N (Traiti des opirations de chirurgie, 1742, p. 368); COL. DE VlLLAUS (Cours de chirurgie dicti aux icoles de mid., Paris, 1747, T. IV, p. 221); AsTitL'C (De morbis veneriis, 1738, p. 242), and Muzell (F. H. L.) (Medicinische und chirurgische Wahrnchmungen, Berlin, 1714, S. 113). Tho import- ance of including the indurated tissue in the urethral incision was well recognized by J. L. 1'KlTT: "All those on whom I practised the boutonniere on account of retention of urine," he says, ''regained freedom of the canal, provided the stricture was comprized in the. incision." (Mem. de I'Acad. de. C'a ir.. ed. Fossone, T. II, p. 17.) Hunteu's operation for perineal fistula (Treatise on the Venereal Disease, London, 1788, p. 160) is memorable in tho history of this operation. His renowned contemporaries, Desault, SlIAKPE, and ClIOl'AUT, condemned perineal incisions, which, apparently, were undertaken about this period so injudiciously that external urethrotomy, discountenanced by these masters, fell into desuetude among European surgeons. The operation was revived in this country by Stevens (The Medical and Surgical Register, consisting chiefly of Cases in the New York Hospital. 1818. Vol. I, p. 7."), and soon afterward Jameson, whose papers are elsewhere cited, D. L. Rookks (Philadelphia Med. and Phys. Jour.. Vol. XIX, p. 186), and J. ('. YVAltltEN' (Boston Med. and Surg. Jour., 1829, Vol. II, p. 321) described eases of its successful performance; and. later, at the New York Hospital, between 18:18 and 1843, external perineal urethrotomy was not infrequently performed. Meanwhile some British surgeons, Chevalier, GL'TIIIME, Ais.v'ott, and BUODIE, especially, endeavored to raise external urethrotomy from the discredit into which it had fallen ; but it remained an exceptional operation until 1844, when .Syme. with great earnestness, recalled professional attention to it and placed its advantages in a new light, maintaining, indeed, that all cases of urethral obstructions that were not curable by dilatation should be treated by internal incision. Syme simplified the operative method, and greatly improved the instruments for performing it. His guide staff, as used by his Edinburgh disciples, is figured in the wood-cut (Fin. 344) on the preceding page. The importance of inclnding in the incision not only the strict urcd portion of the urethra, but a portion of the uncontracted canal, was established by the researches of Syme and of Civiale. The objection to Syme's metallic conductor, that the operator was exposed to the danger of entering and cutting upon a false passage, has been obviated by the employment of filiform gum conductors, or of capillary whalebone guides. A great improvement, suggested by Mr. Aveky. consists in passing a loop of silk through each edge of the incised urethra. Other details in the manual of the operation have been perfected by contemporaneous surgeons. ■Regarding American experience in external perineal urethrotomy, besides the systematic works by Drs. Gloss. Mokland, and Gouley, and papers already cited, the following articles may be consulted, viz: A series of seven cases of traumatic stricture successfully treated by this plan by J.Mason YVaiikex (Surgical Observations, with Cases and Operations, 18(37, p. 234 et seq.): LENTE (F. D.) (Perineal Section for Stricture ofthe Urethra, in the New York Jour, of Med., 1855, Vol. XIV. p. 220; also Surgical Statistics of the New York Hospital, in Trans. Am. Med. Assoc, 1851, Vol. IV. p 330. containing a tabular statement of the results of twenty-seven operations of perineal section); Halsey (W. S y (Strictures of the Urethra treated by SY.ME's .)/• ihod, in the Am. Jour. Med. Sci., 1858, Vol. XXXVI. p. 72): MALUY (It. Ii.), (Traumatic Stricture; Perineal Urethrotomy without a Guide, in The Medical Record, 16'iG, p. 417); VAX BL'liEX (W. H.) (Clinical Lectures on Traumatic Stricture, in The Med. Record. 1865, pp. 180, 278); AsllHL'KST (J., jr.) (Traumatic Stricture complicated with Perineal Fistula; Treatment by external Division, in Am. Jour. Med. Set, 1866, Vol. LII, p. H: : WHITEHEAD (\V. R.) (Perineal Urethrotomy, in The Med. Record.. 1866-67, Vol. I, p. 491); GlIION (A. L.) (Stricture of the Urethra, etc., Perineal Section. L'ecorery, iu the Am. Jour. Med. Set, 1868, Vol. LV, p. 556); CUEAMElt (J.) (External Perineal Urethrotomy, in The New York Med. Jour., 1st.!'. Vol. IX. p. 139); BLKKE (G. M.) I Perineal Section for impermeable Stricture, in The Western Jonr.of Med., 1869); Gavin (M. T.) (Case of impacted Urethral Calculus; External Urethrotomy, in the Boston Med. and Surg. Jour., 1870, Vol. VI, p. 118); IngaI.I.s (\V.) (Urethral Calculus; Rteiition of Urine; External Urethretomy, in Boston Med. and Surg. Jour., 1871. Vol. VII p. 93); Ili.wir (H. S.) (Perineal Urethrotomy, in The M'd. Record. 1871-72. Vol. VI. p. 316): Oils (F. X.) (Remarks on Stricture of the Urethra of extreme calibre, in the Xew York Med. Jour'. 1872, Vol. XV, p. 152); T.WI.OK (B. F.) (Operation for Stricture of the Urethra, with Remarks, in The New Orleans Med. and Surg. Jour.. 1850-51, Vol. VII, p. 331): HINT (\V.) (Traumatic Rupture of the Urethra, recent awl chronic, in The Medical Times, Phila., 1870-71,.Vol. I, p. 173); BlUDDON (C. K.) [Contributions to the Surgery of the Male Urethra, in The Med. Record, is*2. Vol. VII. p. 21!0. SECT, nil OPERATIONS OX THE URETHRA. ?>99 next case, perineal section of a traumatic stricture1 was practised live months after the injury, and, for a time, the operation promised well; but, afterward, a fistule persisted for three years, though it appears, ultimately, to have closed spontaneously; a rare result.2 It is not strange, if the absorbing duties of military surgeons during time of war is con- sidered, that so few operations of this class were then reported, nor that several of them should have been practised in civil hospitals. There were, indeed, more cases of external urethrotomy reported in the five years succeeding3 than during the War; and armv experience of the treatment of traumatic stricture must be owned to be limited.'1 Cask 1004.—Sergeant S. W. Shadle, Co. 1>, 11th .Pennsylvania, aged 'J*i years, was wounded at the Wilderness,May 6', lS,i4. He was sent to l'inley Hospital on May 2(\th. The following entry appears on the unsigned hospital ease-hook: "Shot wound of the right testis, and also injury to the urethra. The testis was removed on the lield, May 7th. On June oOlli he was furloughed, after which lie was readmitted. The wound healed. Out produced stricture of the urethra, for which an operation by external perineal section was performed by Surgeon G. L. i'ancoast, U. S. V., on October 1st. December 8th: The patient is doing well; the catheter is kept in the bladder; the wound of operation has commenced healing since the application of officinal iodine ointment on lint. The wound, which was very indolent at the time, was stopped with the charpie thus prepared. Extra diet and porter were given. On the 10th. a small orifice had made its appearance at the root of the penis on the under side, and communicated internally into the urethra. Cataplasms were constantly applied to the testis. l!y the 16th the new opening just mentioned was quite healed. Iodine ointment was continued, and calomel was given internally. The opening at the root of the penis which closed on the 16th was again open on the 2.3th. This was caused probably by the use of a silver catheter a second time, elastic ones not being used in the hospital. A sulphate of quinine pill was given every two hours. On the following day the remaining testis was inflamed and was quite hard and painful; severe pains also extended to the cord. The patient was attacked by severe chills, followed hy fever, probably of a malarial character; and the tongue was loaded with a yellow coating. Wine and tonics were given. By January 5, 1SI.T>, the patient was much improved; the chills had ceased, and the inflammation in the testis had subsided. But little change took place from this date to February 6th; catheterization was continued; the discharge from the wound had nearly ceased, and the patient's health, generally, was good." This man was discharged August 3, lSo'i, and pensioned. Examiner M. D. Benedict reported, August 4, lH'i."): "A musket ball entered the scrotum and was extracted from the perineum. The right testis was extirpated. The urethra was wounded, and there remains a fistulous opening of the urethra anterior to the scrotum, through which fistula the urine passes in part." Examiner J. S. Crawford reported, January 6. 1868: "The projectile struck the scrotum and carried off the right testis, wounded the urethra iu its upper third, and also the perineum. Urine passes through a fistulous opening in the upper third of the urethra. The left testis is now swelled and inflamed. In erection of the penis, chordee occurs, from the adhesive inflammation of the urethra. His amorous desires are not destroyed. The fistulous opening in this case certainly could be closed by a proper operation, and I endeavored to persuade him to have it done. Successfully done, the operation would remove the unpleasant feature in this man's ease." The same surgeon continues, September 15, 1873, by saying that "the pensioner has incontinence of urine at night; through the day he has to micturate often, and he has neuralgia in the back as the result of the wound. The fistulous opening is closed; the incontinence occurs from partial paralysis of the sphincter muscles, and his disability is total." This pensioner was paid September 4, 18/3. The next case was very complicated, and perineal section was practised, on the tenth day after the injury, for the removal of a bone fragment and the relief of infiltration 'BILLROTH (Th.) (Chir. Briefe aus den Kriegslazarethen in Weissenburg und Mannheim, 1870, S. 20(1) speaks of a case of "shot wound through the perineum with laceration ot the urethra, August 4, 1870; obliteration of the latter; tedious discharge of urine by the perineal listula only. September 2Cth, I performed external urethrotomy, and introduced a catheter by the urethra. On November 15th, 11 err LosskN' had the kindness to write to me: By the urethrotomy the wound of operation has healed some time since. Patient has, for four weeks, urinated through the urethra, and cathetcrizes himself." Herr Lossen (Kriegschir. Erf. aus Mannheim, Heidelberg und Karlsruhe, in Deutsche Zeitsehrift fur Chir., i87 3, 11. II, s. 21) gives the patient's name as Johan Markewilsch, 40th Prussian regiment, and adds: "Both shot wounds granulated finely after ihe operation. About the middle of October, 1870, urine passed through the urethra for the first time. Wound cicatrized rapidly. In November, the patient introduced the catheter twice daily, but was able to pass urine without it.'' Dr. I.ossex saw this patient at Schwctzingen about, tho middle cf January, 1871: ■■ The anterior shot wound had become fistulous again and passed urine in drops. Further information is wanting." Heck (B.) (Chirurgie der Schussverle- tzungen, 1872, S. 560) states that, in the Bavarian Corps, "thrice, external urethrotomy was successfully performed for retention cf urine and infiltration in consequence of injury or traumatic stricture, no retarding complications occurring." Fleoiiy (C. F.) cites a successful case of external perineal urethrotomy after shot injury, from the Franco-German War (Fistules urinaires, pelvienne et fcmorale, suite d'un coup de feu, urithrolomie externe sans conducteur.— Guirisou, in Gaz. des Hop., 1871, No. 41). 2 Williamson (G.) (.)///. Surg., 18b':l, p. 118) mentions two cases of invalids from the Indian Mutiny, under the care of Assistant Surgeon Smith, !)th Lancers very similarly wounded by balls traversing the left testis and wounding the urethra, perineal fistula? resulting. "The fistulous openings in tho canal closed entirely, and the natural passage remained undiminished in size, allowing a full-sized catheter to pass with ease into the bladder." 3 Compare the Report on Surgical Casesin the Army, Circular 'i, S. (1. O.. 1871. Cases DCXCII, DCXCIV. p. 254 ; DCXCV, p. 255. 4 BILLROTH (TIL) (Chirurgische Erf., Zurich, 18!i0-(>7, in Arch, fur Klin. Chir.. 18G0, B. X, S. 532) gives eleven cases of traumatic strictures of the urethra, caused by fails on the perineum. Six of the patients came under treatment early and were successfully treated by gradual dilatation. In a boy oi eleven, with a stricture of one year's standing, a very fine catheter was successfully introduced ; after the second insertion, fatal uraemia super- vened. In four cases—nine weeks, two years, four years, twenty years after the injury, respectively—bougies could not be introduced. In the last three, complicated with urethral fistules, external urethrotomy was performed and catheters were introduced. Death from unemia took place, respectively, on the seventeenth, second, and third days after the operation. In the f.mrth case, while attempting to introduce a catheter, the instrument passed through the weak cicatrix into tlie space between the bladder and symphysis pubis: the attempt was discontinued ; fatal perivesical infiltration of urine resulted. 400 IX.IUPJES OF *TITK PEEVTS. |CHAi\ VII. rather than for traumatic stricture, and the observation, already alluded to on page 2ttl, should, perhaps, have been classified under the head of perineal incisions rather than as an example of external urethrotonxy. Thus far the experience of the latter operation for the consequences of shot injury has been extremely limited. • Cask 1095.—Private E. English, Co. I, 67th New York, aged 21 years, was wounded at Fair Oaks on June 1,18G2. He was sent to the Fifth Street Hospital, Philadelphia, on June 8th, and Acting Assistant Surgeon A. C. Bournonville reported the progress of the case substantially as follows: A round ball had struck on the right buttock, entered the pelvis, fracturing the spine of the ischium, passed through the bladder at the neck, through the right obturator foramen, splintering the descending ramus of the pubis, and emerged on the thigh (passing under the femoral vessels) at the apex of Scarpa's triangle. The femoral vessels were uninjured, but the crural nerves were implicated. On admission, the patient was much prostrated; the right leg was paralyzed and much swollen; urine passed from the wound of exit, and urine and pus from the wound of entry. On passing a sound into the bladder a hard foreign body could be felt. On June 11th, Acting Assistant Surgeon T. G. Morton made a perineal section, three days after the patient's admission, and a catheter was introduced and allowed to remain. A fragment of bone three-fourths of an inch long, which had worked its way through the bladder into the urethra, was extracted on June 13th. Stimulants, tonics, and opiates were subsequently prescribed. The urine flowed freely through the catheter. On June 19th, a large flow of dark clotted blood from the bladder escaped from the wound of exit and from the section. The patient died from extreme exhaustion on June 26, 1862. Three instances were reported of operations of external perineal urethrotomy1 in cases of strictures of non-traumatic origin : Cask 1096.—Private P. Martin, Co. H, 88th New York, aged 30 years, was admitted into Finley Hospital, April 20, 18G4. On the regimental monthly report for April, signed by Surgeon R. Powell, one case of disease ofthe urinary and genital organs is noted, without comment. Surgeon G. L. Pancoast, U. S. V., reported, from Finley: "Stricture of the urethra since April 15th. He could not void water except by drops, and no instrument of any kind could be passed. His general health was very good. On September 28th, chloroform was administered, the stricture was laid open by a cut from without, and a large silver catheter was then passed into the bladder. The patient did well, and was returned to duty January 8, 1865." Cask 1097.—Private J. Ewing, Co. H, 49th Pennsylvania, aged 35 years, was admitted into Cuyler Hospital. May 20, 1864, with amputation at the right shoulder joint performed eight months previously. He was furloughed a short time in June, and subsequently he was treated for stricture, and Assistant Surgeon H. S. Schell, U. S. A., reported as follows : "Stricture of the urethra following an attack of gonorrhoea seven years prior to admission. The stricture was impermeable, and the perineum was the seat of several fistulous openings. On November 15th, the patient was chloroformed, and Acting Assistant Surgeon 15. Rohrer performed the operation of perineal section. A grooved director was introduced into the urethra as far as the point of stricture, which was anterior to the bulb; and the stricture was then divided by an external incision, one inch in length, through the raphe of the perineum. At the time ofthe operation the constitutional condition ofthe patient was good. A No. 8 catheter was introduced immediately after the operation, and left in for a few days. The case progressed favorably, and, by December 20th, the wound was firmly healed, the fistulse closed, and a No. 8 catheter could be passed without difficulty."' He was furloughed December 20th, readmitted, and discharged the service January 16, 18o5. Cask 1098.—Private W. Walton, Co. G, 28th Massachusetts, aged 25 years, was admitted into General Hospital at Boston, November 29. 1861. Assistant Surgeon Edward Cowles, U. S. A., noted: "Stricture of urethra of six years' standing. External perineal urethrotomy was practised by Dr. Henry J. Bigelow, December 14, 1861. The patient had considerable haemorrhage from the wound on the 15th, 17th, 18th. and 19th, 'probably from the artery of the bulb.' Grave symptoms began to appear on the 24th, with probable deep pelvic inflammation. Death ensued December 29, 1861." This scanty series of operations for external perineal urethrotomy does not indicate the estimation in which this resource was held by army surgeons. Its value was highly appreciated ; the risks attendant on it2 were not regarded as great in comparison with those of other operations on the urethra. The lamented H. S. Hewit devised an instru- 1 The contributions of American writers comprise some valuable additions to the literature of the operative treatment of urethral stricture. Among them are papers by: HOUNER (W. E.) (Fistula in pcrineo, with considerable loss of substance, cured by Lunar Caustic, in the Phila. Jour, of Med. and Phys. Sci., 1821. Vol. IX, p. 141); JAMESON (II. G.) (On the Treatment of Stricture of the Urethra by Perineal Section, with Cases, in the Am. Med. Recorder, 1821. Vol. VIII, p. 121; also Practical Observations on Stricture ofthe Urethra, Ibid., 1828, Vol. XII, p 329; also Case of Stricture of the Urethra treated by Perineal Section, in the Maryland Med. Recorder, 1829, Vol. I, p. 177). Dr. Jameson was a pioneer in this country in pro- moting a rational operative treatment of intractable urethral strictures. Besides advocating1 and practising external perineal urethrotomy, lie revived Desault's plan of catheterization on a conductor, which, after falling iuto desuetude for half a century, is now again iu vogue. ClIEW (E. II.) (Descrip- tion of an Instrument for dividing Strictures of the Urethra (with a plate), in the North Am. Med. and Surg. Jour., 1828, Vol. V, p. 341); Wkago (I. A., (Case of impermeable Stricture, operated on through the Urethra, with the Suggestion of a new-shaped Catheter, in Charleston Med. Jour., 1852, Vol. VIII, p. 799); DUGAS (L. A.) (On the Treatment of Stricture of the Urethra, in the Southern Med. and Surg. Jour., 1855, Vol. XI, p. C451; CmsOl.M (I. J.) (Perineal Section for impermeable Stricture, in the Charleston Med. Jour., 1857, Vol. XII, p. 301); BLitr.E (J. II.) (Dilatation of Strictures in the Urethra, in Am. Med. Monthly, 18;;2, Vol. XVII, p. 419); Browne (W.) (Incision of Stricture of the Urethra, in The Stethoscope, 1851, Vol. I. p. 025): STEIX (A. W.) (Retention of Urine, in Nev York Med. Jour., 1874, Vol. XIX p 41)4;. *BlLLHOTU (TIL) (Chirurgische Erfahrunge-x, Zurich, 18oO-G7, in Arc'i.fur Klin. Chir., 186'9, B. X, S. 532) observes: "It is a well-known fact that in cases of serious disease of the bladder, ureters, and kidneys consequent on old strictures, operative interference, even by the introduction of a catheter, is not without danger. The alternatives are the rejection of such operations or the risking of them, hoping for exceptionably favorable results." OPERATIONS ON THE URETHRA. 401 merit to facilitate the performance of the operation. This apparatus is figured in Plate XI I, opposite page ;>')">, as Figure I. It has not come into general use. Urethroraphy and Urethroplasty.—Notwithstanding the comparatively large number of cases of urethral fistules reported, few instances are noted in which methodical plastic procedures1 were undertaken. The following may be compared with those cited on p. 3(32: CASE. 109!).—Private E. Olney, ('<>. G. 44th New Vork, aged 29 years, was wounded at Spott- sylvania, May 8. 1864. and, on the 17th, was admitted to Harewood Hospital. He was transferred to Satterlee Hospital, Philadelphia, on July 20th, where the following history of the case is recorded on the case-hook of that hospital: "Gunshot wound of the scrotum; loss of half of the penis hy gangrene and .slough; fistulous opening at hase of penis anteriorly; edges of listula pared and united hy silver sutures. November 2d, has some pain of head and hnnhar region at times; urine passes too freely. December 15th, is improving and growing fat. He continued to improve, but had occasional headache and pain in the back, and, on January 16th, was acting as ward-master. January 2jth, swelling and abscess of scrotum. On February 3d, he was furloughed for twenty days, but, not returning, was reported a deserter. On April 27, 1865, he was again admitted. May 10th, there were troublesome fistulous openings of the scrotum, allowing the escape of urine. June 14th, ls;i"), improved, and recommended for discharge. Surgeon J. E. MacDonald, V. S. V., certified: "Wound of penis and scrotum; ablation of penis, and fistulous opening into the bladder." This soldier was pensioned. Examiner T. O. Scudder, of Rome, reported, October 5, 1865: "A rifle ball passed through the penis and left side of the scrotum. One-half of the penis was amputated; wound healed. There is still inflammation of the mucous membrane of the bh Ider, and dribbling of urine; disability total." This pensioner was paid at the Detroit Agency, September 4. 1871; since which time nothing has been heard from him. Case 1100.—Private W. G. McK------, Co. G, 94th New York, was wounded at Manassas, August 29, 1862, and sent to Judiciary Square Hospital. Of several wounds by buckshot, three penetrated the urethra. Surgeon F. H. Hamilton, l\ S. V., states2 that the surgeon in charge of the hospital [Surgeon Charles Page, U. S. A.], after two of the three abnormal orifices of the urethra had closed spontaneously, succeeded in closing the remaining fistula, near the meatus, by refreshing the edges of the fissure and bringing them together by sutures, completely restoring the form of the organ. This soldier was returned to duty January 23, 1863. He has not applied for pension. Case 1101.—Private C. Meninger, Co. I, 119th Pennsylvania, aged 25 years, was wounded at the Wilderness, May 5, 1864. From Douglas Hospital, Washington, where the patient was admitted on the 25th, he was transferred to Haddington Hospital, Philadelphia, June 1st. Surgeon S. W. Gross, U. S. V., reported: ''Wounded bya mini<3 ball; antero-posterior perforation of the anterior third of the penis, and wound of the right groin. Before his coming here the penis had retained its usual shape, but no attention was paid to the urethra. June 2d, wound in groin suppurates freely; it is five inches long and appears to have been one inch deep. Under the fraeuum there is a sinus com- municating tortuously with the urethra; through this the urine escapes guttatim, irregularly. A straight bistoury, entering the meatus one inch and a half, reached the urethral stricture; a gum catheter being introduced, urine passed freely. Slight suppuration on the 17th. The following clay, the catheter being removed, urine flowed freely. The urethra is reclosed, June 30th, and urine again passes through the sinus. On July 21st the patient was chloroformed, and Acting Assistant Surgeon L. E. Nordman made an incision from the meatus urinarius one inch aud a half anteriorly downward. A silver catheter was passed up, and the divided parts approximated by four silver sutures over the fixed catheter. There was some haemorrhage, but no vessels required tying. July 22d, the bladder is occasionally emptied by unplugging the catheter. On the 24th the sutures were removed and adhesive straps applied; little swelling existed, and some sleep was enjoyed. The incision line was not quite healed by August 8th, and a bougie was introduced to prevent the closing of the urethra." Meninger was discharged the service March 25, 1865; he is not a pensioner. Fio. 345— Nelatox's urethroplastic method. J. FIG. IMG.— Incisions for urethroplasty. [After DJT- TEL.l •On urethroraphy and urethroplasty consult: A. Cooi'Eit, Eaule, Delpecii, and BRODIE, cited elsewhere, and DlEFEENBACII (J. F.) (Heilung widernaturlicher Oeffnungen der vorderen miiiinlichen Harnrohre, mit Abbild., in Zeitsehrift fiir diegesammte Medicin, Hamburg, B. II, S. 1). This remarkable memoir is translated in the Dublin Jour, of Med. Set, 1836, Vol. X, p. 279, the Gaz. mid. de Paris, 18:16, p. 803, and Arch. gin. de mid., 1836-37, 2«s6rie, T. XIII, pp. 69, 206. See also Diefeexisacii (Die Operative Chirurgie, Leipzig-, 1845, S. 526); SEGALAS (Lettre a Dieefenbacii sur une urithroplastie, Paris, 1840); ItlCOUO (Urethroplastic par un procidi nouveau, in Ann. de la chir. franc, et itrang., 1841, p. 62, andGaz. mid., 1843, p. 163); Allioi (F.) (Obs. cliniques, in Gaz. mid. de Paris, 1834, p. 348); Goykand (Gaz. mid. de Paris, 1843, p. 172); Vioal (Path, ext et Mid. opirat, 5« §d., 1861, T. IV, p. 702); MALGAIGNE (Man. de mid. op., 7e ed., 1861, p. 709); Nelaton (Nouv. procide d'anaplastie pour la curation des fistules urithro-piniennes, in Gaz. des Hop., 1853, p. 373, and Slim, depath. chir., 1859, T. V, p. 486); BOULANO (Cons, sur la trait, des fistules urithro- piniennes, These de Paris, 1854, No. 254); Bruxeau (Desfist, nrin.urith. chez I'homme, Ibid., No.337); LE GltOS Clauk (Large Opening into the ant. part of the Urethra * * Successfully treated by Operation, in Med. Chir. Trans., 1845, Vol. XXVIII, p. 413); BLAXDLX (Autoplastic, etc., 1836, p. 180); Jobert (Traiti de chir. plast, 1849, T. II, p. 139, et Reunion en chirurgie, 1864, p. 326); RODGEltS (D. L.) (A New Operation for the Re-estab- lishment of the Urethra, in Phila. Med. and Phys. Jour., Vol. XIX, and Surg. Essays and Cases in Surgery, Newark, 1849, p. 122); VON AMMON (F. A.) (Die Plastische Chirurgie, Berlin, 1842, S. 269); Ricord (Nouvelle observation pour servir a I'histoire de Vurethroplastic, in Gaz. mid.. 1850, p. 779); Neudorfkr (J.) (Handbuch der Kriegschirurgie, 1837, S. 816), Case of Reiter, 15lh Jtegers, shot at Solferino, June 24, 1859, through the root of the penis with great loss cf substance; successful urethroraphy. - Hamilton (F. H.), Lecture on Gunshot Wounds of tlie Penis, in Am. Med. Times, 1864, Vol. IX, p. 61. and Treat, on Mil. Surg.. 1865. p. 386. 51 402 INJURIES OF THE PELVIS. |C1IAP. VII. 1'IG. :>47.-rrcthroplasty by scrotal Hap. Attempts to close urinary fistules by tbe Indian method of borrowing integuments from tlie neighboring parts, were made by Sir Astley Cooper,1 in 1818, and by J)elpech, in 1830, with partial success. The flaps were taken from the scrotum. Delpech also operated by taking flaps from the inguinal region and the integuments of the penis.2 Dieffenbach's elaborate illustrated paper, trans- lated in the Dublin Journal, in 1836, by Swift, proposed several urethro- plastic operations by the French method of glissement. Vigurie, Alliot, Seaalas, Clark, and Ricord also described operative procedures, some of which are illustrated by Figup.es 346 and 347. The most successful operation appears to be that of Nelaton (Fig. 345), and I have thought it was not impossible that its success was due to a cause analogous' to that on which hinges the result of operations for anal fistules and of staphyloraphy. If the reader will turn to page 348, to the wood-cut 282, borrowed from Henle, he may be reminded that the transverse incisions in Xelaton's operation would divide the muscles surrounding the root of the penis, much after the fashion of Sir W. Fergusson's incisions in cleft- palate ; and it is possible that this explains the greater success of this than of Dieffen- bach's plan, with longitudinal incisions. The three cases mentioned on the preceding page, and Case 1061, on page 365, are the plastic procedures on_ account of the conse- quences of shot wounds of the urethra reported during the War. Another instance of urethroplasty occurred in a more common form of perineal laceration: Cask A10.—Peter F------, quartermaster department, age 21 years, was admitted into the post hospital at Washington on May 1, 18S6, with two fistules of the membranous portion of the urethra, the result of a severe lacerated wound of the perineum, caused by a fall astride of a plank. Cauterization of the edges of the fistules hy bromine, nitrate of silver, and the actual cautery, was at intervals unavailingly essayed. ^A plastic operation had already been performed by Dr. N. S. Lincoln, without success. On June 3d, Assistant Surgeon \V. Thomson, U. S. A., pared the edges of the apertures and approximated them by silver sutures. A catheter was retained in the bladder, the urethra having been dilated freely by the daily use of bougies. There was dysuria and frequent micturition on the following day, and, on the Gth, the sutures were removed. The posterior orifice appeared to have closed; but it reopened, and recourse was again had to cauterization, without advantage. There was such loss of substance, nearly a third of the cylinder of the urethra being destroyed, that the restoration of the canal was a very difficult problem. After a few weeks, the callous edges of the fistules were again refreshed and approximated by sutures, which soon tore out, and it was discovered that the. patient had received visits after this, as after the former operation, from a young woman to whom he was affianced, whose tender ministrations induced a local hypersemia very prejudicial to the success of any plastic procedure.3 The recent employment of the vesical siphon in the treatment of urinary fistules4 has obviated one of the great difficulties in the successful management of these lesions. M. Voillemier essayed to prevent the contact of the urine with the edges of the fistule by utilizing the capillary attraction of a few cotton threads passed through a catheter. M. Panas has shown that a small rubber tube, long enough to be used on the principle of the siphon, will effectively drain the bladder. 1 COOPEU and TltAVEIlS, Surgical Essays, 1st Am. from 3d London ed., 1831, p. :180. 2 DELPECII. La Lancette francaise, T. IV, p. 285, et T. IX, pp. 277-8. % BoYEit (Traiti des mal. chir., T. IX, p. 270) relates the case of " un chef d'cscadron de trente-six ans, affeete d'une fistule longue de 3 lignes et situee au devant des bourses. Aprds qu'une sonde eut etc introduite dans la vessie, on fit I'avivement avec le bistouri; les bords de la plaie furent parfaitement reunis par trois points de suture. Mais le malade, qui avait une femme jeune et jolie, ayant eu I'imprudence de la fairo coucher avec lui, il 6prouva une forte erection qui tirailla les points de suture. II survint de gonflement, de I'inflammation, et le troisieme jour, les parties embrass6es par les fils furent divbs§es. Aussi l'operation n'eut aucun succes; elle fut meme nuisible en ce qu'elle contribua a. l'agrandissement de la fistule.' 4 GRIP AT (H.), Du Siphon visical dans le traitement des fistules urinaires par la sonde a demeure, Paris, 1873. Fig. 318.—Partiallv successful urethroplasty for peri neal fistula, [from Phot. 181, Vol. IV. p. 31. Sur. Phot Ser., A. JI. 31.] SECT HI OPERATIONS ON THE URETHRA. 403 Deplorable as it is to abandon a patient to the necessity of voiding his urine through an artificial perineal apparatus, and to a calamity that annihilates the sexual and social relations of life, there appears to be no alternative when the entire circumference of the urethral canal is destroyed to the extent of an inch or more, and an irremediable fistula is left. Twenty or thirty pensioners, or more, afflicted with this infirmity, should be provided each with at least two urinals, to preserve them from contracting a repulsive urinous smell. Professor Gross, at page 403 of the second edition of his treatise on the urinary organs, figures several urinals, shaped somewhat like Florence flasks, and capable of holding about twelve ounces. Latterly, the incon- venience of the bag shape has been avoided by having a long caoutchouc tube descending along the inner seam of the trousers. The contrivance of Gariel (Fig. 350) is probably the best of the metallic urinals. It is readily maintained in place, and has been approved by the experience of numerous invalids. Sometimes it is possible to dispense with an external urinal by using such an appa- ratus as that devised by Mr. Oliver Pemberton1 (Fig. 349). As indicated on page 372, there are now at least thirty-eight sufferers from urethral fistules consequent on shot wounds received during the War of the Rebellion. In Germany, pensioners with urinary fistules receive the largest sum accorded to any class of sufferers.2 In this country, no discrimination has yet been made in behalf of these unfortunates It has been suggested, on page 362. that they should be assembled, to receive such succor as art can afford, from some one skilled in this branch of surgery. In operations on the urethra, for strictures or for fistules, there are two sources of danger, of which the prudent practitioner is alwTays regardful. These are urethral fever3 and false routes.4 A fig.35o.-gamel'sunnai. knowledge of the utility of quinine in the former affection, and the FlG. 349.-PEMBERTON's perineal canula: a, silver tube, not unlike a female catheter; 6, inner canula closely fitting the outer, and provided with a faucet, opened by the key k ; c, elastic thigh-straps to be attached to a body-band. •Mr. 0. Pemberton (On Traumatic Destruction of the Urethra, and its Relief by a suitable Apparatus in the Perineum, in Lancet, 18G1, Vol. I, p. 258). Mr. Pemberton reviews the annals of surgery, and finds that, while they afford some scanty materials leading to the conclusion that a limited destruction of the urethra Iuig been repaired, there is no evidence that a new canal has ever been permanently formed where the entire calibre of the urethra has been destroyed for the space of an inch. Eaule'S case (Pract. Obs. in Surgery, London, 1823, pp. 197, all), in which an inch of the urethra was wanting, and a cure was effected after three operations, a new passage being formed by common integument, no raucous membrane being visible. The subject three years subsequently was reported as able to expel urine by the meatus in a full stream, as having married and become a father. In Houston's case (Dublin Jour, of Med. Sci., Vol. VIII, p. 11), the evidence that the entire circumference of the urethra was destroyed is defective. In Brodie's case (Works, Hawkins's ed., 186">, Vol. II, p. 449), an artificial passage was made to supply the loss of three-quarters of an inch of the urethra; but the permanence of the cure is not established. In Symk's case (H. THOMPSON'S Path, and Treatment of Stricture, 1st ed., p. 368), failure resulted from the contraction ofthe new passage, formed of common integument. Consult further: Lapeyrk (Sur un regeneration du canal de I'uretre iotalement ditruit par une gangrine de cause interne, in Vandeumonde's Recueil, Paris, 1757, T. VI, p. 281); Pktrequin (J. L.) (De la ponclion prostatique de la vessie, el de la restauration de I'urithre dans un cas de destruction de ce canal par une contusion violente du pirinie, in Bull. de I'Acad. de Mid., Paris, 1858-59, T. XXIV, p. 613); and Fine (Observation d'une ritention d'urine produite par un ritrecissement de I'uretre et guirie par un procidi opiratoire pariiculier, in Jour. gin. de mid., etc., par SEDILLOT, Paris, 1810, T. XXXIX). 2Bekthold, Stat, der durch den Feldzug 1870-71 inval. gewordenen Maunschaften des 10 Corps, in Deutsche Mil. Zeits., 1872, B. I. S. 433. Consult Marx (E.) (Des accidents fibriles et desphlegmasies qui svieent les opirations pratiquies sur le canal de I'urethre, Paris, 1801); ROSEK (Das sogenannte Urethralfieber, in Archiv der Heilkunde von WuxdEuuch, IIO.seu, und Guieslnger, 1867, S. 246); Banks (\V. M.) On certain rapidly Fatal Cases of Urethral Fever after Catheterism, in Edinb. Med. Jour., 1871, p. 1074); Malheube (De lafiivre dans les mat des voies urinaires, 1872). 4 Consult Diitel (Falsche Wege der Harnrohre, in Handbuch der Allg. und Spec Chir., 1872, B. Ill, Abth. 2, S. 185); VOILLEMIER (Fausses Routes, Chap. IX de son Traiti des maladies des voies urinaires, 1868, p. 456) See BECK (Chir. der Schussverletzungen, 187a, S. 567) for an instance of false passage after shot injury of the urethra,—the case of a subaltern of Garibaldi, on whom Dr. Thomann performed suprapubic puncture of the bladder. Consult also Mr. Bip.ttETr's article, and the references in the works of HOW3HIP, DUCAMP, WlIATELY, GUTHRIE, and MEUCIElt. 401 INJURIES OF THE PELVIS [CHAP. VII. Fig. 351.—Normal relations of the adult male urethra. [After BOL'GEEY.] Fig. 352.-Capil- lary whalebone expedients for the ready recognition of the latter, are comparatively recent advances. The diagnosis of strictures is now made with approximate precision by the use of properly contrived bulbous sounds. Sir Charles Bell's invention1 has been happily mod- ified by M. Leroy and others (Fig. 355), and the acorn- pointed gum bougies now generally employed afford the best means of appre- ciating the locality and ex- tent of strictures. Impres- sions with wax or other material give no accurate information respecting the nature of strictures,2 and the various urethroscopes3 have not brought such aid to pre- cision in diagnosis, as was anticipated. Electrolysis has been discarded as valueless.4 In the exploration of narrow strictures, filiform bougies of gum or boTgie 1 Bell (Charles), A System of Operative Surgery, 1st ed., 1807, Vol. I, p. 104 ; 2d ed., 1814, Vol. I, p. 70. 2 Consult AltNOTT (J.) (Treatise on Strictures, 1819, p. 76); DUC.VMP (Traiti des ritentions, etc., 1822. p. 176); MEllCTER (Recherches anat, etc., in Gaz. Mid., 1845, p. 145); Civiale (Traitiprat, etc., 1842. p. 148); Bigelow (II. J.) (Boston Med. and Surg. Jour., 1849, Vol. XL, p. 9). 3 In the Philadelphia Journal of the Medical and Physical Sciences, 1827, Vol. XIV, p. 409, may be found an erudite review, by Dr. Isaac Hays, of the various instrumental devices that were known, at that date, for illuminating, in living bodies, dark cavities having external openings. The instrument of BORRINI, of Frankfort, and the unfavorable reports thereon of the Josef Akademie and Faculty of Vienna (Bull, de la Soc. mid. d'Hmula. tion, Avril, 1808) are referred to, and the ''urethro-cystic speculum" pre- sented by Segalas, December 11, 1826, to the Paris Academy of Sciences, as well as the speculum of BOMBOLZINI for the exploration of the bladder, stomach, large intestines, and uterus; and a full description, with a figure, is presented of an endoscope designed, in 1824, by Dr. JOHN D. Fisher, of Boston. Twenty years later, Cazenave (Nouveau mode de Vexploration de I'urithre, etc., Bordeaux, 1845) and Avery (Dublin Med. Press, December, 1845), at the Charing-Cross Hospital, experimented on the ocular inspection of strictures in the pendulous portion of the urethra. M. Desor.meai'X (Note sur un instrument a I'aide duquel on voit dans I'intirieur de I'urithre, in Bull, de I'Acad. de Med., November 29,1853, Gaz. des Hop., p. 573, Gaz. J Med., p. 770), in 1853, first described his ingenious though complicated endoscope, and subsequently de- tailed the improvements he successively adopted (De Vendoscope et de ses applications au diagnostic et au traitement des affections de I'urethre et de la vessie,\8tSo). The paper of Dr. F. H. CRUISE on The Utility of the Endoscope as an Aid in the Diagnosis and Treatment of Disease (Dublin Quart. Jour, of Med. Set, 1865, Vol. XXXIX, p. 329), illustrated by a chromolithograph of the appearances of stricture viewed through a tube, if it does not vindicate its title, contains some interesting * historical information regarding endoscopy. Dr. It. Newman's essay (The Endoscope, in the Trans. Med. Soc, New York, 1870) is profusely illustrated by wood cuts and lithographs, and abstracts of cases in the writer's practice. The endoscope of Dr. P. S. Wales, U. S. N., is figured by Professor GROSS (System, etc., 5th ed , Vol. II, p. 715) with the observation that, "after a fair trial with this instrument, surgeons have very generally concluded that it is practically of little utility." M. VOILLEMIER, Sir H. Thompson, and Herr Stilling accord a similar verdict in regard to the instrument of M. Desormeaux. Dr. GOULEY (loc. cit, p. 23) and Drs. Van BUREX and Keyes (A Practical Treatise on the Surgical Diseases of the Genito-urinary Organs, 1874, p. 75) agree that the light rubber canula proposed by Professor F. N. Oris, illuminated by a suitable concave reflector, will answer every practical purpose to which urethroscopy is now applicable. A pattern is deposited in the Army Jledical Museum (Spec. 4903, SECT. I). Other urethroscopes have been proposed by Herr Gruxfellj (Zur endoskopischen Untersuchung der Harnrohre, in Wiener Med. Presse, 1874, S. 225) and by M. LAXGLEBEttT (Gaz. des Hopitaux, 1868, p. 463). •> The early efforts of CEL'SELL (Die ele.ctrolytische Heilmethode, in Neue med.-chir. Zeit, 1847), and the pretensions of MIDDELUORI'E (Die Galvano- caustik, Breslau, If 541. of BuEXXER (Untersuch. und Beobacht. auf dem Gebiete der Electrotherapie, 18C8), and of MM. Mallez and TltU'lER (De la guerison des retricissements de I'urethre par la galvanocaustique chimique, 2m* ed.. 1870), and of a pupil of the latter, M. BAUTISTA (De la galvano- caustique chimique comme moyen de traitement des ritricissements de I'urithre, 1870), have been experimentally reviewed by Professor MEREDITH CLYMEIL late Surgeon U. S. V. (see GOULEY, op. cit, 1873, p. 55), and by Dr. E. L. Keyes (Practical Electrotherapeutics, in New York Med. Jour., 1871. Vol. XIV, p. 586), with results worse than negative, and suggestive of the lesson, that it is unwise to strike heavy bljws \a the dark. FlG. 353.—Endoscope of DESORMEAUX. FIG. 354.-Contort- ed filiform bougies: 1, 2, after LEROY ; 3, after Bell. 30 SECT. III.] INJURIES OF THE TESTIS. 405 whalebone (Figs. 852, 354) are of the utmost utility. Benjamin Bell appears to have first perceived the advantage of abruptly bending the extremity of bougies in dealing with eccentric strictures. The seeming paradox that in operations on the urethra the surgeon should forget his anat- ©_ omy, has its truthful side ; but ©^ only those who have a good stock of anatomical knowledge to be temporarily ignored, .l^-su-charles bell's bulbous probe. should undertake operations on the urethra, (Fig. )>51.) Injuries and Dis liases of the Testis.—The instances reported of contusions, contused wounds, and lacerations of the testis1 from shot injury, numbered five hundred and eighty-six ; a few cases of wounds of the testis from other causes were reported; and numerous examples of hydrocele or of hematocele of alleged traumatic origin. Orchitis was very common among the troops in garrison, and syphilitic diseases of the testis were not rare. Other morbid alterations of the testis were comparatively infrequent. Atten- tion will be invited mainly to the shot lesions, and the other traumatic affections and the diseases will be cursorily noticed. Wounds of the testes are less frequent than might be anticipated from their exposed position. Their mobility and rounded form, and the suppleness of the tissues investing them, explain the facility with which these organs escape injury (Velpeau)." Shot Injuries of the Testis.—Of the five hundred and eighty-six cases of this group, by far the largest proportion consisted of lacerated wounds of one or both testes, and the majority of these were complicated by concomitant wounds of either the penis, thighs, perineum, or pelvis. There were sixty-six fatal cases, the deaths resulting in most instances from the complications. Three hundred and forty cases, in which the seat of injury was precisely specified, presented one hundred and thirty-six examples of wounds of both testes, ninety-five cases of wounds of the right, and one hundred and nine of wounds of the left testis. Wounds of the testis commonly caused acute pain, radiating to the loins, and were generally attended by faintness, and often by vomiting. It has been asserted that severe contusions of the testes may occasion shock of fatal severity. I have not met with unequivocal evidence that an instance of this sort has been observed. In one of the reported cases, death was, indeed, ascribed to a shot contusion of the testes;3 but the fatal event ensued a fortnight after the reception of the injury, and there is nothing in the report to oppose the supposition that there was some concomitant mortal complication. 'Testis, Gr., op^is; Lat., Testiculus, from testis, a witness, as testifying to virility; PH^DRUS, Lib. Ill, Fab. 11 (Eunuchus ad Improbum): " En, ait, hoc unum est, cur laborem validius, Integntalis testes quia desunt mihi." Compare Juvenal, Sat, Lib. II, Sat. 6, 339, and Martial, Epig., Lib. IV, Epig. 24, 5.—Fr., Testicule; It. and Sp., Testicolo; Germ., Hode. 2On wounds of the testis consult VELPEAU (Plaies du testicule, Diet, de Mid., 1844, T. XXIX, p. 434); Cooper (A.) (Obs. on the Structure and Diseases of the Testis, 2d ed., 4to, 1841, p. 79); Curling (T. B.) (A Pract Treatise on the Diseases of the Testis, etc., 2d Am. ed., 1856, Chapt. Ill); Kaltschmid (Diss, de testiculoper varias operationes subprsefecto militum post vulnera antehac infelici successu curato, Jenae, 1762); Sebitz (Examen vulnerum smgularum, Argentorati, 1633, Pars III, § 159 et seq.); BOYER (Traiti des mal. chir., Paris, 1849, T. VI, p. 700, Des plaies des testicules); Demme (H.) (Studien, 1861, B. II, S. 165, Schusswunden des Hodensacks). 3 Case of Private J. Meehan, Co. B, 90th Illinois, was injured at Mission Ridge, November 25, 1863. Surgeon W. W. Bridge, 46th Ohio, reported, from the field hospital of the 4th division. Fifteenth Corps, "a severe contusion of the testicles bya minig ball; death, December 9, 1863, from the injuries." A case reported by Dr. W. Schlesier, in CASPER'S Wochenschrift fiir die gesammte Heilkunde, 1842, No. 43, S. 689, under the title Plotzliche Todtung durch Quetschung der Hoden, was believed by the author to be a unique example of sudden death from contusion of the testis. In 1836, a healthy man, engaged in a fray, shrieked out, fell into convulsions, and died in five minutes. The only injury found was the rapture of both spermatic arteries and veins at the internal rings, produced by the testicle having been pulled down by one of those with whom the man was fighting. The ease is cited by Messrs. Curling (loc. cit, p. 100) and PAGET (Brit and For. Med. Rev., January, 1844) as a remarkable evidence of the sympathy of the vital organs with the testes. 106 injuries of the pelvis. [CHAP. VII 'Shot Lacerations of the Testis.—About four-fifths of the shot injuries were perfora- tions or grave lacerations of the testis. Nineteen examples of this form of injury have been presented in preceding subdivisions.1 Thirty other instances, selected from cases of recovery without operative interference, will be related here : Case 1102.—Private A. B------, Co. C, 5th Michigan, was wounded at Fair Oaks, May 31, 1862, and sent to Balfour Hospital, Portsmouth. Assistant Surgeon H. L. Sheldon, U. S. A., noted: "Gunshot wound; the ball passed through the scrotum, causing extensive laceration." The patient was transferred to St. Mary's Hospital. Detroit, February H, 1864. Acting Assistant Surgeon D. 0. Farrand reported : ''Transferred to the Veteran Reserve Corps, March 22, 1834, for gunshot wound of the left testicle and right thigh, producing permanent lameness and constant neuralgia." This man was mustered out June 17, 1835, and pensioned. Examiner W. B. Thomas reported, June 28.1839: " Ball passed through the upper and posterior portion of the right thigh, and thence through the-scrotum, wounding the left testicle. The testis- is very much atrophied and painful. The muscles ofthe thigh are atrophied and weak and considerably contracted, producing considerable lameness." Examiner D. Clarke reports, September 11, 1873, that " the ball passed through the left testicle, and thence just back ofthe head ofthe right femur. In consequence of this wound he has a weakness in those parts, which debars him from lifting and any laboring occupation. His disability is three-fourths." This pensioner was paid on September 4, 1H73. Case 1103.—Private Andrew B------, Co. E, 1st West Virginia Artillery, aged 38 years, was wounded at Buckhannon, August 30, 1882. The early history is not recorded. At Cumberland, September 9, 1863, Surgeon J. B. Lewis, U. S. V., reported: " Wounded by a carbine ball, which penetrated the scrotum below the centre ofthe right side, and made its exit near the raphe at about the same line, chipping the lower extremity of the right testis and bruising the left. The treatment consisted of topical applications of ointments, and occasional cleaning with castilo soap-suds during the process of granulation. The cicatrix broke open and the ulcerative process recurred several times. The wound has now been healed for more than three months; the testes are both extremely tender and sensitive to the touch." This man was transferred, convalescent, February 1, 1864, to hospital at Parkersburg, returned to duty April 2d, and mustered out of service December 23, 1834. Not a pensioner January 4, 1874. Case 1104.—Private John If. L------, Co. D, 1st Maryland Battery, aged 28 years, was wounded at Gettysburg, July 3, and was treated in Seminary Hospital till the 28th, when he was sent to West's Buildings Hospital. Surgeon George Rex, U. S. V., reported "gunshot wound, causing the loss of the left testicle. On August 5th, an abscess in the scrotum was opened. The case progressed favorably, and the wound* was nearly healed when the man was paroled, August 22, 1863." Case 1105.—Private Jonathan C------, Co. F, 87th Indiana, aged 31 years, was wounded at Chickamauga September 20, 1883. Surgeon P. J. A. Cleary, U. S. V., reported, from hospital No. 3, Chattanooga, a "gunshot wound of the penis and scrotum ;" and was subsequently treated in hospitals at Nashville, Louisville, New Albany, and Jeffersonville, and mustered out May 30, 1865. and pensioned. Examiner N. Sherman, of Plymouth, Indiana, reported, April 28, 1866: "Applicant received a ball destroying the right testicle, and, passing into the right thigh behind the adductor longus muscles, came out near the inferior portion of the os coccygis, causing pain and sickness upon slight exertion. Disability temporary." Examiner W. Hill reported, September 4, 1873: "Gunshot wound of the right testicle, scrotum, and inside of the right, thigh on a line with the lower portion of the testicle. There is adhesion ofthe scrotum with the testicle, tenderness in the cicatrix, and pain along the spermatic cord. Disability total." Case 1106.—Private H. D------, Co. H, 45th Pennsylvania, was wounded at Cold Harbor, June 3, 1864. Surgeon James Harris, 7th Rhode Island, reported, from a Ninth Corps hospital, a "gunshot wound of the scrotum." Thence the patient was transferred to Carver Hospital, remaining under treatment until September 9th, when he was sent to Satterlee Hospital. Surgeon I. I. Hayes, U. S. V., reported: "Gunshot wound of the lower extremity and genital organs; the ball entering the scrotum and destroying the left testicle, passed onward, entering the upper third of the right thigh on the internal side, and coming out on the posterior and internal aspect of the same, the distance between entrance and exit wounds being about four and a half inches." The wound healed and the patient was returned to duty January 5th, and, on May 16, 1865, he was discharged and pensioned. Examiner N. Parker, of Lawrenceville, reported, October 15, 1870: " Gunshot wound of the left testicle and atrophy ofthe right; injury of the sciatic nerve and partial paralysis ofthe right lumbar region, with a difficulty in stooping. Disability seven-eighths." This pensioner was paid September 4, 1873. Case 1107.— Private James M. P------, Co. I, 29th Ohio, aged 25 years, was wounded in the hip at Dug Gap, May 8, 1864, and, after treatment in hospitals at Nashville, Louisville, and Camp Dennison, was returned to duty on October 4th. On November 9th, he was again wounded at Bardstown, and sent to Clay Hospital, Louisville, and transferred, on December 19th, to West End Hospital, Cincinnati, wliere "wounds of the scrotum, penis, and left thigh" were noted; thence he was sent, April 20, 1635, to Camp Dennison, and mustered out and pensioned, June 21, 1865. Examiner W. M. Eames, of Ashtabula, January 9, 1838, reported: " It is supposed that Perkins has a minie" ball lodged near the femoral artery, at the upper third of the thigh, which causes contraction of the muscles and occasional severe spasmodic action of the muscles of the thigh and leg, and also interferes very much with locomotion. He was also Avounded in the natis, penis, and testes, which wounds are a source of considerable trouble and inconvenience, the former having caused abscesses and extensive exfoliation and lameness." In a certificate dated September 12, 1867, the same physician reports: " He received a musket ball through the left thigh, which passed backward to the hip bone, striking the ischium and splintering it, and remaining in some ten months; also one through the penis and left testicle, and a minie ball in the left thigh near the side of the femoral artery, which ball is lodged near the sciatic nerves. Dis- ability total." This pensioner was examined September 12,1867, and a claim for further increase of pension was pending in 1873. 'Cases 1013, p. 352; 1014, 1016, p. 353; 1021, p. 355 ; 1028, p. 356; 1041, p. 357; 1032, p. 358; 1039, p. 359; 1042, p. 360; 1046, 1048, p. 361; 105.2, 1053, 1054. p. 362; 1055, p. 363; 1060, p. 364; 1061, p. 365; 1072. p. 370 ; 1079, p. 373. SECT. Ill 1 SHOT WOUNDS OF THE TESTIS. 407 Neuralgia and atrophy of the organ are the most frequent causes of complaint with pensioners for shot injuries of the testis.1 It is curious to note the various estimates of the pravitv of these disabilities : o Case 1108.—Private Thomas Johnson, Co. G, 27th Ohio, aged 19 years, was wounded at the battle of Kenesaw Moun- tain, June IS. 1864. sent to a Sixteenth Corps hospital at Marietta, and thence to hospital No. 19, Nashville, where Surgeon W. II. Thorne, U. S. V., reported, June 29th, "gunshot wound of the right testicle;" thence the patient was transferred to Jeffersonville, July 7th, where Surgeon M. Goldsmith, U. S. V., gave a similar description of the injury. When convalescent, this soldier w;;s sent to Camp Dennison, and discharged at the expiration of his term of enlistment, August 30, 1864. Examiner J. W. Oustine, of Panora, Iowa, reported, July Ui, 1SC.D : 'A severe flesh wound of the scrotum and buttock; ball entered the scrotum above the right testicle, near the cord, and passed out through the gluteal muscles of the left side. There is neither induration nor thickening of the parts; the wound is healed, and the health is good ; no disability." On this certificate the applicant's claim for pension was rejected, July 29, 1839. Case 1109.—Private W. E------, Co. F, Otl? Maryland, aged 21 years, was wounded at the Wilderness, Mayo, 1864, treated on the field until the 26th, and sent to Harewood Hospital, and thence to Satterlee, May 31st. Surgeon I. I. Hayes, C S. V.. noted a " gunshot wound of the genital organs," and the patient's transfer to Baltimore, to Camden Street Hospital, July 8th. Surgeon Z. E Bliss, V. S. V., reported: " Ball grazed the anterior aspect ofthe right thigh, at the upper third; entered the scrotum, injuring both testicles and the inner aspect of the left thigh." This man was returned to duty October 8, 1864, and discharged July 6, 1835. and pensioned. Examiner T. Owings, of Baltimore, reported, October 26, 1866: " Gunshot flesh wound of both thighs, and through the right testicle, destroying it; right leg somewhat disabled by contractions at the point ofthe wound; disability one-half and permanent.'' Drs. II. E. Goodman, T. H. Sherwood, and J. Collins, at Philadelphia, reported that the "ball passed across the thighs and destroyed the right testicle; disability total." This pensioner was paid September 4, 1873. Case 1110.—Private S. A. E------, Co. I, 1st Massachusetts Artillery, aged 19 years, was wounded at Cold Harbor, June 1, 1834. He was sent from a Second Corps hospital to Lincoln Hospital on June 7th, and the case was registered as a '"shot wound of the right testis and thigh." The wound granulated kindly under simple treatment; the patient convalesced rapidly, and, after two furloughs, he was returned to duty, February 3, 1865. He was discharged and pensioned, August 16, 1865. Examiner David Choate, of Salem, reported, November 12, 1863: " Ball passed through the right half of the scrotum, and, probably, through the right testicle; re-entered the inner surface of the thigh, and escaped behind, an inch below the junction with the natis. He suffers chiefly from pain and weakness in the loins and pain in the groins, especially after such work as lifting or reaching tip, and is frequently obliged to quit work. The pain continues on into the night. The testis is much reduced in size and altered in form—dumb-bell shaped—as though part gone, and swells if he takes cold or receives an injury. There is some dribbling of urine after micturition; the wound through the thigh occasions but slight inconvenience; disability one-half." Examiner C. A. Carlton, in an examination for increase of pension, September 17, 1873, after describing the wound as above, adds: "Right testicle completely wasted; he complains of almost constant pain in the testis, extending up to the back, and is aggravated by lifting or walking. Disability total." Case 1111.—Sergeant M. G------, Co. 1,117th New York, aged 31 years, was wounded at Drury's Bluff, May 16, 1864. At an Eighteenth Corps hospital, a "gunshot flesh wound of the right thigh and privates" was noted; at Fort Monroe, on the 19th, a "gunshot wound of the testicles." On July 12th the patient was transferred to McDougall Hospital, and sent, Septem- ber 2d, convalescent, to Rochester, and thence returned to duty, January 24, 1835; discharged June 8, 183."), and pensioned. Examiner H. B. Day, of Utica, reported, June 29, 1885 : " The ball passed through the scrotum from left to right near the root of the penis, and through the right thigh. There iu but little left of the right testicle ; several small pieces of bone have been discharged from the wound in the thigh in the last eight days. He is quite lame, and walking is painful; disability two-thirds." Examiner J. W. Randall reported, when this pensioner was paid, September 4, 1873: "A ball entered the left side of the scrotum, passed through the right testicle, and entered the right thigh about two inches from the pubic bone, passing posterior to the femur, and came out near the tuberosity of the ischium. The testicle is atrophied and the cord contracted and painful. Disability three-fourths." Case 1112.—Private J. F. Alexander, Co. F, 40th Indiana, aged 20 years, was wounded at Kenesaw Mountain, June 27,18G4. Surgeon E. II. Bowman, 27th Illinois, from a Fourth Corps division hospital, reported a "gunshot flesh wound ofthe hip and scrotum," and the patient's transfer to hospital No. 2, Chattanooga, and admittance on July 3d. After treatment at hospital No. 19, Nashville, the patient was sent, to Brown Hospital, Louisville, September 4th, and the injury was noted as a "gunshot flesh wound ofthe right buttock, thigh, and testicle." The patient convalesced, was furloughed, and finally mustered out December 21, 1865, and pensioned. Examiner M. H. Bonney, of Lebanon, reported, August 9, 1868: "This man was wounded in the scrotum, the right testicle being implicated. While in Texas he contracted ague, which left him paralyzed, so that he was not able to labor. I think the ague was the cause of the paralysis." Examiner J. K. Bigelow reported, September 29, 1869 : "Ball passed through from just posterior to the right great trochanter to the inner aspect ofthe thigh, where it made its exit, passing thence through the scrotum, injuring the right testicle and causing an ugly cicatrix attaching the scrotum to the testicle, which, in addition to a profound malarial influence, has developed a peculiar nervous prostration which resembles chronic alcoholism. His habits are correct. I am of the opinion that his disability at the above rate, three-fourths, is wholly permanent." He was paid to September 4, 1873. '.For published cases of wounds of the testis not cited elsewhere, consult PuitDY (A. E. M.) (Cases of Gunshot Wounds, in Am. Med. Times, 1863, Vol. VI, p. 66); Thomson (W.) (Cases of Hospital Gangrene, Case VII, in Am. Jour. Med. Sci., 1864, XLVII, p. 385); HAMILTON (P. H.) (Gunshot Wounds of the Scrotum and Testes, in Am. Med. Times, 1864, Vol. IX, p. 61); Homans (J., jr.) (Gunshot Wound of the Testis and Femur, in Boston Med. and Surg. Jour., 18!io, Vol. LXXII. p. 15). 408 INJURIES OF THE PELVIS. [CIIAI*. VII. Cases.—In the following shot injuries of the testis pensions were allowed: 1113. Private W. McC------, 3S(,h Ohio was wounded at Missionary Ridge, November 25. 1863. Assistant Surgeon II. T. Legler, U. S. V., reported, Januarv 4, 1S64 : "Gunshot wound of right thigh and testis." Discharged September 17, 1834. Examiner W. Ramsay reported. April 16. 187;{: " Ball entered left thigh, passed through scrotum and right thigh; one testis entirely destroyed." Pension paid September 4, 1873. —1114. Private J. G------, wounded at Chickamauga, September 19, 1833 Duty at Camp Chase April 7, 1864. Discharged December 5, 1864. Examiner S. W. Jones, Leavenworth, reported, April 11, 1865, " destruction of left testis." Examiner II. S. Roberts, September 5, 1873, reported: "Ball destroyed left testis and wounded the adductor muscles ofthe left thigh." Paid September 4, 1873.—1115. Private J. R. S------. 3d Vermont, aged 23, wounded at the Wilderness, May 5, 1834. Surgeon E. E. Phelps, U. S. V., reported : " Gunshot wound of external genitals." Duty December 27, 1864. Mustered out June 19, 1865. Examiner J. E. Stickney, of New Hampshire, reported, January 30, 1866: "Gunshot wound through left thigh and testis." Examiner H. A. Cutting reported, October 8, 1873: " Gunshot wound of left thigh ; left testis shot away, causing abscess; now healed." Paid to September 4, 1873.—1116. Sergeant W. G. B------, 5th Vermont, aged 2l, was wounded at the Wilderness, May 5, 1864. Surgeon O. A. Judson, U. S. V., recorded, May 11th, "gunshot wound of scrotum." Duty July 9, 1864. Discharged July 10, 1865. Examiner L. D. Ross, Vermont, reported, December 21, 1865 : "Wounded in left thigh and testicle, a portion of latter carried away; wound has healed, uniting scrotum and testis." Dr. A. P. Belden, of Xew York, corroborates above, adding : "And at times all the ease he gets is to lie flat on his back for two or three days at a time." Disability total. Paid September 4, 1873.—1117. Private C. R. Fiske, 4th Vermont, aged 22, was wounded at the Wilderness, May 5, 1834. Surgeon S. J. Allen, 4th Vermont, records: " Shot in the left testicle." Assistant Surgeon J. C. McKee, U. S. A., reported, May 25th, "gunshot wound of left testis and right nates." Duty July 29, 1834. Discharged July 13, 1865. In his declaration for pension, applicant states that the " ball carried away his left testicle, passing round hip, coming out in fleshy part of buttock; that after these wounds healed he had fistula in ano." Examiners Porter and C. L. Allen, at Rutland, reported, February 1, 1871: " Testicle was removed, for injury, at the time the wound was received. There is fistula in ano." Paid September 4, 1873.—1118. Private J. M. W------, 188th Pennsylvania, aged 17, was wounded at Cold Harbor, June 3,1864. Veteran Reserve Corps, October 8, 1864. Discharged August 8, 1865. Examiners G. McCook and J. W. Wishart, of Pittsburg, reported, February 1, 1871 : "Ball entered below glutei, passed behind femur, and out on inner side of thigh, injuring left testis." Same Board reported, May 1, 1872, "destruction of left testis." Paid September 4, 18/3.—1119. Private G. P------, 9th U. S. C. T., aged 36, wounded at Deep Bottom, August 17, 1864. Surgeon J. H. Taylor, U. S. V., reported, August 20, "gunshot wound of left thigh and testicle." Discharged May 27, 1865. Examiner J. Cummiskey, of Philadelphia, reported, June 12, 1865 : "Ball entered inner side of left thigh and passed through left testis and head of penis; testis entirely destroyed and leg slightly contracted from wound in thigh." Examiners G. W. Fay, H. W. Owing.*, and A. W. Dodge reported, November 1, 1871: "Loss of left testis; cicatrix on inner aspect of left thigh, which is slightly atrophied." Paid December 4,1873.—1120. Private D. W. S------, 114th New York, aged 30, was wounded at Winchester, September 19, 1834, and discharged August 8, 1835. Examiner I. Spencer, of New York, reported, September 29, 1865: "The first ball passed through both thighs and the scrotum, destroying the left testis." Examiner V. W. Mason reported, November 39, 1838: "Ball entered lower and posterior part of left hip, destroying left testis, and passed out at upper and outer part of right thigh." Paid December 4, 1873.—1121. Private D. IT------, 13th Michigan, aged 32, was wounded at Chickamauga, September 19,1863. Surgeon B. Cloak, U. S. V., recorded, November 11th: "He received six Avounds, viz: wound of left thigh, two wounds of the right; another ball carried away the glans penis and one testis; wound of right shoulder, aud gunshot fracture of three fingers of right hand." Duty August 9, 1864. Discharged March 9, 1865. Examiner E. Amsden reported, September 4, 1873: "First, loss of fingers; secondly, loss of testis and an opening inside of prepuce; thirdly, bayonet wound in thigh. In addition there is gunshot wound of thigh, one of left shoulder, and one of natis." Paid September 4, 1873.—1122. Private S. M. Y------, 5th Illinois, age'd 25, was wounded at Chickamauga, September 19, 1833. Assistant Surgeon B. E. Fryer, U. S. A., reported: "Gunshot wound of right thigh, ball passing through both testes." Duty September 13, 1864. Discharged January 16, 1865. Examiner R. Barney, of Missouri, reported, March 12, 1872 : "Gunshot wound of the forearm, right thigh, and testicles." This pensioner was paid September 4, 1873.—1123. Private J. F. W------, 13th Pennsylvania Cavalry, was wounded at Samaria Church, June 24, 1865. Surgeon T. R. Spencer, U. S. V., reported : "Gunshot wound of the right testis and groin." Duty March' 15, 1835. Discharged July 14, 1865. Examiner J. S. Crawford, of Williamsport, reported, January 13, 1839, that "the testis was entirely removed; lame- ness of leg from injuries to muscles." The same examiner reported, August 7, 1872: " The scrotum is healed soundly."— 1124. Private G. P------, 15th New York Heavy Artillery, was wounded at Spottsylvania, May 19, 1864. Surgeon J. Hopkinson, U. S. V., reported: "Gunshot Avound of left testis and right thigh." Duty September 29, 1834. Discharged April 3, 1865. Examiners Phelps, Smith, and Deming, of New York, reported, February 5, 1873: "Ball carried away left testis, passing through right thigh."—1125. Private J. B. W------, 105th New York, was wounded at Fredericksburg, December 13, 1832. Surgeon O. A. Judson, U. S. V., reported, June 2, 1833 : "Discharged for gunshot wound of both thighs and left testis; disability total." Examiner H. T. Montgomery reported, March 1, 1866: "A ball passed through both thighs and the left testis." Paid June 4, 1873.—1126. Quartermaster Sergeant G. S S------, 2d Sharpshooters, aged 32, was wounded at Spott- sylvania, May 13,1864. Duty September 1,1864. Discharged February 20,1865. Examiner L. D. Ross reported, September 8, 1863: "Wound caused by ball, destroying left testis, passing through right thigh." Special Examiner A. L. Lowell reported, April, 1871: "A ball carried away left testis, entering at perineum, emerging from right natis; wounds fully healed." Paid June 4, 1873.—1127. Private J. V. J------, 2d Maine, aged 30, was wounded at Fredericksburg, December 13, 1862. Discharged June 4, 1863. Examiner J. C. Weston reported, June 10, 1863: "Applicant received shell wounds in both thighs and right testis, the latter being destroyed. All the muscles in front of right thigh, down to the bone, appear to have been severed." Disability total. Paid September 4, 1873.—1128. Private J. A. B------, 8th Michigan Cavalry, aged 33, was wounded at Henrysville, November 23, 1864. Discharged May 12, 1865. Acting Assistant Surgeon D. O. Farrand reported: "Gunshot wound ihrough left testis, ball penetrating right thigh, and is lodged there." Examiner Dorsch, September 4, 1873, added, "ball came out, after four years, below the seat. Disability total." Paid December 4, 1873. SECT, in.] EXCISIONS OF THE TESTIS FOR SHOT INJURIES. 409 Case 1129.—Private T. J. F------, Co. A, .r>lsl. Pennsylvania, aged 19 years, was wounded at Spottsylvania, May 12, 1834. Surgeon M. K. Hogan, U. S. V., reported, from a Ninth Corps hospital, "gunshot wound of the right thigh and testicles; testicle removed." On the ~8lli, this patient was sent to Armory Square Hospital, and remained under treatment until September 24th ; when transferred to Satterlee Hospital the medical officer iu charge of Ward G reported : "Shell wound ofthe right thigh and groin, carrying away the right testicle; poult ices and simple dressings were applied. By February 6, 1835, he had so far recovered as to be recommended for duty with his regiment, •and was transferred to another ward. A piece of the shell still remained deeply buried in the wound near the situation of the femoral artery; and, on February 16th, Acting Assistant Surgeon \V. F. Atlee made an incision about one inch long and extracted the piece of shell. Tliere was but little hsemorrhage, and no ligatures were used. The anaesthetic used was one part chloroform to three of ether. When the operation was performed the wound was somewhat inflamed. Flaxseed poultices and cerate dressings were applied to the wound, and the patient did well until April 20th, when an abscess began to form on the inner side of the thigh below tlie wound. The parts were painted with tincture of iodine, and, on the 27th, the abscess opened and discharged a quantity of bloody pus. On May 11th, there were syphilitic warts all over the corona of the glans penis." This soldier was mustered out June 24, 1865, and pensioned. Examiner T. S. Harper, of Philadelphia, May 3, 1871, reported: "A ball entered the right inguinal region a few lines above the middle of Poupart's ligament, causing a suppurating wound, which still continues to discharge, resolution never having taken place since he was wounded. Immediately titter having received the above-described wound, while being carried from the field of battle, he received several other wounds by the bursting of a shell, one fragment of which carried away the right testicle, and another fragment caused wounds in the upper and middle thirds of the right thigh, which is now covered with numerous cicatrices. Disability from these wounds has increased." This pensioner was paid September 4, 1873. Case 1130.—Captain E. S------, Co. I, 17th Missouri, aged 37 years, was wounded at Arkansas Post, January 11, 1833. He was treated at a Fifteenth Corps hospital and at the Officers' Hospital, Memphis, for "chronic diarrhoea," and was returned to duty on July 6, 1863. On July 21, 1834. he entered Main Street Hospital at Covington; a board of surgeons reported: ''Gunshot wound of the lower extremity and scrotum." This officer was discharged July 27, 1834, and pensioned. Examiner J. Bates, of St. Louis, reported, September 3, 1834: "Ball passed through the upper fleshy portion ofthe left thigh and through the scrotum, and out through the fleshy part of the right thigh." Examiner J. Baker, of Jefferson City, January 15, 1872, reported: "A ball passed through the left testicle and right thigh; the testicle has entirely disappeared, leaving the adjacent structures in an irritable condition, so that occasionally the parts become inflamed and ulcerated." * * Dr. Baker again reported, September 4, 1873: '■ Wounded by a ball in the left testicle, which was afterward removed. The ball then penetrated the right thigh, and passed out near the trochanter major. He is unable to bend the thigh to the abdomen, and suffers from lameness and inability to take active exercise; tbe cicatrix of the scrotum is tender; disability three-fourths." Case 1131.—Private S. S------, Co. F, 18th Illinois, aged 18 years, was wounded at Fort McAllister, December 24, 1834. and sent to hospital at Beaufort on the next day, and registered: "perforating gunshot wound ofthe left testicle and right thigh bya conoidal ball; testicle removed." On January 1, 1833, this patient was sent by hospital steamer to De Camp Hospital, New York, and thence, by rail, on March 18th, to Quincy, Illinois. Acting Assistant Surgeon D. C. Owen reported: "Wounded by a niini<3 ball, which totally destroyed the left testicle; thence, entering the right, thigh, the ball passed through the gluteal muscles; both wounds are healed; full diet was given ; the patient improved slowly, and, May 17, 1835, was discharged and pensioned." Examiner Joseph Robbins, of Quincy, reported, May 18, 1833: "Ball struck the scrotum, took out the left testicle, entered the right thigh on the inside, passed obliquely through and out on the outer side posteriorly. The leg is weak, and soon becomes weary when exercised; he has pain and weakness in the left groin, aggravated by exertion; disability three- fourths." Examiner A. T. Barnes, of Centralia, reported, February 9,1872: * * "The testicle being destroyed entitles him to one-half pension, and the wound in thigh to one-fourth; the spermatic cord is also painful, the pain being annoying rather than severe." This pensioner was paid September 4, 1873. Excisions of the Testis for Shot Injury.—Sixty-one, or about one in nine, of the cases of shot injury of the testis were treated by extirpation of the injured organ. In twenty- five the right testis, in thirty-one the left, and in three both testes were removed; in two cases this point was not specified. The mortality of these cases was 18 per cent. In the cases treated by expectation, the mortality was 11.9 percent.: Case 1132.—Private James L------, Co. B, 10th Infantry, was wounded at the Wilderness, May 12, 1834, and sent to a Ninth Corps hospital. Surgeon M. K. Hogan, U. S. V., reported: "Gunshot wound of testicle, necessitating castration." May 26th, this soldier was transferred to Lincoln Hospital, and registered as a case of "loss of left testicle, excised for gunshot wound." He was sent to Patterson Park, Baltimore, convalescent, on June 6th, and returned to duty July 22, 1831. No application for pension. Case 1133.—Sergeant Samuel B------, Co. G, 70th Ohio, aged 25 years, was accidentally wounded at Columbia, South Carolina, February 18, 1835. He was admitted to a Fifteenth Corps hospital on the same day. Assistant Surgeon J. W. Brewer, U. S. A., reported: "Gunshot wound ofthe right thigh, injuring the scrotum and wounding the left testicle; the injured testis was removed by Acting Assistant Surgeon G. M. Wilson." The patient was transferred to Foster Hospital, New Berne, April 4th, and thence to Grant Hospital, New York, on the 16th; was returned to duty June 2d, and discharged from service August 14, 1835, and pensioned. Examiner Thomas W. Gordon, of Georgetown, Ohio, reported, August 14, 18;>5: "The ball entered the inside of the left thigh iu the upper third, carried away the left testicle and injured the right one, passed into the upper third of the right thigh, and was removed from its posterior side through the glutei muscles. An abscess was after- ward found in the middle third of the thigh, inside, and the muscles sloughed. The leg is a little diminished in size by the loss of nervous and muscular power, and is thereby weakened." This pensioner was paid September 4, 1873. 52 no INJURIES OF THE PELVIS. < HAP VII. The two foregoing abstracts, and six on this and three on the succeeding page, relate to excisions of the left testis,1 which is probably more exposed than its fellow to shot injury, in a degree inadequately expressed in the statistical summary on page 385: Case. 1134.—Sergeant L. J------, Co. I, 134th New York, aged 18 years, was wounded at Gettysburg, July I, 1863. Surgeon II. Janes, U. S. V., reported: " Severe gunshot wound of the genitals and removal of the left testicle." On July 16th the sergeant was sent to Annapolis, and, on October 5th, was registered as "convalescent from an excision of the left testis for gunshot wound, and returned to his regiment," He was discharged June 10, 1835, and pensioned. Examining Surgeon J. A. Dockstader, of Sharon Spa, reported, February 3, 1870: 'Gunshot wound in the left testicle, which was removed on July 4, 1833. The ball in its course penetrated the soft parts in the neighborhood, ascending into the region of the groin. It has made sad inroad upon his health." Dr. J. J. Swart reported, January 2, 1872: "Wound of left testicle, which is entirely removed. No inconvenience from the castration as regards his health. The disability is permanent in its present degree." Surgeons R. B. Bontecou, W. H. Craig, and C. H. Porter reported, September, 1873, that the "ball passed through the left testis, which was removed, and also injured the muscles on the under side of the left thigh." Case. 1135.—Private James E. L------, Co. C, 105th Pennsylvania, aged 21 years, was wounded at the Wilderness, May 6, 1831. A conoidal musket ball perforated the scrotum and inflicted a slight wound in the thigh. The left testis was so much injured that it was excised on the field by Surgeon J. Ebersole, 19th Indiana. The patient was sent to Harewood Hospital May 26th,. and transferred to Jarvis Hospital June 6th, thence convalescent to Camp Parole, July 19th, and returned to duty August 23,1834. He was promoted sergeant and served till the muster out of his regiment, and was honorably discharged and pensioned July 11, 1863. He was in good health, though rated as totally and permanently disabled, in July, 1872. The injured testicle was contributed to the Museum, and is represented in the wood-cut (FlG. 355). Case 1136.—Sergeant Oscar T------, Co. I, 77th-New York, aged 24 years, was wounded at Spottsylvania, May 12, 1834. Surgeon S. J. Allen, 4th Vermont, reported that "a ball entered the outer side of the right thigh, passed through, and wounded the left testicle. On the same day the iujured testis was removed. The patient entered Carver Hospital May 24th. He was furloughed June 28th, and returned to his regiment to be mustered out January 30, 1853. June 11. 1870, Pension Examiner W. H. Miller reported that this man "complained of pain in his left Fig. 356.—Shot wound of the thigh when he labored hard; that he was not able to retain his urine as long as formerly; and left testis. Spec. 2500. 4. tj(at tne disability was not increased to more than three-fourths." Case 1137.—Lieutenant-Colonel Benjamin G. B------, 2d Pennsylvania Heavy Artillery, aged 38 years, Avas wounded at Petersburg, June 30, 1834. Surgeon Horace Ludington, 100th Pennsylvania, reported that a conoidal ball penetrated the left testis and perineum. The wounded officer was placed under the influence of chloroform and the disorganized testis was excised. The patient was sent to the Seminary Hospital, at Georgetown, August 3, 1834, recovered, and was furloughed on August 23, 1864. He was discharged the service November 19, 1834. Examiner James Neil reported, April 30, 1867, that " this pensioner has lost his virile power and has partial paralysis. The disability is rated as total and permanent." Examiner T. F. Smith reported, September 23, 1873: "Constant pain in scrotum, extending to the groin." Case 1138.—Private L. B------, Co. C, 2d Wisconsin, aged 23 years, was wounded at the Wilderness, May 5, 1864, and. taken prisoner. He was exchanged, September 23, 1834, and sent on the steamer New York to an Annapolis hospital, where Surgeon B. A. Vanderkieft noted a "gunshot wound of the scrotum, destroying the left testicle." After furlough, this soldier entered Swift Hospital, Prairie du Chien, November 24, 1834. Acting Assistant Surgeon W. F. Kelly reported: "Gunshot wound of the right hip and perineum; the ball entered at the root of the penis on the left side and lodged in the left hip. The patient states that, under the circumstances, the wound did well. He lay on the battle-ground for thirty-two days with very little treatment, was removed to Gordonsville and remained eleven days, and then was removed to Lynchburg. On May 6th, the ball was cut out by a Confederate stretcher-bearer, and, on May 13th, Surgeons Thompson and Phillips (prisoners on the field) removed the left testis." On admission, the wound was discharging and inclined to slough, but speedily amended, and the soldier was transferred to the Veteran Reserve Corps, April 13, 1885; discharged July 29, 1855, and pensioned. On July 5, 1871, Examiner J. Conant, of Prairie du Chien, reported: "The ball entered on the left side and just above the penis, and injured the left spermatic cord and testicle, so that it became necessary to remove the latter." Examiner L. G. Armstrong reported, September 20, 1873: "Gunshot wound at the left external abdominal ring, causing castration of the left testicle." The reports of the examiners indicate that this pensioner's disabilities arise principally from the effects of wounds in the thigh and forearm. Case 1139.—Corporal A. C------, Co. E, 61st New York, aged 21 years, was wounded at Hatcher's Run, March 31,1885, and sent to City Point. Acting Staff-Surgeon J. Aiken reported: "Gunshot wound of the penis and scrotum. A conoidal ball passed through the prepuce and glans penis, the left testis, and the fleshy part of the left thigh. The testis was split by the ball and lay bare. The patient was enfeebled by irritation and suffering, which had been excessive. On April 5th, chloroform was administered, and an operation was practised by Acting Staff-Surgeon W. J. Burr, by removal of the left testis and part of the glans penis, paring the edges of the scrotum, which had sloughed considerably, aud uniting them with sutures. The parts healed slowly by granulation, and by April 21st were nearly well." The corporal was sent to duty April 28th, transferred to Carver Hospital May 2d; to Whitehall, Bristol, May 27th; to De Camp Hospital July 14th, and thence mustered out July 26. 1865. No application for pension. 1 Case 1016, p. 353, and Case 1054, p. 363, were instances of primary ablation of the left testis; and other examples will be recorded as Cases 1149. 1152. 1153. p. 412; 1158. 1160, 1161, 1163, 1164, 1163. and 1169. p. 413. SECT. III. 1 EXCISIONS OF THE TESTIS FOR SHOT INJURIES, 411 Eventually the three following cases resulted fatally; but a connection between the operation, or the injury even, and the fatal termination, is apparent in Uase 1142 only:1 Case 1140.—Corporal E. A. P------, Co. I, 1st Massachusetts Artillery, aged 17 years, was wounded near Petersburg, June 16, 1834, and sent from a Second Corps hospital, on July 4th, to Judiciary Square Hospital. Assistant Surgeon A. Ingrain, U. S. A., reported: "Wound through the right buttock and left testicle; the testis has been removed on the field." This soldier was twice furloughed, readmitted, and returned to duty November 30th; discharged June 2, 1H35, and pensioned. He states that "a minie ball entered at the testicle and passed out through the fleshy part of the right thigh, at Petersburg, June 16, 1864, and that, on March 31, 1865, he was again wounded, at Hatcher's Kun, by a musket ball, which entered near the right shoulder-blade, passing through or near the spine, and that after remaining about a month the ball was taken out near the left shoulder-blade." Examiner A. Garcelon, of Turner, reported, April 23, 1863: "Loss of left testicle, and injury of the adductor muscles ofthe thigh, interrupting free progression. Injury of spine near lower angle ofthe scapula, causing weakuess of the upper extremities; disability three-fourths." This pensioner died September 23, 1867. Case 1141.—Private James Knight, Co. A, 63d Ohio, was wounded at River's Bridge, South Carolina, February 3, 1865, and was admitted to a Seventeenth Corps hospital, where Surgeon .1. A. Follete, 39th Ohio, noted "gunshot wound of abdomen and privates: left testis excised by Surgeon Arthur B. Monohan, 63d Ohio." This patient was sent to hospital at Beaufort on February 6th, where Surgeon J. Trenor, jr., reported that "he died of pyaemia, on February 10, 1835." Case 1142.—Private Samuel F. G. Yeomans, Co. G, 2d New York Mounted Rifles, aged 18 years, was wounded at Petersburg, June 19, 1831, and sent to a Ninth Corps hospital. Surgeon James Harris, 7th Rhode Island, reported a "gunshot wound of the thigh and scrotum; castration of the left testis." This soldier was transferred to Lovell Hospital, Portsmouth Grove, June 26th, and died, July 11, 1834, from the effects of chronic diarrhoea. The next series of abstracts are of cases of excision of the right testis: Case 1143.—Private J. P------, Co. F, 119th New York, aged 23 years, was wounded at Chancellorsville, May 2,1883. He was taken prisoner, released, and, about May loth, received into the Log Hospital, near the deserted battle-field. Surgeon George Suckley, LT. S. V., reported: " Shot wound of scrotum, lacerating it so as to expose the right testis, which was disorgan- ized. The testis was removed on May 12th. The patient was sent to Columbian Hospital, May 15th, and four days afterward to Mower. The wound did well till July 20th, when an ulcer appeared on the penis, which healed under a mild zinc lotion. On September 30th, the patient was able to do light duty, and was recommended for the Invalid Corps December 22, 1863. It is noted that the influence of the sexual passion in this case has suffered abatement." No application for pension. Case 1144.—Corporal W. N. C------, Co. H, 10th Vermont, aged 22 years, was wounded at Mine Run, November 29, 1833, and sent to Hallowed Hospital, Alexandria, December 4th. Surgeon E. Bentley, U. S. V., reported: "Gunshot wound of tlie right testicle. Ball cut out December 7th, and testicle removed." On September 9, 1884, the patient was sent to Governor Smith Hospital, Bratileboro'; returned to duty December 27th; discharged March 9, 1835, and pensioned. Examiner D. XV. Hazelton, of Cavendish, reported, April 26, 1866: "Ball first passed through and destroyed the right testicle, entering the thigh on the inside close to the body, passing through, making its exit from the right buttock. The wound is still discharging, and fragments of bone come away from time to time. The wound is painful, and very troublesome in the act of sitting; disability total." Drs. H. Pierpont and C. A. Gallagher, of New Haven, reported, September 3, 1873: " Ball entered from before through the adductor loDgus muscle, passed-backward, and emerged from the gluteus minimus muscle. The wound of exit is open occasionally, and also abscesses in the inner portion of the thigh near the perineum. He is troubled much the most during warm weather." This pensioner was paid September 4, 1873. Case 1143.—Corporal C. S------, Co. A, 2d New Jersey, aged 27 years, was wounded at Spottsylvania, May 12, 1864, and sent, on the 26th, to Alexandria. "Shot wound; the ball passed through the right testis. Both testicles were much injured, greatly inflamed, and exquisitely painful. On Ma}- 28th, the patient being chloroformed, the right testicle was excised by Surgeon Edwin Bentley, U. S. V. With simple dressings, and nourishing diet and tonics, the case progressed favorably, and, by June 30th, the wound was healing kindly." This soldier was furloughed July 27th, readmitted, and transferred, November 1st, to Beverly, New Jersey, and returned to duty January 8, 1S85, and, February 6th, discharged and pensioned. Examiner W. II. McReynolds, of Cincinnati, January 16, 1837, reported: " Ball entered the anterior aspect of the scrotum one-fourth of an inch to the right of the raphe, passed through, and lodged against the left ischium, whence it was afterward removed. The right testis had been excised, and there is considerable induration of the scrotum, and a varicose condition of the veins of the left side. He has lameness and neuralgic pains ofthe left leg; continued walking or other exertion causes painful swelling of the scrotum, and his disability is three-fourths and permanent." Examiner G. K. Taylor, September 29, 1873, reported: " Loss of right testis; left testis is enlarged and painful, and the veins are varicose. There is a small thickened cicatrix just in front of the left tuber ischii; also a healthy, small, unimportant cicatrix on the left natis. His disability is undiminished." Case 1143.—Sergeant Robert D------, Co. F, 49th Pennsylvania, aged 22 years, was wounded at Spottsylvania, May 10, 1834. Surgeon E. B. P. Kelly, 95th Pennsylvania, reported "a shot wound of the scrotum, with laceration of the right testis, which was excised at the field hospital of the 1st division, Sixth Corps." The patient was treated at Lincoln and Jarvis Hospitals until August 22d, and was returned to duty from Annapolis, by Surgeon B. A. Vanderkieft, U. S. V., September 13, 1834. This soldier is not a pensioner. At several hospitals the injury was referred to the left testis. 1 The prudent advice of Pakij (Des plaies en particulier, Liv. 8"", Chap. XXXVI) regarding the treatment of wonnds of the testis, will bear repetition: "Or quant aux playes des Tosticules et parties genitales, parce qu'elles sont necessaires a la generation, et qu'ellcs font la paix en la maison, on les conseruera le plus soigneuseinent qu'il sera possible, y procedutit ainsi que l'on verra estre necessaire. suivant la doctrine donnee par cy devant, diversifiant les remedes selon les accidens qui viendront." 412 INJURIES OF THE PET-VIS. [CHAP. VII. The two following cases relate to primary excisions of the right testis, and are followed l>v a series of live primary operations, two on the right and three on the left testis:1 Case 1147.—Lieutenant C. D. FI------, Co. C, 47th Massachusetts, aged 40 years, was wounded at the Wilderness, May 6. 1864. Surgeon H. W. Ducachet, U. S. V., from the Seminary Hospital, Georgetown, where this officer was received May 12th, reported: " Gunshot wound of penis, scrotum, and right thigh. The right testis was removed on the field, May 7th. The patient states that the scrotum was very much lacerated. The wound of the thigh was slight. The patient says that the operation was performed by Surgeon Nathan Hayward, 20th Massachusetts. This officer's wound healed readily, and he was furloughed June 4, 1834, and discharged October 13, 1864. Examining Surgeon David Choate, of Salem, November 12, 1864, reported: "The ball struck the right testicle in front, passed into the right thigh near the perineum, and escaped from the right natis a little below the centre. Considerable sloughing followed near the wound of entrance in the thigh; the loss of substance is now apparent. The thigh is emaciated; he suffers from almost constant tenderness and sense of soreness, with frequent pains on the outer side of the thigh, and also pain in the four lesser toes, evidently neuralgic; there is partial loss of power in the whole limb, which is apt to drag in walking, requiring constant care to avoid stumbling; it is especially difficult for him to ascend stairs, and exercise and fatigue cause pain, aud the right foot and ankle swell at night. The right testicle is gone. He is slowly improving, but his disability is total." Another report, from the Examining Board at Boston, Surgeons Chase, Foye, and Treadwell, is dated November 2, 1870: "Ball passed through the right side of the glans penis, carried away the right testicle, then passed through the gemellus muscles, injuring the tibial nerve, producing, at times, much sensitiveness along the course of that nerve. His disability is reduced to one-half." This officer received his pension September 4, 1873. Casio 1148.—Lieutenant J. W. R------, Co. H, 61st Pennsylvania, was wounded at Spottsylvania, May 12, 1864. Surgeon S. J. Allen, 4th Vermont, reported, from the 2d division, Sixth Corps, a "gunshot flesh wound of the left thigh and the left testis, requiring removal of the latter." This officer was sent to Washington and treated in hospital until May 27th, when he was furloughed. On July 21st, he entered hospital No. 1, Annapolis, and returned to duty on the following day. He was mustered out at the expiration of his term of service, September 13, 1854, and pensioned. Examining Surgeon T. S. Harper, of Philadelphia, reported, August 10, 1869: * * "He received a wound of the genitals, a ball having entirely shot away the right testicle. Although a great loss to him personally, and disqualifying him for marital duties, I cannot perceive that the result of his wound adds to or increases his disability to perform manual labor." It is gratifying to observe that this rigorous interpretation ofthe law was overruled, and to find this officer, December 27,1871, an applicant for increase of pension. Examiners T. S. Harper, T. H. Sherwood, E. A. Smith, J. Collins, and G. C. Harlan then reported "gunshot wound of the upper portion of the right thigh, chipping the femur and destroying the right testis, so that he is unable to make positive engage- ments for business; he has no sexual desire, and has no children." In an examination made in September, 1873, when this pensioner was paid, the Board rated his disability at one-half for the thigh wound and one-half for the loss of the testis. Casks.—In the following instances of shot wounds of the testis the injured organ was excised, and the patients recovered and were pensioned: 1149. Private R. J------, 125th Illinois, was wounded at Kenesaw, June 27, 1864, in the left tetis; and immediate castration was practised by Surgeon C H. Mills, 125th Illinois. The patient was transferred to the Veteran Reserves, November 19, 1864, and discharged July 5, 1835. Examiner W. Somers reported, May 15,1839, that "the ball, in addition to destroying the testis, passed through the right thigh ; the outer side of the thigh is paralyzed." Examiner E. A. Kratz reported, September 6, 1873, that the disability was undiminished.—1150. Private D. L. M------, 64th Ohio, was wounded at Murfreesboro', December 31, 1862, in both thighs and right testis. Assistant Surgeon H. P. Anderson, 64th Ohio, removed the portion of the testis remaining. Discharged January 27, 1863. Examiner C M. Johnson, March 1,1872, reported: "The ball passed through the upper part of left thigh,' injuring the sciatic nerve, and, passing through the scrotum, injured the lower extremity ofthe left testis and entirely destroyed the right." This pensioner was paid December 4, 1873.—1151. Private F. S------, 9th Iowa, aged 27 years, was wounded at Dallas, May 27. 1834. Surgeon J. Pogue, 66th Illinois, recorded extirpation of right testis for shot wound. This soldier was discharged May 29, 1835. Examiner H. Ristine, of Marion, reported, September 5, 1873: "The ball passed through the left testicle, injuring it to such an extent as to require its removal, and through the muscles of the posterior part ofthe right thigh, which are so much injured as to somewhat impair the use ofthe limb in walking." Paid June 4, 1873.—1152. Private J. W. B------, 205th Pennsylvania, was wounded at Petersburg, April 2, 1865. Surgeon M. F. Bowes, 209th Pennsylvania, reported: " Gunshot wound of thigh and scrotum; left testicle removed." This soldier was discharged July 14, 1865, and pensioned. Examiner D. L. Beaver, of Reading, reported, January 29, 1872, that "a ball passed through both thighs and scrotum, injuring testicles, one of which was removed immediately; the other remains intact and was healthy until lately; it is now painful to touch, and wasting away. Erection and power of coition are very slight; there is but small desire left, and this will probably soon disappear; disability total."—1153. Private J. B------, 16th Maine, aged 19, was wounded at Hatcher's Run, February 7, 1835. Surgeon D. A. Chamberlain, 94th New York, reported: "Severe gunshot wound of the genitals, and castration of the left testicle." This pensioner was paid September 4, 1873. 1 Instances of excision of the testes for shot injury are rarely mentioned by early writers on military surgery. My notes include none prior to the present century; but I have not searched exbaustivelj'. A few references are given here, and in foot-notes further on: Laurky (D. J.), in his Clinique chirurgicale, T. Ill, p. 58, observes: "Lorsque l'un des testicules est atteint par un projectile, de maniere a etre denud6 de ses tuniques ou disorganise dans une grande partie de sa substance, il faut n6cessairement en faire l'extirpation. C'est en effet la conduite que nous avons tenue dans plusieurs circonstances dont nous avons parl6 dans autres articles." The cases are not specified in other articles. Seidel, in Med. Chir. Zeitsehrift, 1804, B. Ill, S. 472, cites a case: "Heilung einer Schusswunde am scroto welche die Castration des rechten Testicles erforderte." THOMSON (J.) (Report of Obs., <>i.—,">. Corporal P. K------, Co. E, 115th Pennsylvania, wounded at Gettysburg, July 1, 1833; Surgeon C. K. Irwine, 72d New York, reported: "Left testis excised for shot injury; duly, July 11, 1864."— 6. Private I. W. II------, 2d Louisiana, was wounded at Port Hudson, May 27, 1-33; Surgeon F. Paeon, IT. S. V., reported: " Removal of right testis for gunshot wound ; duty, February 7, lSi4."—7. Private R. U------, 61th New York, aged 35, was wounded at Fair Oaks, June 1, 1862. Acting Assistant Surgeon A. C. Boumonville reported: "Wound of left side of scrotum, left testis and cord; left testis removed on the field; discharged, July 27, 1862."—3. Corporal James S------,28th Massachu- setts, aged 18, was wounded at Chantilly, September 1, 1832. Surgeon W. Clendenin, U. 8. V., reported: "Gunshot wound of the left testicle, the ball passing through the fleshy part of the left thigh; the testes were much swollen, the left test is protruding. On September 12th, the patient was chloroformed aud the testis was removed. On the 14th, be was no better; the parts were swollen and erysipelatous. Tincture of iron was given thrice daily, wine and chlorate of potassa were given, and lead lotions were applied." The case progressed favorably, and tbe patient was well December 4, 1832, and was returned to duty.'2— 9. Private J. P------, 1st New Jersey Cavalry, aged 25, was wounded at Weldon Railroad, August 23, 1834. Surgeon R. B. Bontecou, U. S. V.; recorded the following, September 12th : "Gunshot wound ofthe right testicle ; removed on the field on day of injury; operator unknown. By September 30th, the wound was nearly healed. Furloughed October 11th; November 30, 1834. deserted."—10. Private J. H. I------, 4th Virginia, was wounded at Petersburg, March 25, 1885. Surgeon W. L. Baylor, P. A. C. S.. recorded: "Wounded in the left testis by a minie ball; the testis was removed, March 26th, by myself assisted by Drs. J. P. Smith and J. T. Kilty. This soldier was nearly well when he left hospital, April 1, 1833."—11. Private E. F. B------, 101st Ohio, was wounded at Jonesboro', August 31, 1864. Surgeon M. G. Sherman, 9th Indiana, recorded: "Shot wound of privates; left testicle removed by Surgeon T. M. Cook, 101st Ohio." Discharged June 12, 1835. Fatal Cases of Excision of the Testis.—Of sixty-one cases of excision of the testis for shot injury, eleven, or 18 per cent., resulted fatally. The following examples indicate the proportion in which death was traceable to the operation. There were five ablations of the testis for traumatic lesions not produced by shot, with one death; and eleven cases of removal of the testis for disease, with two deaths : Case 1165.—Private G. Cornick, Co. F, 7th Wisconsin, aged 23 years, was treated in a Fifth Corps hospital for a wound received at Spottsylvania, May 11, 1834. He was sent to Washington on the 15th and admitted into Emory Hospital, where Surgeon N. R. Moscley, LT. S. V., reported: "Gunshot wound of the scrotum, with laceration and protrusion of the right testicle. The parts became gangrenous, and there was severe constitutional disturbance from the infiltration of pus in the right iliac region. The wound was ragged and the turgid testis was assuming a gangrenous appearance, and there was great tender- ness of the abdomen. Chloroform and ether were administered to the patient on the 19th and the right testis removed, the operation being followed by cold-water applications to the wound. Peritonitis set in on the same day; it was treated with calomel, opium, brandy, and turpentine stupes to the abdomen;" but unavailingly, as the case terminated fatally on May 23. 1834. Cases.—The following complicated cases of excision of the testis for shot injury also proved fatal: 1163. Private G. C----, 7th Wisconsin, wounded at Spottsylvania, May 11, 1834, in right testis, which became gangrenous, and was excised by Surgeon N. R. Moseley, FT. S. V. Death from peritonitis, May "23d.—1167. Captain A. J. S------,9th New Hampshire, was wounded at Spottsylvania, May 18, 18 J4. Surgeon M. K. Hogan, U. S. V., reported : "Shell wound with extensive laceration, and castration of one testis." Death, May 20, 1834.—1168. Corporal C. P. D------, 6th Vermont, aged 23 years, wounded at the Wilderness, May 5, 1834. Surgeon O. Everts, 20th Indiana, noted: "Wound of head and testis; castration of left testis May 6th." Died, from fracture of skull, June 3d.—1169. Private A. J. B------, 37th Wisconsin, aged 27 years, wounded at Petersburg, July 30, 1864, in "right thigh and scrotum." Surgeon A. F. Whelan, 1st Michigan Sharpshooters, removed*left testis. Death, August Cth.—1170. Sergeant A. C------, 12th Pennsylvania, aged 15 years, was wounded at Cold Harbor, June 2, 1834. Surgeon C. N. Chamberlain, U. S. V., recorded : "Wound of perineum and testes; removal of one of them." The patient died July 17, 1884.—1171. Private J. H------, 74th Illinois, wounded at Marietta, June 27, 1834. Surgeon E. H. Bowman, 27th Illinois, reported: "Testis destroyed; excision." Death, July H, 1834. 1 SociN (A.) (Kriegschir. Erf, 1872, S. 100) gives the case of II. Eenslage, wounded at Gorze, by a ball passing through the penis, then through the scrotum, lacerating the testis. The wound of the penis healed in nineteen, that of the testis in fifty-one days. Professor SOCIN distinguishes this as a " complete perforation of the penis without injury to the urethra, owing perhaps to the small size of the Chassepot projectile, or possibly to an exceed- ingly large German calibre"! '2 The report of the Adjutant General of Massachusetts. 1865, p. 572, shows this man was subsequently captured, and that he died iu Richmond, March 13, 1864. 414 INJURIES OF THE PELVIS. |CHAH. vu 1-jH-cisioit of both Testes.—This operation is still frequently performed,1 according to Curling, by oriental barbarians ; but is rarely resorted to, even in Italy, among civilized communities, except on account of hopeless disorganization of the testes by injury or disease. When the testes are badly lacerated by shot, some military surgeons2 are of opinion that primary ablation3 is preferable to an expectant treatment because of the greater rapidity of recovery after operation. Three cases were returned in which both testes4 appear to have been removed for shot injury, although the reports are somewhat vague : Case 1172.—Thomas Fisher, an unassigned substitute recruit of the 13th Pennsylvania Cavalry, aged 24 years, having received gunshot wounds of the left thigh, right hand, and both testicles, at the Soldiers' Rest, Washington, September 9, 1834, was taken to Judiciary Square Hospital, anaesthetized, and both testicles were excised, and the right hand was amputated a little above the wrist (see Specimen 3210, Sect. I, A. M. M.), by Acting Assistant Surgeon J. F. Thompson. During September the patient progressed favorably, but he died October 16, 1834, from exhaustion from surgical fever. Case 1173.—Lieutenant J. A. V------, Co. A, 153d New York, aged 32 years, was wounded at Cedar Creek, October 19, 1S04. A Sixth Corps hospital register states: "Gunshot flesh wound of the left thigh and both testes by a minie" ball. On October 23d, Assistant Surgeon, J. G. Thompson, 77th New York, excised the right testis. Charcoal poultices, followed by simple dressings, were applied, and the case progressed favorably, so that by November 7th the patient was able to walk about." November 19th, this officer was sent to the National Hospital, Baltimore, thence to the Annapolis Officers' Hospital; on the 23d granted leave of absence, aud readmitted January 25, 1885. Acting Assistant Surgeon J. H. Longenecker reported : " This officer had suffered from a gunshot wound of the scrotum, with loss of the right testicle; and also from a wound of the upper third of the left thigh by a minie ball, which entered at the right side of the scrotum, carrying away the right testicle, entering" again at the upper third of the left thigh, passing backward, and emerging at the tuberosity of the ischium. The wounds are healed and require no treatment." This officer was honorably mustered out and pensioned, February 18,1865. Examiner P. R. Furbeck, of Gloversville, reported, May 7, 1836: " Was wounded by a minie ball passing through the scrotum, destroying both testicles, and thence through the left thigh. He has since been subject to some pain in the thigh and at the end of the right spermatic cord, and has not regained his strength ; disability one-third, probably permanent." Examiner B. B. Kelley, September 24, 1873, reported: "The ball passed through the scrotum, destroying both testicles; a portion of the right testis still remains; the ball entered the inner side of the thigh and came out about two inches below the trochanter major, splintering the back part of the femur, pieces of which were taken out at the point of exit. The action of the limb is.interfered with by the passage of the ball, causing lameness when use is continued, as in walking all day; disability one-third." Case 1174.—Private R. W. C------, Co. C, 33d Iowa, was wounded at Jenkins' Ferry, Arkansas, April 30, 1884, and taken prisoner. He was admitted into hospital at Camden, Arkansas, where Assistant Surgeon W. L. Nicholson, 29th Iowa, reported: "May 11th, castration of testicles while in the enemy's hands." This man was discharged July 6, 1885, and is now an applicant for pension. He states that he was treated, while a prisoner, in Confederate hospitals at Princeton, Camden, and Magnolia, Arkansas. Examiner A. A. Dye, of Lamar, Missouri, February 18, 1874, reports an examination of claimant: * * "The thigh wound was produced by a ball, which struck the scrotum in front, carrying away the right testicle, entering the right thigh at a point opposite, and made its exit three inches below and an inch posterior to the trochanter major. There is weakness of the limb, with anaesthesia of the parts supplied by the obturator nerve." This man also received a wound of the leg, and a pension for total disability is recommended. One example was reported of excision of both testes in a case of laceration not resulting from shot injury :5 Case 1175.—Private W. Lucas, Co. E, 1st Virginia Battalion, aged 45 years, was wounded and captured at Farmville, April 7, 1865, and sent to the Second Corps hospital at City Point on April 13th. Acting Staff-Surgeon John Aiken reported: " Contused wound of the abdomen and testes by running against an abatis. Both testicles were severely injured, and the scrotum entirely sloughed away from them. On April 14th, Acting Staff-Surgeon W. J. Burr removed both testicles, and also an extensive slough from the scrotum. On April 18th, an abscess, which had formed in the inguinal region, was opened. Inflammation of the lungs supervened, and the patient died April 24, 1855." 1 Tiileis (Med. epistolse et consilia, Lipsiae, 1665, Lib. Ill, Casus XLVI) relates a case of ablation of both testes for inflammation, observing that the patient lived at the date he wrote: " quantum mutatus ab illo Bectore." 'BILLROTH (TH.) (Chir. Briefe aus den Kriegslazarethen, u. s. w., 1872, S. 20fi) observes: " Of two cases of 6hot lacerations ofthe testicles that I treated (Nos. 37 and 38), I performed castration lege artis in one ; in the other I only removed the torn tissues and clotted blood; the former patient recovered more rapidly than the latter, and suffered far less." 3 Beck (B.) (Chir. der Schussverletz., 1872, S. 597) cites four cases of shot wounds of the testicles from the campaigns of Werder's Bavarian Corps. Two recovered with atrophy; two, wounded at Worth, August 6, lt<70, underwent immediate castration by Dr. Beck, and recovered rapidly, one being well in a fortnight. 1 Matthkw (T. P.) (Surg. Hist, of Brit. Army in Crimea, etc., 1858, Vol. II, p. 335) notes four cases of shot wounds ofthe scrotum and testicles. In the case of an officer, the wound in the scrotum was brought together with hare-lip pins and twisted suture; in another case, the ball lodged in the body of the left tcs'.icle and was cut out; in the third case, the entire body of one testicle was removed by a fragment of shell, but the wound healed readily; in the fourth, the testis was only slightly wounded, but at the end of five months had nearly disappeared by absorption, and that ofthe opposite side was diminished in bulk. 'Hll'I'OCEAlus (Aph. VI, 28 and 30) gives those who have lost the testes the consolation that they are unlikely to suffer from gout. Evvbvxoi ov iro&a}pidaiv, obSe QaKaKpoi ylvovrai. For an extended commentary on this subject, with citations from the Greek paets, who personified Podogra as the daughter of Bacchus and Venus, compare Adman Spigelius. Opera omnia, Amsterd.. 1645. T. II, p. 69. SECT. III.) EXCISIONS OF THE TESTIS KOIl SHOT INJURIES. 415 The forty-three cases immediately preceding the last abstract, and Case 1016, on page 353, and Case 1094, on page 3i)i), are all of the sixty-one operations of excision of the testis from shot injury of which any particulars of moment are recorded. Cask 1176.—Private J. II. Perry, Co. A, 9th Maine, aged 18 years, was wounded at Port Wagner, July 18, 1863, admitted into hospital at Morris Island with a "gunshot wound of the privates," and, on the next day, sent to hospital No. 8, Beaufort. Surgeon David Merritt, 53th Pennsylvania, reported: •Gunshot wound of external genitals; a mini6 ball, tearing open the scrotum on the right side anteriorly, passed through the thigh posteriorly, and was extracted, on the field, from the gluteal muscles. Had the testicle been put in the scrotum and sutures used, thereby closing the scrotum, the result of the case might have been different; but, after waiting a few days, and applying cool and soothing lotions, the resulting condition was such that invited surgeons and myself deemed an operation necessary, and castration was accordingly performed. This case, with all major amputations, was sent north on the steamer Cosmopolitan, and was doing well when last seen." On July 30th, the patient was admitted into McDougall Hospital, thence transferred to Lovell Hospital, returned to duty April 18th, and discharged September "27, 18,>4, and pensioned. Examiner \Y. II. Page, of Boston, reported, April 12, 1835: * * "A ball struck the right testis, which testicle has been removed, passed into tbe inner side of the right thigh, and came out at the lower border of the glutens maximus behind." Examiners C. S. Jones, on September 11, 1W), and J. B. Treadwell, Hugh Doherty, and Horace Chase, on September 18, 1873, reported substantially as above, rating tbe soldier's disability at three-fourths. The pensioner was paid to December 4, 1873. Atrophy of the Testis1 was naturally a very common result of shot injury :~and3 Case 1177.—Private E. C------, Co. E, 17th Ohio, aged 22 years, was wounded at Chickamauga, September 19, 1883. He was sent from a Fourteenth Corps hospital, on the 23th, to hospital No. 15, Nashville, where the injury was noted as a ."gunshot wound of the left testiele. the ball passing through." On March 13th he was sent to Brown Hospital, Louisville, and similarly registered. On March 31st he was transferred to Madison; thence to Camp Dennison, and was discharged, on certificate of Surgeon W. Varian, U. S. V., September 8, 1831, for "atrophy of the left leg, gunshot wound of the scrotum, and expiration of service," aud pensioned. Examiner W H. Corwin, of Lebanon, reported, June 10, 1872: "A musket ball passed through tbe left testicle, in which he suffers sharp pains; these pains extend to the groin, up the left side, and across to the right side, over the region of the stomach. He has pains also in the left arm and leg, which pains are succeeded by numbness and partial paralysis. He" cannot with his left hand bold up an ordinary-sized chair for two minutes." Examiner I. L. Drake reported, September 8, 1873: "A musket ball passed directly through the left testicle, the point of entrance being in front, that of exit behind. There is enlargement of the spermatic cord and external veins of the scrotum, with tenderness, weight, and pain in the testicle. Disability one-half." This pensioner was paid September 4, 1873. Cases.—Atrophy of the testis after shot injury was observed in the following instances: 1178. Private W. B. G------, 35th Iowa, was wounded at Tupelo, July 16, 1834. Assistant Surgeon J. C. G. Happersett, U. S. A., reporte.l: "Gunshot wound of both thighs, penis, and scrotum; duty November 17, 1861." Discharged May 6, 1885, and pensioued. Examiner C. Hershe, of Muscatine, reported, July 20, 1835: "Ball entered two and a half inches above right knee and emerged from the upper part of the thigh, then passed through the penis and divided the cord of the left testis, making its exit half an inch below joint of left hip; was in kneeling posture when the wound was received." The same examiner reported, in December, 1867, that the "left testicle is wasted to nothing, or nearly so. His penis is very much deformed, and cords of his leg are getting shortened, so that he is lame; disability total." Paid March 4, 1873.—1179. Corporal A. K------, 8th Xew Jersey, aged 38, was wounded at Petersburg, June 16, 1864. Surgeon J. F. Dyer, 19th Massachusetts, reported: "Gunshot wound of hip and testis." Duty February 6, 1835. Discharged July 17, 1835. Examiner A. W. Woodhull, of New Jersey, reported, July 13, 1887: " Ball entered left groin, passed through scrotum, and came out about four inches below Poupart's ligament. Both testes are now atrophied; tbe patient has consumption; disability total." Death, from phthisis, February 11, 1868.—1180. Private W. W. Bailey, 11th Vermont, was wounded at Petersburg, June 2, 1834. Veteran Reserve Corps, November 23, 1864. Pis- charged July 31, 1865. Examiner D. W. Hazelton, of Cavendish, reported, February 25, 1838: "Gunshot wound, first of penis, cutting off a portion of the glans, injuring the left testis so that it has completely atrophied, and, further, of left thigh." Exam- iner W. S. Robinson, in his report, alluding to wound in scrotum and testis, says: " Testicle of left side lost by the wound." Paid September 4, 1873.—lis]. Private A. W------, 14th Connecticut, aged 24, was wounded at Morton's Ford, February 6, 1864. Discharged June 14, 1885. Examiner R. McC. Lord reported, December 22, 1888, that the " ball passed through scrotum and right thigh. Almost complete atrophy of both testes." Paid September 4, 1873.—1182. Private H. E. Davis, 2d New York Mounted Rifles, was wounded before Petersburg, June 17, 1864. Discharged February 12, 1835, Surgeon G. L. Pancoast, U. S. V., certifying: "Gunshot wound of scrotum and right thigh; unfit for Veteran Reserves; disability two-thirds." Exam- iner D. H. Decker, of Monticello, reported, September 8, 1873 : "Atrophy of left testis; both are sensitive. The injury to the thigh produces a peculiar gait; disability total and permanent." Paid September 4, 1873. 1 Berthold (Statistilc der u. s. w., invalide gewordenen Maiiusekaften des 10 Armee-Corps, in Deutsche Militairarztliclie Zeitsehrift, 1872, B. I, S. 466), describing the disabilities of eighteen hundred and four invalids, states: " There were four shot injuries ofthe testicles. * * The injured testicles all became atrophied." 2 Williamson (G.) (Military Surgery, 1803, p. 117) observes: "Wounds of the testicle and spermatic cord are not infrequent, and usually heal rapidly; but the portion which remains is often of little use, although the patient does not like to lose it." He cites two cases: Forbes, 00th Ilegiment. wounded at Delhi, June 18, 1657; ball through left testicle, pubis, and bladder; recovery; and Young, 75th Ilegiment, shot at Delhi, September 14, 1857; musket ball passing through the urethra, left testis, and left thigh, emerging at left buttock: left testis sloughed away; urethral fistule closed spontaneously. 3CHENU (J. C.) (Rapport, etc., pendant la camp, d'Orient, 1865, p. 237) cites eleven cases of recoveries from shot wounds of the testicles, with loss of one testicle in six, and atrophy in four cases. IDEM (Stat. mid. chir. de la camp, d'ltalie en 1859 ct I860, T. II, p. 518 et seq.) gives thirteen cases of recoveries from shot wounds of the testicles, with loss of one testicle in eight, and atrophy in three cases. It is not specified whether the loss of the testes was due solely to the effect of projeotiles, or to subsequent ablation by the knife. 4Hi INJURIES OF THE PELVIS. jl'lIAI'. VII. An analysis of the five hundred and eighty-six cases of shot injury of tlie testis leads to the conclusion that there has been gross exaggeration in the statements heretofore made regarding the influence of such lesions on the morale of invalids. A decent aversion (o publicity as to their mutilations is the only marked characteristic the editor has observed in the numerous cases brought to his notice. The following are the only examples of the profound melancholy and suicidal tendency sometimes attributed to the loss of the testes that have been found in the records: Case 1183—Private J. A------, Co. F, 1st Michigan Cavalry, aged 22 years, was admitted to Judiciary Square Hospital, January 11, 1831. Assistant Surgeon A. Ingrain, U. S. A., reported that "an accidental wound, received prior to enlistment, had deprived this soldier of both testes and left a urethral fistula, which persisted in spite of various attempts to obtain reunion. Profound melancholia had resulted, and the patient was unfit even for modified duty in the Veteran Reserves. He was discharged May 3, 1864." Case 1184.—Private H. C. Chamberlain, Co. K, 33th Massachusetts, aged 23 years, was wounded at Spottsylvania, May 12, 1834. He was treated in a Ninth Corps hospital for a "wound of scrotum," and, on the 23th, was sent to Fairfax Seminary Hospital, where Surgeon D. P. Smith, U. S. V., noted a "wound ofthe scrotum, with loss of testicle, by a conoidal ball." This soldier was furloughed October 7, 1884, and discharged May 29, 1835. Examiner E. F. Upham, of Massachusetts, reported: "Left testicle extirpated in consequence of a wound from a ball. There is extreme tenderness of the spermatic nerve and vessels, which by reflex nervous action causes general debility; there is also spinal irritation in the lumbar region, and the system is suffering from excessive fatigue and partial sunstroke; the joint effects of the injuries cause excessive nervous irritability, and, at times, partial aberration of mind." Dr. Upham subsequently testifies, in an affidavit, that when the above- named soldier came home on furlough from Fairfax Seminary Hospital he was insane; and that after his discharge he committed suicide, November 24, 1866, by standing before an approaching engine, wdiich passed over him and destroyed life." This man's pension was allowed until the date of death, and, April 11, 1870, the pension was continued to the father of the deceased. It is unusual for malingerers to attempt to simulate diseases of the testis, yet the following apparently represents an instance of the kind: Case 1185.—Private H. C. Gardner, Co. B, 93th Pennsylvania, aged 24 years, is alleged to have been wounded at Antietam, September 17, 1862. There is no record of his case prior to April 14, 1863, when he was received at hospital No. 1, Frederick, with "anasarca." At Jarvis Hospital, whither he was subsequently sent, an "injury to the side by a spent ball" was registered. From Hammond Hospital, Point Lookout, where the patient was sent on July 3d, Acting Assistant Surgeon W. F. Buchanan reported: "This wounded man stated that he was struck by a spent cannon ball in the region of the spleen and stomach; and, while being carried off the field, a shell exploded, wounding his right testis, since which time it has healed and become much atrophied. He states that he has had haemoptysis and haematemesis. His lungs were auscultated and percussed, and were found in good condition. He complains of swelling of the injured testis and the abdomen during damp weather or when taking long walks. There is no apparent swelling at present. On September 10, 1863, after a board of survey, this man was returned to duty." Fungous protrusion from the testis1 and sloughing of that organ and of the scrotum were rare. There was one example of what von Ammon terms oscheoplasty :2 Case 1186.—Private M. E. C------, Co. B, 5th New Hampshire, aged 22 years, was wounded at Farmville, April 7, 1865, and was treated in a Second Corps hospital, and thence sent to City Point. Acting Staff-Surgeon J. Aiken reported: "Gunshot wound, the ball passing through the right testicle and left thigh, causing sloughing of the scrotum and testis. On April 13th the injured testicle was removed, the sloughing tissue of the scrotum excised, and the edges freshened and united by sutures, by Acting Staff-Surgeon W. J. Burr." The patient did well, and was transferred to Armory Square Hospital, May 19th. Surgeon D. W. Bliss, U. S. V., reported : "Gunshot wound of the scrotum and left thigh, the ball grazing the anterior surface of the right side of the scrotum, destroying the right testicle, passing behind the left, and making its exit about the junction of the scrotum and integument of the left thigh, near the outer surface of the same." The patient was transferred to Webster Hospital, Manchester, June 26th, and was mustered out July 25, 1885, and pensioned. Examiner H. Powers, of Morrisville, Vermont, September 30, 1865, reported: "Shot through the testicles; right one removed, the other disabled; the ball then passed through the upper third of the left thigh, shattering the bone and injuring the nerves, causing the loss of sensation in part of the flexor muscles of the thigh." Examiner E. J. Hall, September 29, 1873, reported: "The ball struck the right thigh near the scrotum, passed through the right testicle into the left thigh. The right testis was removed and the left has become considerably atrophied; it is quite painful, and occasionally becomes inflamed. The muscles of the thigh on the outer side have become somewhat contracted." This pensioner was paid September 4, 1873. ■Referring to shot wounds of the testis, Hexxkv (Princ. of Mil. Surg., :jd ed., 1829, p. 451) remarks: "In some instances, the scrotum has sloughed extensively, leaving the testis quite uncovered; in others, the testis has thrown out, with great rapidity, a fungous protrusion. In some of these fungous cases I have seen the whole tribe of escharotios employed in vain, and the ultimatum of castration has been adopted. This is a remedy often unnecessary, for, by removing the fungous growth with the knife, and cautiously dissecting away the excrescence in slices until we come to the sound structure, the parts frequently heal up with the usual dressings." 2 AMMOX (l\ A. V.). Die Plastische Chirurgie, u. s. w.. Berlin, 1842, p. 255. SECT. III.l WOUNDS OF THE SPERMATIC CORD. 417 Injuries of the Spermatic Cord were not infrequently referred to in connection with shot wounds of the genitals. Cases 979 and 980, on page 237, have been adduced as instances of ligation of the spermatic artery,1 an operation rarely required,2 though described in routine by systematic writers.3 Tlie five following are examples of shot lesions of the spermatic cord : Case 1187.—Sergeant C. Upjohn, Co. E, 101st Pennsylvania, aged 21 years, was wounded at Laurel Hill, Spottsylvania, May 12, 1864. Surgeon L. W. Read, U. S. V., reported, from a Fifth Corps hospital, a "shot wound of the right thigh and scrotum." The patient was sent to Lincoln Hospital, and transferred, June 14th, to York, and on July5th to Broad and Cherry Streets Hospital, and thence returned to duty April 14, 1865, and discharged May 30, 1865, and pensioned. Examiner J. Cum- miskey reported, September 27, 1866: "Applicant was wounded by a ball passing upward through the front of the right thigh and cutting through the spermatic cord, coming out ofthe penis, and, according to the applicant's statement, entirely destroying all virile power in that organ. Though he is not thereby disabled for manual labor, I think his permanent injury of the procreative organs should be considered, and a pension granted." Examiner T. B. Reed reported, July 31, 1867 : " The appli- cant is suffering from gunshot wound ofthe thigh at the upper third. The wound was a large, ragged laceration, and gangrene and sloughing followed, leaving a large adherent cicatrix, which has a tendency to discharge from time to time. The leg is very much weakened, its use and power are much impaired, and be cannot stand or walk on it any length of time. His disability is three-fourths and permanent." This pensioner died July 3, 1873. Case 1188.—Private J. E. Gleason, Co. I, 27th Michigan, aged 30 years, was wounded at Spottsylvania, May 12. 1864. He was treated in hospitals on the field, at Fairfax Seminary, City Point, and Beverly, no mention being made in any of these hospitals to injury of the testes. He was afterward sent to Detroit, and admitted into Harper's Hospital on December 23d. Acting Assistant Surgeon D. O. Farrand noted a "gunshot wound of the testicles by a minie' ball." This soldier was discharged May 23, 1865, and pensioned. Examiner L. W. Fasquelle, of St. John's, May 18, 1866, reported that "one buckshot passed into the scrotum on the left side and cut the spermatic cord off; the testicle is almost absorbed; the wound is not yet healed. He has also a flesh wound ofthe left thigh." In an examination for increase of pension, April 27, 1837, this physician also states that the "wound is still discharging large quantities of fetid pus every twenty-four hours ; so excessive is the discharge that he is too weak to work." In a renewed claim for increase of pension, March 26, 1871, the pensioner stated, under oath, that he was wounded "by a bullet and buckshot in the groin and testicles; the bullet entering the left groin, and, passing downward, coming out on the inside of the left leg; the buckshot, two in number, passing into the testicles, from whence they have since been taken." In a biennial examination, September 5, 1873, Dr. Fasquelle says the testicle "is shrivelled and useless, and painful at times from the injured nerve connected therewith ; disability total." This pensioner was paid on September 4, 1873. Case 1189.—Private G. M. Oberly, Co. D, 129th Pennsylvania, was wounded at Chancellorsville, May 3, 1833, and was treated in the field hospital of the 3d division, Fifth Corps, until the 19th, when he was transferred to Campbell Hospital, where Surgeon J. H. Baxter, U. S. V., reported the case as a "gunshot wound of the pelvis," and returned the man to duty June 3, 1833. Pension Examiner Edward Swift, of Easton, reported, February 19, 1868, that " the ball had entered the upper part of the scrotum on the left side, injuring the spermatic cord and the os pubis, and passed out two inches above the anus and one inch to the left of the sulcus. He remained under treatment for more than a year. .In August, 1863, I removed a spiculuui of bone from the anterior orifice, one and a half inches long by about one-fourth of an inch thick. The last fragment of bone came away in July, 1864. The left testicle is nearly absorbed. September 8, 1837, he continues feeble and is unable to take much active exertion." On July 23, 1838, he reported that "he still has considerable pain in the region of the wound, and is much debilitated from its effects. He has been unable to attend to any business since receiving the wound; disability total and permanent." This pensioner was paid to June 4, 1873. Case 1190.—Private W. H. L------, 70th New York, was wounded at Gettysburg, July 2, 1863. Veteran Reserve Corps, January 31, 1864. Discharged June 27, 1834. Examiner J. T. Keables, of Michigan, reported, February 15, 1870: " Ball entered middle third of right thigh, passed through right side of scrotum, injuring testicle, entered left thigh, and passed through." Examiner J. L. Wakefield reported, September 4, 1873, as above, adding: "severing the spermatic cord." Case 1191.—Corporal S. C. T------, Co. C, 3d Michigan, aged 27 years, was wounded at the Wilderness, May 5,1864, and was sent from a Second Corps hospital, May 24th, to Harewood. Surgeon R. B. Bontecou, U. S. V., reported: "Gunshot wound of the testicles and of the upper third of the left thigh." At McClellan Hospital the same record was made, with the additional statement that "the ball carried away the right testis; the soldier was returned to duty, cured, November 22, 1864." He was discharged July 5, 1865, and pensioned. Examiner L. W. Fasquelle, of Michigan, November 12, 1887, reported: " The ball cut off the spermatic cord and the artery running to tbe right testicle; the testicle is entirely destroyed; the ball passed out on the right side of the rectum, injuring it slightly; disability one-half." The same examiner reported, September 5, 1873, substantially the same as above, except: " Ball passed through left side of rectum, destroying the sphincter muscle and causing much trouble in controlling tbe movement of the bowels." I Allusions to ligations of the spermatic artery, except in cases of castration, are rare. SOCIN (Kriegschir. Erf, 1872, S. 50) cites a case: Mohamed- ben-Raute, 12th Tirailleurs, shot at Worth, August fi, 1870, through the left side of the scrotum and the soft parts of the right thigh. There was profuse bleeding on the eighth day, and the spermatic was ligated by Professor HECKKK. BECK (Chirurgie der Schussverletz., 1872, S. 306), in a list of ligations practised by him, mentions one of the spermatic artery. Malgaione also (Revue mid.-chir., Juillet, 1850) gives a case of ligation of the spermatic artery for a traumatic aneurism of the dorsal artery of the penis. 'LOHMEYER (Die Schusswunden, 1859, S. 174) observes: "If the injury to the spermatic cord is followed by copious bleeding, it becomes necessary to ligate the spermatic artery; the testicle of the injured side becomes atrophied, but its extirpation, as advised by DuruYTKEN, even when it is injured, is entirely unnecessary, as it offers no advantages and only causes the patient useless speculations as to his condition." 3LANGENBECK (C. J. M.) (Nosologic und Therapie der chir. Kranlch., 1830, B. IV. S. 599) observes: " Injuries of the spermatic cord necessitate ligation, and considerable lacerations of testicles, castration." 53 418 INJURIES OF THE PELVIS. [CHAP. vu. Contusions of the Testis.—Bruises of the testes, especially by compression of the organs against the pommel of the saddle, were common among mounted men, and the origination of hydrocele and hsematocele was often ascribed to this accident. Brief abstracts of shot contusions of the testis are noted below. In notes on pages 405 and 419 evidence is adduced that negatives the doctrine that grave contusions of the testis are necessarily attended by extreme shock: Case 1192.—Private J. Purit, Co. I, 4th Cavalry, received a contused wound of the testicles from a shell, at Chapin's Farm, September 30, 1864. He was sent, October 4th, to hospital at Fort Monroe, and returned to duty November 28, 1864. Case 1193.—Private Harman Bosack, Co. A, 24th Illinois, aged 25 years, was wounded at Chickamauga, September 11), 1863, and sent to a hospital at Louisville. Surgeon R. R. Taylor, U. S. V., reported "a severe contusion of the testis by a spent ball." The patient was transferred to Quincy. Surgeon R. Nicholls, U. S. V., reported: " The testicle was swollen and inflamed. The inflammation subsided after the application of iodine, linseed poultices, and rest. Duty on January 26, 1S>4." Case 1194.—Corporal T. Fitzgerald, Co. K, 72d New York, aged 23 years, was wounded at Gettysburg, July 3, 1863. Surgeon A. J. Ward reported that he was taken to Seminary Hospital with a wound of the right thigh. Transferred, July 11th, to Summit House Hospital. Acting Assistant Surgeon T. G. Hunt reported "a bruise of the testes by shell," and the patient's transfer to Mower Hospital on July 29th. Here Surgeon J. Hopkinson, U. S. V., reported that " the injury to the testis was received by a large solid shot striking a rail on which the soldier was sitting. With a suspensory bandage, he gradually improved, and did duty as a sentry after September 9th, and was sent to his regiment November 23, 1833." Sarcocele, in one hundred and thirty-eight cases, and unspecified diseases of the testis, in two thousand two hundred and twenty-eight cases, were noted on the monthly reports;1 but details were given of very few of these cases. Specimen 3654 furnished the Museum2 with a good example of cystic disease of the testis, and the following case illustrates the effects of chronic inflammation: Case 1195.—[The following memoranda of the ablation of a diseased testis, supposed to be affected by tuberculous degeneration, are gleaned from a voluminous report by Acting Assistant Surgeon A. W. Tryon, who presented the pathological specimen to the Army Medical Museum.] Recruit H. D. Taner was received at Grosvenor Hospital, Alexandria, March 4, 1865. He related a long story of a fall in January, 1863, astride the walking-beam of a lake steamer, whence contusion and laceration of the perineum and scrotum, and confinement to bed for four months, and a surgical operation of unknown nature. Recovering, he had served a year as engineer on a steamboat, had then enlisted at Toledo, been ordered to Tod Barracks, arrested, tried, and imprisoned for desertion; sent to King's Street Hospital on account of a scrotal enlargement, again imprisoned, and finally sent to Grosvenor Hospital, under Dr. Tryon's care, with " acute orchitis." The scrotum was poulticed. On March 23d, an abscess on right side opened and discharged. On April 2d. " the operation of emasculation ofthe right testis was performed." " Ice and warm poultices were applied alternately, the former for one hour, the latter for two hours, for the next six days, and iodide of potassium and infusion of cinchona were administered internally. On April 2'Jd, the scrotal incision was nearly healed." On April 24, 1835, " the patient was transferred to Sickles Barracks, feeling quite well," and was discharged May 8, 1865, for "excision of right testicle for strumous disease." On examination of the removed testis, " tuberculous inflammation was found to have attacked the lower end ofthe tunica vaginalis, and there was tuberculous deposit throughout. The testis was much broken down by inflam- matory action; but on microscopical examination it was found to be non-malignant." [On microscopical examination of this specimen (FlG. 357) at the Museum, after hardening in Fig. :i57—Section of right testis alcohol, disintegration of the tubular structure bv tuberculosis was not observed. The tunica enlarged by chronic inflammation. ° * . Spec. 406G. vaginalis and surrounding structures were thickened and enlarged by inflammatory exudations. J Instances of traumatic displacement of the testis were published3 by Surgeon J. W. Thompson, of Paducah, and Assistant Surgeon E. J. Hall, 1st Vermont Cavalry. In the editor's opinion, the facts adduced do not conclusively establish these malpositions as examples of dislocation from violence rather than of congenital cryptorchidy. 1 First Medical Volume, pp. 640 and 712. * Cat. of the Surg. Sect, 18G6, p. 493, Specimen 3654: " The left testicle enormously enlarged and excised entire. The organ, when removed, weighed two and a quarter pounds.'' Operation by Assistant Surgeon S. J. 15UMSTEAD, 29th Illinois, in the case of W. Slaughter, aged 50. 3 THOMPSON (J. "W.) (A Case of probable Dislocation of the Testicle, in The Nashville Jour, of Med. and Surg., 1866, Vol. I, p. 39): Case of Private E-----, 3d Kentucky. HALL (E. J.) (Dislocation of the Testicle, in The Med. and Surg. Reporter, 1867, Vol. XV, p. 304): Case of Private X-----, Co. K, 1st Vermont Cavalry. SECT. Ill] WOUNDS OF THE SCROTUM. 419 Wounds of thf Porotum.1—These lesions, when uncomplicated, are attended by little pain or danger, and may be generally regarded as trivial. The extensibility of the tissues permits large solutions of continuity to be readily approximated, and even when there has been great loss of substance, reparation is commonly surprisingly rapid. Even trifling wounds, however, are liable, in vitiated constitutions, to be attacked by erysipelatous inflammation or the curious affection termed acute oedema of the scrotum,2 and in such cases prompt interference is requisite, with free incisions and ferruginous preparations. Several instances of balls lodging in the scrotum,3 without injuring the contained parts,4 were reported: Case 1196.—Private S. Kratzer, Co. D, 25th Indiana, was wounded at Shiloh, April 6, 1862, by a ball, which entered just below the anterior superior spinous process of the ilium, passed under the sartorius muscle, through the abdominal ring, and then into the scrotum. On July 14th he was admitted, from Savannah, into hospital, at St. Louis. Surgeon T. McMartin, IT. S. V., reported that the ball was extracted from the scrotum, through an incision, before the patient's admission. By September the wound had nearly healed. This soldier was discharged Oetober 14, 1862, and pensioned. Examiner J. W. Crooks, of Rockport, reported, April 17, 13J3: "Tlie ball having entered the left thigh, passed through the muscles into the lower part of the abdomen, and was finally taken out of the scrotum. He is at times quite lame." Examiner E. Mead, of Cincinnati, reported, January 24, 181)5: "The ball entered the left thigh three inches below and anterior to the trochanter major, passed inward, through tbe thigh, anterior to the femur, thence into the left testicle, from which it was extracted. The triceps extensor femoris and sartorius muscles and tbe body of the testicle were injured. There is partial anchylosis of the hip joint, and the power of locomotion is considerably impaired. Injury to muscular structure has resulted in contraction; pain in the testicle occurs frequently." Examiner H. S. Woods, of Cannelton, reported, September 15, 1873: "The ball passed in through the fleshy part of the thigh and into the lower part of the abdomen, injuring the cord of the left testicle and causing it to become soft and enlarged, which prevents his walking to a great extent." Cask 1107.—Private William L------, Co. G, 83d Pennsylvania, was wounded at Bull Run, August 30,1862. Assistant Surgeon Warren Webster, U. S. A., reported that he entered Douglas Hospital September 7, 185'J. A conoidal musket ball had entered the gluteal muscles two inches back ofthe great trochanter, passed inward and downward under the neck of the femur, and lodged in the scrotum. He had been made a prisoner, had been paroled, and had remained on the battle-field five days. When admitted, an abscess bad formed in the scrotum. This was opened, and its cause was found in a ball, which was extracted. October 29th, the wounds were doing very well, and had nearly healed. There was some rigidity of the muscles of the thigh. The patient was discharged from service November 14. 1862. On July 15, 1871, Pension Examiner W. S. Welsh reported "a cicatrix remaining, about one inch in diameter. The pensioner has considerable difficulty in walking, cannot ride a horse, and suffers pain at times. His disability is rated at one-half and permanent." Case 1198.—Private J. B. Van Armies, Co. K, 106th New York, aged 23 years, was wounded at Petersburg, April 2, 1865. Surgeon W. A. Child, 10th Vermont, reported a shot wound of the pelvis. Assistant Surgeon J. S. Ely, U. S. V., at the Sixth Corps hospital, reported a wound of the thigh and testes. Assistant Surgeon W. F. Norris, U. S. A., reported that this man was admitted into Douglas Hospital, June 19th, from Judiciary Square,—a conoidal ball had been extracted from the scrotum on April 24th, twenty-two days after the reception of the wound. Atrophy of the left testicle ensued. The patient was discharged from service on July 3, 1865, and was pensioned. In September, 1871, Pension Examiner B. F. Sherman reports that this invalid suffered no disability from the wound in the leg. The left testicle was atrophied; the right apparently healthy; disability one-half and permanent. Another case, recorded as a shot wound of the scrotum, appears to have been com- plicated by incarcerated scrotal hernia: Case 1199.—Sergeant G. W. Fox, Co. A, 112th Xew York, aged 33 years, was wounded at Chapin's Farm, September 29, 1864, and admitted on the same day to a Tenth Corps hospital with "a gunshot wouud of the scrotum." He was sent thence to Hampton Hospital, October 1st, apd transferred to New York, to Grant Hospital, October 18th. He was returned to duty December 3d, and discharged June 13, 1865. In his application for pension, March 20, 1871. the sergeant states that "he was shot through the bag containing his testicles, rather on the left side, severing the cords; that he was obliged to wear a false bag for a number of years; that said wound was about a third of the distance from his body." * * Examiner J. H. White- house, of Michigan, January 1, 1872, reported this man as totally and permanently disabled, from "strangulated scrotal hernia, caused by the striking of a spent ball. It inflames at times and becomes painful." ■SCROTUM, Gr., Kiipuxos, bursa testium, scrotum, by metastasis from "scortum, quod pellera significat" (FACCIOLATI); saccnlus e pelle quo testiculi continentur." Fr., Bourses; Ger., Hodensack; OldEng., Cods, "from Saxon Codde, a case or husk in which seeds are lodged."—S. Johxsom. - Listox til.), Remarks on the Acute Form of Anasarcous Tumour of the Scrotum, in the Medico-Chirurgical Transactions, 18:39, Vol. XXII, p. 288, may be profitably consulted on this subject. 3 Among the paintings in the Edinburgh Museum, No. 29">1 is a sketch, from Sir CHAltl.ES Bell's collection, of a man wounded in the scrotum (Cat, 1836, p. 361). The ball went through both testicles without touching the thighs. There is more inflammation, a larger wound, and a greater quantity of slough, on the side on which the ball passed out. Two cases of shot perforation of the scrotum are recorded in Circular 3, S. G. O., 1871, p. 56. There was not excessive shock in either case, and both patients speedily recovered. 4 Glandorp (M L.) (Speculum chirurgorum, Bremen, 1H19) cites a case of shot wound of the scrotum; the ball cut out from the opposite thigh. 420 INJURIES OF THE PELVIS. [CHAP. VII. Hydrocele.—Fifteen hundred and eighty-six cases of hydrocele, with seven deaths, were returned on the monthly reports of sick and wounded,1 and ninety-four cases of discharge2 for disability arising from this affection. On the surgical reports, twenty-seven cases of operations for hydrocele3 were reported, three of which terminated fatally. The causes of death in four other cases returned numerically, are not given. The cases of operations will be briefly noted: Cases.—When not otherwise specified, it will be understood that the operations consisted in puncture and an astringent injection of the sac of the tunica vaginalis, usually of dilute tincture of iodine. The name ofthe surgeon, the date of operation, and the disposition made ofthe patient, will be noted if recorded: 1200. Private T. B. Blizzard, Co. K, 2Gth Pennsylvania, was treated, at Chester, November 2, 18G2, by seton and by incision. On March 18, 1863, Acting Assistant Surgeon B. Stone reported that this man had been tapped, at Harrison's Landing, August 20, 1832, for hydrocele ascribed to a contusion received at the battle of Williamsburg. This soldier was transferred to the 99th Pennsylvania, was wounded at Petersburg, March "25, 1865, and mustered out July 1, 1835.—1201. Private W. Henderson, Co. G, Purnell Legion, aged 34 ; operated on at Frederick, August 16, 1862, by Assistant Surgeon R. F. Weir; fell into enemy's hands.—1202. A. Merrins, Nurse at Satterlee Hospital, November 5, 1862, was operated on by Professor S. D. Gross, and returned to duty Decembers, 1832.—1203. Private J. Simms, Co. A, 11th Missouri, aged 40, operated on at Quincy, October, 18G2, for traumatic hydrocele of left side; nearly a pint of serum was drawn off; duty December 8, 1862.—1204. Private Cordeman, 55th Pennsylvania; hydrocele prior to enlistment; entered regimental hospital at Hilton Head in November, 1862, and Surgeon D. Merritt, 55th Pennsylvania, tapped the tumor and evacuated a "pint and a half of straw-colored fluid;" returned to duty radically cured.—1205. Private J. Shisler, Co. B, 84th Pennsylvania; Assistant Surgeon J. S. Waggoner, 84th Pennsylvania, operated on at Culpeper, September, 1833; discharged—date not given.—1206. Private R. Goss, Co. I, 69th Pennsylvania, oeprated on at Alexandria, January 11,1863, by Surgeon C. Page, IT. S. A., for hydrocele of right side, by incision and the introduction of a seton ; cured; duty June 13,1833.—1207. Sergeant J. M. Hotz, Co. B, 7th Maryland, aged 61; fourteen ounces of yellow serum from right tunica vaginalis evacuated by Acting Assistant Surgeon A. W. Holden, at Frederick, September 19,1833; intense inflammatory action; cured, and discharged September 19,1864. 1208. Private A. Bourke, Co. F, 7th Kansas Cavalry, aged 25; at St. Louis Marine Hospital, July 12,1854, Surgeon A. Hammer, U. S. V., operated for double hydrocele; duty September 6, 1864.—1209. Corporal J. J. Garner, Co. F, 10th New Jersey, aged 25; at McClellan Hospital, April 15,1864, Acting Assistant Surgeon J. G. Murphy operated, without injection; effusion; returned to duty February 8, 1865.—1210. Private J. Irvin, Co. L, Michigan Engineers, aged 59; operated on at Madison, April 1,1864, by Acting Assistant Surgeon W. B. Greene; discharged October 8, 1834.—1211. Private J. Flanigan, Co. C, 14th Michigan, aged 40; Acting Assistant Surgeon D. O. Farrand punctured the left vaginal tunic, at St. Mary's Hospital, Detroit, June 5,1834; the disease recurred; discharged August 10, 1834.—1212. Private G. A. Potter, Co. B, 1st New York Cavalry, aged 40; at Frederick, May 16, 1864, Acting Assistant Surgeon J. II. Bartholf punctured the right tunic and evacuated ten ounces of serum. 1213. Private W. W. Spearin, Co. G, 6th Vermont, aged 32; Acting Assistant Surgeon E. G. Waters punctured the hydrocele, August 20, 1864; modified duty in the Veteran Reserves September 15,1834.—1214. Private II. A. Shorpe, Co. E, 7th Maryland, aged 24; hydrocele of left side of six months' standing; punctured at Jarvis Hospital, Baltimore, August 6, 1834, by Acting Assistant Surgeon E. G. Waters; recurred; transferred to Veteran Reserves October 2, 1834.—1215. Private J. Walker, Co. L, 5th New York Cavalry, aged 23; operated on by Acting Assistant Surgeon B. Rohrer, at Cuyler Hospital, February 24,1835; deserted March 27, 1865.—1216. Sergeant L. L. Sweet, Co. I, 37th Iowa; scrotum enlarged for several years; swelling ascribed to a bruise received on a rail-car; Acting Assistant Surgeon J. Z. Hall tapped and evacuated "three pints of water" from the tunica vaginalis; discharged April 22, 1885, with atrophy of testis.—1217. Private L. Doty, Co. H, 38th Massachusetts, aged 25; encysted hydrocele; Acting Assistant Surgeon W. S. Adams operated at Frederick, February 18, 1835; cured, and discharged on expiration of service, June 30, 1835.—1218. Private J. Robertson, Co. L, 2d Iowa Cavalry, aged 45; operated on at St Louis Marine Hospital, by Surgeon A. Hammer, U. S. V., for hydrocele of left side, July 12, 1834; eleven ounces of serum evacuated; duty August 3, 1864.—1219. Farrier R. Stetson, Co. K, 2d Massachusetts Cavalry, aged 43; operated on at Jarvis Hospital, October 29, 1834, by Medical Cadet H. McElderry, U. S. A., for hydrocele of six months' duration, ascribed to a fall from a horse; transferred to Veteran Reserves, Co. 72, October 16, 1834.—1220. Private R. Rawlins, Co. II, 142d New York, aged 18; operated on at Troy, March 17, 1865; mustered out June 13, 1835.—1221. Private P. McVeigh, Co. D, 103th New York, aged 42; Acting Assistant Surgeon E. R. Ould operated at Frederick, February 9,1835, by incision; discharged June 6,1835.— 1222. Private E. Longcoy, Co. M, 21st New York Cavalry, aged 19; Acting Assistant Surgeon T. O. Cornish operated at Frederick, March 23, 1835; discharged, cured, May 19, 1835.—1223. Private J. Grosskloss, 39th Ohio, aged 31, was wounded at Atlanta, July 22, 1864, and was discharged and pensioned June 19, 1865. Examiner G. O. Hildreth, of Marietta, reported that a ball penetrated the soft parts of the left thigh and the scrotum, and lodged somewhere near the ramus of the ischium. In 1871, the same surgeon reported that the ball was removed in the autumn of 1865, and that in the winter of 1870 hydrocele was developed on the left side, doubtless from the chronic irritation resulting from the shot perforation of the scrotum. The hydrocele was operated on, but reappeared the following year. The case is related in detail, and there appears to be no reason to doubt the relation between the injury and the disease. 1 These cases were returned in reports of an aggregate of six million four hundred and fifty-four thousand eight hundred and thirty-four cases (white troops, 5.825.480; colored, 629,354 = 6,454,834), occurring in a mean strength of five hundred and thirty-one thousand nine hundred and twenty (white troops, 468,275; colored, 63,645 = 531,920). See First Medical Volume, pp. 641, 712. 2 The discharges were from a total number of discharges for physical disability of two hundred and twenty-three thousand five hundred and thirty-five (discharges from white troops, 215,312; from colored, 8,223 = 22:1,535). See First Medical Volume, pp. 648, 718. 'The Library of the Surgeon General's Office is rich in papers on hydrocele, to which the catalogue supplies references. Among tbe classical authorities are: BEETRANDI (Mim. sur I'HydrocUe, in Mim. de I'Acad., 1757, T. Ill, p. 84); POTT (P.) (Pract. Remarks on the Hydrocele, London, 17C2); SECT.IU.J OPERATIONS FOR HYDROCELE. 421 The causes of the fatal terminations of three operations for hydrocele were reported respectively as : old age, meningitis, and pneumonia, the cases exemplifying the old lesson of grave consequences from trivial surgical interference : Cask 1224.—Private .1. Barley. Co. D, 37th Iowa, aged 61 years, was admitted to Adams Hospital, Memphis, July 29, 1834, with remittent fever, lie was transferred to Jefferson Barracks, and thence, convalescent, to Keokuk, August 20, 1804. Surgeon M. C. Taylor, U. S. V., reported: "Hydrocele of the left side. The parts were much enlarged with thickening ofthe wall of the tunica vaginalis. On August 20th the patient was a"na?sthetized bya mixture of chloroform and ether; the sac was punctured and its contents evacuated by a trocar, and a dilute solution of bromine was then, injected. The patient was of feeble habit." The hospital register adds : "Died September 1, 1S34, of hydrocele and old age." Case 1225.—Private J. H. Ellis, Co. F, 7th Wisconsin, aged 21 years, was admitted to hospital No. 1, Frederick, March 5, 1833. Assistant Surgeon R. F. Weir, V. S. A., reported: "Hydrocele; died April 7, 1803, of meningitis." Acting Assistant Surgeon Alfred North furnished a history and pathological preparation (dd. :(5M) from this case: "On March 11th, this patient was operated on by Dr. North, for hydrocele. The sac was punctured and the following injection was thrown in: Tinct. loilinii, f-ij. lodiill Potass., 3ij—M. No dressing applied. March 12th, moderate amount of inflammation established. March Kith, swelling of scrotum subsiding. Lest the inflammation excited might be insufficient to insure the success of the operation, tincture of iodine was painted outside. March 20th, pulse quick and weak; tongue slightly furred; skin dry and warm; bowels rather costive; compound cathartic pill and castor oil ordered. March 25th, patient has improved; says bis scrotum pains him little; appetite poor; there has been slight excoriation of the integuments covering the scrotum, but no signs of erysipelas. March 30th, patient not so well; says that he has had a chill, and is this morning quite feverish; pulse full; tongue coated and dry; skin dry and hot; appetite poor; bowels inclined to constipation; the scrotum appears to be doing well and is still smaller. March 31st, there arc small ulcers here and there over scrotum; parts red and much swollen; ordered as a local application an ounce of simple cerate, with ten grains each of powdered opium and acetate of lead rubbed in ; patient is taking ale and generous diet. April 2d, has had no chill since last note; complains of severe headache, and has no appetite; bowels inactive; patient quite morose; ordered eight grains of compound cathartic pill, U. S. P. April 4th, scrotum has diminished in size, and in every respect looks to be doing well; general condition about the same; tliere is still some slight cerebral disturbance; feels quite weak, and has scarcely any appetite. April 5th, cerebral symptoms more strongly marked; pupils much dilated; pulse 110 and feeble; nausea and vomiting; bowels are moved only by the action of purgatives; seems unwilling to answer questions ; ordered cups to temples, hot bricks to feet, purgatives and diaphoretics. April 6th, patient worse, and above symptoms continue; ordered a blister to the nucha and an enema of a drachm of spirits of turpentine, in two ounces of mucilage; scrotum looks about the same; ordered cups behind the ears; five P. M., patient is comatose; ordered head shaved and cold applications. April 7, patient now and then answers a question; pulse very weak ; ordered beef-tea to be freely given, and a wineglass of milk-punch every two hours; has had two fa?cal evacuations since last P. M. April 8th, Assistant Surgeon R. F. Weir, U. S. A., being called, ordered patient's bead to be shaved and cold cloths applied; bowels are opened and scrotum looks to be doing well, but patient is delirious and fast failing. April 9th, patient continued to fail, and at half-past eleven P. M. died. Post-mortem twelve hours after death : Eigor-mortis well marked. Upon opening the chest, the right lung was found hepatized, the outer surface being filled with miliary tubercles. In the upper portion of the middle lobe a mass of tubercular matter the size of a pullet's egg was found in a softened condition; throughout the entire lung tubercles were scattered. Left lung in same condition. Thymus gland filled with softened tubercular matter. Liver somewhat enlarged and highly congested. Kidneys highly congested and capsule firmly adherent to the organ. Brain: Membranes FjG :j58.—Hydrocele of the left tunica vaginalis. highly congested ; blood-vessels distended with dark-colored pus; substance of Spec. 4078. brain highly congested, especially the white substance. Removed the tunica vaginalis and contents of right side, this being a hydrocele which was operated upon by Dr. North twenty-nine days antecedent to death. On opening the sac, it was found to contain four ounces of albuminous serum. The tunics were somewhat thickened; there were no adhesions to be found at any point." Case 1226.—Private D. L. Glines, Co. K, 31st Wisconsin, aged 38 years, was admitted to hospital No. 1, Nashville, November 10, 1864, with hydrocele. Surgeon B. B. Breed, U. S. V., reported that, " on November 13th, Acting Assistant Surgeon M. L. Herr operated for the radical cure of the hydrocele, evacuating eight ounces of fluid and inserting a seton. The hydrocele was cured, but pneumonia supervened, and terminated fatally December 16, 1804." Eari.e (Treatise on the Hydrocele, London, 1791); Dean- (W.) (Obs. on the different Methods for the radical Cure of the Hydrocele, Dublin, 1782); Bkll (B.) (Treatise on the Hydrocele, on Sarcocele, and other Diseases of the Testes, Edinb., 1794;; MONRO (A.) (Of Hydrocele, Hsematocele, etc., in Edinb. Med. Essays, Vol. V, p. 299) ; Brodie (B. C.) (Remarks and Obs. on Diseases of the Testicle, in London Med. and Phys. Jour., 1826) ; HOLUEOOK (J.) (Practical Obs. on Hydrocele, etc., London. 18.'.j); BENEDICT (Bemerkungen uber Hydrocele. Sarcocele, und Varicocele, Leipzig. 1831); Blandin (PH. F.) (Hydrocele, in Diet, de mid. et chir. prat, 18:13, T. X, p. 108); Velpeau (Diet de mid., 1837, T. XV, p. 442); Gerdy (Considerations pratiques sur Vhydrocele et le sarcocele, in Arch. gin. de mid., 1838, ?.' ser., T. I, p. "i7); Beuaud (Consideration sur Vhematocele ou ipanchements sanguins du scrotum, in Arch. gin. de mid., 18ol, 4" ser , T. XXV, p. 281). Consult, also, Specimen 10H1, Scot. I, A. M. M. 122 INJURIES CF THE PELVIS. [chap. vu. Varicocele.—Recruiting regulations require military surgeons to attach considerable importance to the affection thus designated.1 Fourteen hundred and fifteen men are reported as discharged from service, during the War, on account of this form of disability.2 But operations for this affection were not common. In a special report, Surgeon J. R. Smith, U. S. A., remarks : "I have operated six times for varicocele, five of the cases being citizens, and one a soldier named Howard, of Co. E, Battalion of Engineers. He is reported as a case of varicocele in one of my monthly reports from Jefferson Barracks, but tbe report of tbe operation was forgotten. These varicoceles were all of tbe left side, were operated ou by subcutaneous ligature, and were all successful." The bias that leads advocates of discharged soldiers to refer physical disabilities to traumatic causes has been adverted to in treating of hernial protrusions ; it is not less noticeable in the reports of other varieties of scrotal enlargements : Case 1*2-27.—Private E. Haines, Co. G, 41st Ohio, aged 36 years, was wounded at Rocky Face Pidge, May 8, 1834. Surgeon R. D. Lynde, U. S. V., reported, from a Fourth Corps hospital, "a shell contusion of the right shoulder." Surgeon F. Salter, U. S. V., made a similar report from Chattanooga, and recorded the patient's transfer to Nashville, whence he was returned to duty, May 20th, by Surgeon R. R. Taylor, U. S. V. On June 6, 1834, this soldier was admitted to hospital No. 1, Murfreesboro', where Surgeon H. H. Seys, 15th Ohio, recognized a ■■gunshot contusion, producing varicocele of the left side." This man was sent to duty July 4th, and discharged November 2, 1864. In his application for pension, he states that he was severely wounded at Stone River, December 31, lfc62, in his right arm; at Chickamauga, September 19,1863, in the left leg; and at Buzzard Roost as described above. He says of this injury that he " was struck by a piece of shell on the brisket, and the shock was so severe as to injure the groin, and entire hip, and also to cause the left testis to swell badly, rendering it painful." The best modern authorities are adverse to operative interference with varicocele, advising,-in serious cases, suspensory bandages.3 A very good suspender is that recently 1 Varicocele, a term of hybrid formation (varix and KTJAr;), is commonly understood to imply a varicose enlargement of the veins of the spermatic cord. Yet some authors define the affection as a dilatation of the veins of the scrotum, and term varices of the spermatic veins Cirsocele (Kipcros and kjjAij), a distinction known to Celsus. Drs. VAX BuitEN and Keyes (A Practical Treatise on the Surgical Diseases of the Genito- Urinary Organs, 1874, p. 408) declare that : "Varicocele is constituted by a varicose enlargement of the pampiniform plexus and veins of the cord." In army practice, varices of the spermatic cord, epididymis, or scrotum would probably be classified under the head of varicocele in making reports. 2 On the monthly reports of sick and wounded, there were recorded seven thousand two hundred and seventy (7,270) cases of varicocele, with one (1) death (First Medical Volume, pp. 639, 711) ; and there were fourteen hundred and fifteen (1,41£) discharges (1,390 white and 25 colored soldiers) from this form of disability (Ibid , pp. (.47, 717). The mean strengths and aggregates from which these cases were derived are specified in note 1, p. 4:20. 3 Chapman ( Varicose Veins, their Nature, Consequences, and Treatment, 1850, p. 49) justly appreciates the objections to which the operatious for ligation of the spermatic veins arc obnoxious : ''Phlebitis, once provoked, is so little under our control that * * I cannot bring myself to believe that any surgeon is justified in deliberately encountering so formidable a risk, remote as he may deem it, for the sake of an advantage which is at best merely transitory." And, iu the latest work on the subject, received since the foregoing observations were in print, Professor Van BU'KEX and Dr. KEYES (A Practical Treatise on the Surgical. Diseases of the Gen'to-Urinary Organs, 1874, p. 471) declare that " all the operations proposed for varicocele have been attended by fatal consequences, and it is unsurgical to endanger life for a disease in itself harmless." Dr. ASHHUKS'l' (The Principles and Practice of Surgery, 1871, p. 9:36) believes that the operation for the radical cure of varicocele " can only be justifiable in exceptional cases." Professor Gitoss (System, etc., 5th ed., Vol. II, p. 867), after practising strangulation of the veins by the twisted suture in fifteen cases, was led to abandon the operation because one of his patients "unexpectedly perished from phlebitis and pyaemia." The editor of these pages was a witness, in 1851, of the fatal consequences of ligation of the spermatic veins, in two cases, in the hands of VlDAL, a skilful advocate of the operation, and author of an important monograph relating to it (De la cure rad. du varicocele, etc., Paris, 1850). Dr. J. H. BiUNl'ON, in an elaborate paper (Description of a Valve at the Termination of the right Spermatic Vein in the Vena Cava, with Remarks on its Relations to Varicocele, in Am. Jour. Med. Sci., 1856, Vol. XXXII, p. Ill), explains the greater frequency of varicocele on the left side by the absence, in the spermatic vein of thut side, of a valve (Fig. 359), found by him uniformly present near the origin of the right spermatic vein in the adult male human subject. Ejimeut (Lehrbuch der Chir., 186:2, B. Ill, S. 866) corroborates this observation. Curling (A Pract. Treatise on the Diseases of the Testis, Am. ed., 1856, p. 348) compiles statistical returns from the British Army Medical Department showing that there were 3,911 * ■emits rejected for varicocele in the ten years ending March 31,1853, of whom 3,360 had the disease on the left, 282 on the right, and 269 on both sides. MARSHALL (H.) (On the Enlist- ing, Discharging, and Pensioning of Soldiers, 2d ed., Edinburgh, 1839, p. 32) asserts: "Cirsocele seldom occurs, except en the left side. I do not recollect having ever seen a well-marked case of it on the right side, although 1 have examined nearly 30,000 recruits." It is of historical interest to recall that Delpech, an eminent surgeon of Montpelier, was assassinated, October 29. 1832, by a man whom he had treated for varicocele. The murderer, Demptes, had understood that Delpech had been consulted by the relatives of a person he wished to many, and had given an intimation that a matrimonial engagement was, under the circumstances, undesirable (The London Med. Gazette, 18:13, Vol XI, p. 223, and Annual re Mi dico- Chirurg teal, 1833, sepiteme annee. p. 635). Compare, on this subject: Fnn>cin (Uber die Radicalcur der phlebectas spermat. int., oder die sogenannte Varicocele, Freiburg, 1839); Nela- TO.n (Considirations sur la varicocele, in Gaz. des Hop., 1858, p. 451); Thomson (L.. 11.) ( Varicocele treated by Pressure, in Monthly Jour, of Mat Set., 1849, Vol. IX, X. S.. Vol. Ill, p. 195); Bla.ndin (P. F.) (Article Varicocele, in Diet de mid. et chir. prat, 1836, T. XV, p.550) ; MOUiox (Article FIG. 35!'.—Di.-section of the vena cava, emulgent and spermatic veins, showing .he right spermatic valve. [After Bisixtox.J SECT. Ill] CONCLUDING OBSERVATIONS. 423 suggested by Mr. Morgan,1 of Dublin, which is figured in Mr. Thomas Bryant's excellent manual of surgery, and is useful in various affections of the testis. Concluding Observations.—A retrospect of the several subjects discussed in this Chapter, with a summary of the different groups of cases, will be of convenience here. The lists of the different groups of injuries of the pelvis sum up as follows: Table IX. Numerical Statement of Three Thousand One Hundred and Seventy-four Cases of Injuries of the d\'lvis reported during the War. NATURE OF 1N.1UKV. Shot fractures of the pelvis............................................ Punctured and incised wounds......................................... Shot penetrations of the pelvic cavity without known injury to the viscera Shot wounds of the bladder........................................... Shot wounds of the prostate........................................... Shot wounds of the rectum............................................ Wounds of pelvic nerves and bloodvessels............................. Shot wounds of the penis.............................................. Shot wounds of the urethra............................................ Shot wounds of the testis.............................................. Shot wounds of the spermatic cord.................................... Shot wounds of the genital organs indefinitely described................ Total.................................................... , 41)4 15 103 179 309 105 586 32 120 3,174 918 12 25 ti'J 4 59 94 268 83 520 30 104 544 3 13 96 4 44 85 41 22 66 2 13 Result Unknown. The cases of shot fractures of the pelvis are accounted for on page 255; brief abstracts are presented of 1-40 instances, of which 136 are classified according to the bone chiefly injured (72 cases being referred to the ilium, 9 to the pubis, 16 to the ischium, 24 to the sacrum, and 15 to the coccyx), while abstracts of 4 cases illustrate complications of shot fractures of the pelvis. There were specified 1,545 shot fractures of the several pelvic bones; but these occurred in 1,494 patients, as above indicated. The mortality rate Cirsocele, in Diet des. sci. mid., T. V.); Helot (J.) (Du varicocele et de sa cure radicate, in Arch. gin. de mid., 1844, 4e ser., T. VI, p. 1, and T. VIII, p. 287); Gagnebk (Dilatation variq. des veines, 183C); Landouzy (H.) (Du varicocele, 1838); BltESCHET (Cr.) (Mim. sur une nouvelle meth. de trait et deguirir le cirsocele et le varicocele, in Gaz. mid.de Paris, 1834); Beraro (A.) (Article Varicocele, in Diet de mid., 1846, T. XXX, p. 553). There are in the library of the Surgeon General's Office many theses on varicocele; e. jr.. papers by Delageneste, Gaultier-Duparray, IIacque, Henry, Boissel (H.), Brioux, Bureau (E.), Chaumas (E.), Codet (C), Garcia (F.), Gkuhardt (C. H.), Janvier (E.), Jeanselme (J. L. G.). Joseph (G.), Lee (H.), Letorsav (H.), Litzica, Pouzet (J.), Puunaire, Schwering, Seltmann, Straube, and Trandafiresco. Mr. Curling, who, in his Practical Treatise on Diseases of the Testis, and paper on the Testicle, in the Cyclopaedia of Anatomy and Physiology, sums up most of what is known on this subject, recalls the measurements of Ckuveilhier (Anatomic descriptive, 1834, T. II, p. 731), who found the adult human testicle to measure two inches in length, an inch in breadth, and eight lines in thickness,—Sir Astlf.y Coopeu'S estimate (loc. cit, p. 12) of a long diameter of two inches, a transverse diameter of one and a half inches, a lateral diameter of one inch and one eighth,—and records the mean dimensions of the testicle, accord- ing to his own measurements, as an inch and three-quarters in length, an inch and a quarter across, and an inch in thickness. Sir A. CoorER stated the average weight of the testicle at one ounce. Meckel (Manuel d'Anatomic gin., desc, etpath., 1825, T. Ill, p. 621) makes it four drachms, "e'est-a-dire, a substance, debarrass6e de toutes les euveloppes." Mr. Curling found a mean of these two estimates, or about six drachms, to be the ordinary weight ofthe sound testicle in a healthy adult, which nearly accords with Krause's measurements (Vermischte Beobacht, in Muller's Archiv fiir Anat, Phys., und Wissensch. Med., 1837, S. 23), who found the moan weight in five instances 334 4 grains. Lauth (Mim. sur le testicule humain, Paris, 1832) aud Husohke (Encyclopedic Anatomique, T. V, p. 347) have especially investigated the anatomy of the seminiferous tubules, which the former estimated at 840 in number, with a mean length of the united ducts of 1,750 feet. It must not be forgotten that Sir A. Cooper, whose beautiful preparations of the testicle are preserved in the Museum of the Royal College of Surgeons of England, succeeded in filling these tubules with size injection, an achieve- ment other anatomists have failed to imitate. Mr. Curling states that spermatozoa are not infrequently found in the testes of men over seventy years of age, and the procreative faculty is sometimes retained to a still more advanced period of life, as in the remarkable instance of Thomas Parr, of Shropshire, who attained the great age of 152 years, and whose body was dissected, in 1635, by the illustrious Harvey. It is related by Bettus (De ortu et natura sanguinis, London, 1669, p. 320): "Genitalibus erat iutegris, neque retracto pene neque extenuato, neque seroto distento ramice aquoso ut in decrepitis solet, testiculis etiam integris et magnis." 'Morgan (On tlie Treatment and Cure of Varicocele by Suspension of the Testis, in the Dublin Quart Jour, of Med. Sci., 1869, Vol. 48, p. 49!)); Bryant (T.) (Tlie Practice of Surgery, 1872, p. 644). 124 INJURIES OF THE PELVIS. ICHAP. VII. ascribed to the cases of pelvic fracture1 appears exorbitant; but when interpreted by the figures in Table VII, and the facts adduced regarding fractures of the several bones, it is plain that the seemingly excessive fatality arises from including in this group cases undoubtedly complicated with grave visceral lesions.2 Some remarkable examples of excisions of portions of the pelvic bones were adduced, and in Plate XLI various forms of cutting forceps, rowel saws, chisels, gouges, and other osteotomes used in these opera- tions were figured. The cases of punctured and incised wounds of the pelvis are briefly adverted to on page 350, and five abstracts are published of instances of this group. The other ten cases were comparatively trivial.3 A few remarkable examples of shot pene- trations of the pelvic cavity without known injury of the viscera were next presented, followed by an exposition in detail of the important material relating to wounds of the bladder. Reference was made to several complete recoveries after shot wound of the bladder, and among them to the case of General R. B. Potter, of which a more definite account has since been obtained: Case A11.—Major-General Eobert B. Potter, U. S. V., commanding the 2d division of the Ninth Corps, while leading the assaulting column on the Petersburg Heights, April 2, 1865, was struck by a musket ball, which traversed the pelvic cavity from a point above and slightly to the right of the symphysis pubis, to the outer side of the left buttock. Tbe axis of the wound indicated that the missile passed near the upper curve of the great sciatic notch. Urine escaped from the shot orifices, but there was no evidence of pelvic fracture. The field surgeons regarded the case as desperate; but the patient, whose courage and intelligence were as conspicuous in the hospital as on the field, argued that, if no bones were broken, his chances of recovery were better than those of patients subjected to lithotomy. The event vindicated these previsions. The flow of urine by the wounds soon ceased; the wounds cicatrized, and in the course of a few weeks the cure was complete. This gallant officer was honorably mustered out of service January 15, 1866, and made no application for pension. In January, 1874, being in Wash- ington, he had the kindness to permit several medical officers at the Surgeon General's Office to verity (by the cicatrices) the course of the ball, and it was ascertained that there was no functional vesical disorder, or, indeed, any inconvenience consequent on the formidable injury received. The reference, on page 264, to the foregoing case, and to other complete recoveries from shot wounds of the bladder, is followed by instances of partial recovery of patients left with urinary fistules. Then follows a remarkable series of examples of foreign bodies in the bladder, including several in which encrusted projectiles were removed from its cavity, and others in which missiles, or the substances driven in by them, as bone, hair, clothing, etc., became the nuclei of vesical calculi. No instances were reported of encrusted bullets found in the bladder after death.4 Such cases are extremely rare. Cases 1 In this tabular statement, as in Table IV, on page 202, difficulties arise from the attempt to account in a tabular form for the fate of a given number of individuals, some of whom were recipients of several of the different varieties of injury enumerated. Should there be apparent contradic- tions, it is believed that the aggregate mortality is correctly set forth. At all events, the tables are compiled from actual count of the individual cases, by name. 2 It has been shown, for example, that shot fractures of the ilium are not necessarily very fatal injuries unless complicated by penetration of the abdominal cavity. It was in the category of cases returned as " guushot fractures of the pelvis " (without specification of the parts immediately injured) that the large mortality rate appears. Now most of these cases were returned from field hospitals, and there is evidence that very many of them were attended by visceral injuries, though the evidence was not sufficiently definite to permit a separation and classification of these cases. 3 Compare Casks 930, p. 323; 977, p. 335; 978, p. 336; 997, p. 344; 1085, p. 374, ante. Of the ten remaining cases of this category, five were instances of bayonet stabs, two of accidents from broken chamber-pots or urinals, and three from other analogous accidental injuries. 4 Mr. DIXON (Med. Chir. Trans., 1850, Vol. XXXIII, p. 199) cites, as examples of calculi formed about bullets and found in the bladder after death. the case communicated to F.usniCIUS Hildanus (Op. qum ext omn., Frankofnrti, 1646, Cent. Ill, Obs. LXV1I, p. 250) by Paulus OFFREDUS, in which a calculus the size of a hen's egg, deposited about a ball, was found in the bladder thirty years after the reception of the wound. Hildanus says that no suffering was experienced for fifteen years; for the last fifteen years of his life the patient suffered greatly. HILDANUS says nothing of an attempt at extraction. Mr. Dixox adduces as distinct cases the observations cf BARTHOLIN is and Bixxingeu. They appear to be identical with each other and with the original observation by Segkr, of Turin. Baktholinus (Epist. Med., Hag*, 1644, Epist. XXXV) speaks of a case related to him by Skgeu, of a calculus the size of an egg, encrusting a ball, found in the bladder after death. BONETUS (Sepulchretum, Geneva?, 1700, T. II, L. Ill, p. 588) quotes this case from Segek, and adds that Bauhin had shown the specimen to him. BlNNINGER (06s. et Curat. Med., 1673, p. 401), who adduces many observations from BARTHOLIN us. describes, in similar terms, an instance of a calculus formed about a ball. Had this been a distinct case, the omnivorous BONETUS would probably have recorded it. There may be added to these cases a very interesting observation by Dr. James W. IIOI'.IXSON (Medical Examiner, 18.35, Vol. XI, p. 328): A man of 35 years was shot through the sciatic notch, in Texas, in 1852, the missile lodging. lie was treated, iu hospitals in Cincinnati and Pittsburgh, for vesicorectal fistula, and died in October, 1853. At the autopsy a large musket ball was found in the bladder, suiTonnded by a calcareous deposition four times as large as the ball. The specimen was in possession of Dr. RoillXSON, at Warfordsburg, I'tniusylvania. Mattiikw (T. P.J (Med. and Surg. History of the British Army in the Crimea, Vol. II, p. 332) remarks 'hat "in the 20th regimental hoi-pital a musket ball was detected, during life, lodged in the urinary bladder, but the case speedily proved fatal.'' SECT. III.] CONCLUDING OBSERVATIONS. 425 of calculi formed about bone-fragments were shown to be less exceptional than recent authorities have supposed. Instances of the successful removal of such concretions by lithotomy, and post-mortem examples likewise were adduced.1 A case of calculus conse- quent on shot injury, a tuft of hair the nucleus of the stone, was then quoted,2 and operations for calculus of non-traumatic origin were adverted to. Reverting to shot injuries of the bladder, examples illustrating their pathological anatomy were presented; the paucity of the materials available on this topic being acknowledged. Since the remarks on page 290 were put in type, information has been received of the fatal termination of another case of this series, with the following notes of the autopsy: Case 827 (Continued).—Dr. A. V;uidervccr, of Albany, states that pensioner Robinson died October 2~>, 1873, and avers that the direct cause of his death was penetrating gunshot wound of the bladder, with a resulting fistula, attended with intense pain and cystitis. The same physician furnished the following report of an autopsy made by him twenty-four hours after death: ''Wilson Robinson, aged 35, American. Post-mortem rigidity well marked. Bed-sore back of and below the trochanter major, on the right side. Cicatrix and mouth of fistula below Poupart's ligament near the pubic symphysis on the right side, one-third way from the symphysis pubis. Body much emaciated. The course of the ball was just below Poupart's ligament, near the pubic symphysis on the right side, and passing through the horizontal ramus of the pubic bone entered the posterior portion of the bladder, passed out and through the tuberosity of the ischium on the left side, was then deflected upward, and finally lodged behind the trochanter major of the left femur, where it was found firmly encased in a fibrous covering. The bladder was divided in two parts by cicatricial tissue and fibrinous bands—apparently the portion ofthe bladder through which the ball had passed. The anterior half of the bladder contained a large calculus, the posterior portion a smaller one. The calculi were soft and phosphatic in character. The fistulous track on the right side connected with the bladder just in front of the opening of the right ureter by a small valvular orifice. The coats of the bladder were much thickened. The ureters were dilated so as to admit the passage of the little finger. The pelves of the kidneys were dilated, and there was slight contraction of the parenchyma; the general structure of the kidneys, however, was normal. The capsules were not adherent and tore up easily. The thoracic viscera were healthy. Encephalon not examined." Injuries of the prostate were next briefly noticed, and eighteen pages were then devoted to an examination of wounds and diseases of the rectum.3 In shot perforations of the rectum,4 the advantages of following the analogy suggested by the treatment of anal fistules, by freely incising the sphincters, was insisted on. It was shown that the number of pensioners with traumatic stercoral fistules, or with stricture or paralysis of the rectum, was so large as to invite serious attention to this group of injuries. The fifth and last subdivision of the Second Section, on wounds of the pelvic blood-vessels and nerves, included abstracts of some remarkable operations on the great arterial trunks. ■Compare notes on pp. 277 and 284, and Cases 849 and 850. Professor Bruns, of Tiibingen (Uber Schussverletzungen mit Eindringen von Fremdkoerpern und nachtraglicher Steinbildung, in Deutsche Zeitsehrift fiir Chir., 1873, B. Ill, S. 529), cites the case of J. S----, 2d Wiirtemberg regiment, shot at Bonneil, November 30, 1870. The ball entered immediately above the left pubic bone and escaped through the left buttock; urine issued from both orifices. Several small fragments of bone escaped from the anterior wound, but finally both wounds healed. On July 21, 1871, lateral lithotomy was performed, and a concretion removed, formed ahout a fragment of bone one by three centimetres. Among the detritus was found a bit of cloth from the uniform, a centimetre square. The patient was convalescent a fortnight after the operation. STROMEYER, (L.l (Handbuch der Chir., B. II, S. 712) states that he "saw, in the summer of 1865, in Professor Esmarch'S clinic, a young soldier from whose bladder the professor had removed, in a peculiar manner, a number of encrusted bone-splinters. The missile had comminuted the horizontal ramus of the left pubis, passed through the bladder and rectum, and escaped posteriorly. Dr. ESMARCH enlarged the deep narrow fistule above the ramus by the use of laminaria digitata, and removed, partly with forceps, partly by injections, in repeated operations, bone-splinters and encrustations, which filled a four-ounce glass. The injec- tions were made with the irrigator, by the urethra, forcing out water and small osseous fragments through the fistule. 2 Examples of vesical calculi having nuclei of the epidermal tissues or appendages are exceedingly rare. Kentmann (De calculis in corporc humano repertis, Tiguri, 1565. Cap. XI) relates that, in 1558, C. von Bernheim was shot in the bladder; urine escaped for eleven weeks through tho wound, which then healed. Subsequently sj'mptoms of calculus supervened, and lithotomy was practised, and a stone removed having a fragment of skin as a nucleus. "Purgata vesica, liberataque a reliquis sordibus, calculis, viscositate, sanie et aliis quae de globo bombardico, lotii acrimenia consumpto, supererant et orificium vesicae obstruxeraut." The piece of skin was flexible, two straws thick, and the width of a finger. Schenckius (I. c, p. 554) cites this case. 3 Two patterns of an ingenious and convenient duck-bill speculum for exploration of the rectum, devised by Colonel J. H. Baxter, Chief Medical Purveyor, U. S. A., were donated to the Museum (Specimens C4'.:8, 6439, Sect. I, A. M. M.) too late for deseription in connection with this subject. 4 Balls penetrating the rectum, or entering by ulcerative absorption, are sometimes passed at stool. CASE 169, p. 37, was possibly an example of this sort. Dr. W. F. Tibballs (Gunshot Wound in the Back—Bullet passed by Rectum Twenty-four Hours after, in The Cincinnati Lancet and Observer, 1867, Vol. X, p. 664) relates the case of a negro, aged 18 years, shot December 21, 1866, through the transverse process of the third lumbar vertebra, the ball entering the rectum, and being discharged with the faeces twenty-four hours afterward. In the First Surgical Volume (pp. 515, 598) instances are recorded of balls voided at stool, and in the preceding chapter of this volume (pp. 36, 37, and pp. 98-102, and notes on pp. 106-7) twenty- eight such instances are enumerated. Two of these were from GUTHRIE, though one of them was earlier described by HENNEN. Guthrie elGewhere relates yet a third case (On Wounds and Injuries of the Abdomen and Pelvis, 1847, p. 70, Case 112), in which the missile appears to have entered the rectum: A French soldier, wounded at Salamanca by a ball, which passed in by the side of the sacrum and lodged, on the sixth day passed the missile by the anus. Thus there appear to be at least thirty recorded examples of war-projectiles voided at stool. 54 426 INJURIES OF THE PELVIS--[CONCLUDED]. jCHAP. vu. In the Third Section, after referring briefly to wounds of the penis,1 wounds of the urethra were discussed in detail, the large number of pensioners with traumatic stricture or urinary fistules demanding special examination of this subject. The question of the propriety of maintaining a catheter after wounds of the urethra was discussed,2 and the recent improvement in the treatment of urethral fistules by the use of the vesical siphon3 was noted. In Pla.te XII, opposite page 395, figures, copied from original plates, are grouped together to demonstrate the creditable share of American surgeons in advances in the operative surgery of the urethra.4 It was suggested that the pension list indicated many cases of disability possibly susceptible of alleviation by urethroplasty. In the large group of cases of shot wounds of the testes, it was concluded that castration had not infrequently been resorted to unwisely. Complaints of neuralgia were made by many of the pensioners invalided for injury of the testes.5 The cases of hydrocele,6 cirsocele, and diseases of the testes were simply enumerated. It was shown that injuries of the pelvis were deserving a separate consideration, and that the gravity of shot wounds in this region had been exaggerated by many writers, conclusions in the main confirmed by the researches of writers on the surgery of the latest European war.7 1 Space was not found on the pages devoted to wounds of the penis for an enumeration of the pathological preparations illustrating this subject iu the Army Medical Museum and in other collections. In SECTION I, A. M. M., Specimens 3000, 3010, 3017, are groups of prepuces 'amputated for syphilis,'' and contributed by Acting Assistant Surgeon R. THOMAIN (Cat, I. c, p. 494). No. 1845 is an amputated penis, studded with venereal warts, donated by Acting Assistant Surgeon T. H. STILLWELL. No. 4843 is a penis affected with cancer, amputated, in 1850, by Dr. It. K. Stone. No. 4844 is a fine illustration of the effects of rupture of the urethra. No. 5463 is a portion of the penis affected by epithelioma, and amputated, in 1868 (prior to the notoriety of cundurango), by Dr. D. W. Bliss. In the Pennsylvania Hospital Museum (Cat. 1869, p. 110), Specimen 1680 is the "self-amputated penis of a man of 59 years " In the Museum of the Boston Society for Medical Improvement (Cat. 1847, p. 221), Specimen 705 is a penis studded with venereal warts and affected with phymosis, and amputated by Dr. C. H. Steadman. Specimens 706, 707, 708, of the same collection, illustrate removals of the penis for cancer or for syphilis. In Guy's Hospital Museum (Cat. 1857, Vol. II, p. 148). Specimen 2427£0 consists ofthe penis and testes of a man, extirpated by himself, from religious motives. (See the Gospel according to St. Matthew, Chapt. XIX, 12.) In the Museum of .';t. Barthol- omew's Hospital (Cat. 1846, Vol. I, p. 413), Specimen 38 of Series XXX is a prepuce affected by epithelioma. A penis, removed by self-mutilation, is preserved (Series XIII, Specimen 1) in the Museum of St. George's Hospital (Cat. 1866, p. 576). A number of preparations of portions of the penis amputated for disease may be found in the Museum of the Royal College of Surgeons of England (Desc. Cat, 1849, Vol. IV, p. 283 etseq.). 2 In a dissertation published in 1873 (Inconvinients des sondes a demeure), M. J. A. QUIROS presents the following conclusions, which probably express the views taught at present in the school of Paris: 1. "Si, dans certains cas, on est oblige de laisser un corps etranger dans l'urothre, il faut le faire le moins possible et employer des sondes souples. 2. Dans les cas de maladie de la prostate et de la vessie, qui exigent l'emploi de ces instru- ments, il faut preferer, s'il est possible, que les malades se sondent eux-memes toutes les fois que cela devient necessaire. 3. Laisser apres les opera- tions pratiquees sur le canal, la sonde le moins longtemps possible et se servir des instruments qui ne forcent pas I'urethre. 4. Preferer, dans les cas des fistules uretbrales, le catheterisme repete, s'il etait possible. 5. Dans les retrecissements, la dilatation arrivee a un certain degre, il faut cesser la dilata- tion permanente, et avoir recours soit a la dilatation temporaire, a l'ur6throtomie ou a la divulsion, selon les cas." 3 GRIP at, Du siphon visical dans le traitement des fistules urinaires, Paris, 1873. 4 Some American contributions on genito-urinary surgery are referred to in notes on pp. 398 and 400. Among many other papers may be consulted: Bliss (J. C.) (A Dissertation on Permanent Strictures of the Urethra, New York, 1815); M'JUXKIN (J. B.) (Case of Wound of the Genitals, in Am. Jour. Med. Set, 1834, Vol. XV, p. 123); Betton (Th. F.) (Laceration of the Urethra from a Fall on the Perinseum, with consequent Retention of Urine, for which Operation of Puncturing the Bladder was performed, ibid., 1836, Vol. XIX, p. 389); Hays (1. I.) (On Laceration of the Urethra, ibid., 1836, p. 392); MORRISON (M.) (Urinary Fistulse, ibid., 1838, Vol. XXII, p. 323); Annan (S.) (Laceration of Urethra, ibid., 1839, Vol. XXIV, p. 314); SMITH (N. R.) (Paracentesis vesicse for Relief of Suppression caused by Rupture of the Urethra, ibid., 1839, Vol. XXIII, p. 63); NORUIS (G. W. (Fistula in Perineo, following a Fall—Operation—Cure, ibid., 1843, N. S., Vol. V, p. 21); ATLEE (W. L.) (Two Cases of Perineal Operation on the Urethra, ibid., 1844, N. 8., Vol. VIII, p. 338); RusCHENBERGKK (W. S. W.) (Fracture of the Penis, ibid., 1849, Vol. XVII, N. S., p. 410); BURLING. HAM (H. D.) (Compound Fracture of the Sacrum, followed by Discharge of Urine through the Wound; Recovery, ibid., 1868, N. S., Vol. LV, p. 393); Shelve POCRATES (EIEPI EAK.QN, CEuvres Completes, ed. LlTTufi, 1849, T. VI, p. 429), in the twenty-third section of his work on wounds, treats briefly of those of the back, referring almost exclusively to those inflicted by the lash. After lacerations of the back by fustigation or other causes, he commends the application of cataplasms of boiled onions or squills, and, later, an ointment of goat's grease, or fresh lard, with oil, resin, and a salt <.f copper. Flogging in the United States Army was abolished by an act of Congress approved August 5, 1861, promulgated in General Order 49, for that year, of the War Department. .Section 3 of the act reads: "And be it further enacted, That floggiug, as a punishment in the Army, is hereby abolished." As indicated by a fuot-note to the 87th Articlk OF Wai:, "the infliction of corporeal punishment by stripes or lashes was forbidden by Act of May 16, 1812; but by Act of March 2. 1833, flogging was again officially authorized in cases of desertion. Flogging in the Xavy was abolished September 28, 1850 (Stats, at Lirge, Vol. IX, p. 513). 3Dr. T. P. Matthew, the official annalist of the surgery of the British Army in the Crimea, records (op. cit. Vol. II, p. 336) 323 cases uf slight and severe "simple flesh contusions and wounds," with twenty deaths, under the head of "gunshot, wounds of the back and spine." These 323 instances are from an aggregate cf 7,660 determined cases. The proportion of shot flesh wounds of the back was, therefore, in this series, 4.21 per cent. Demme (Mil. chir. Studien, 1881, B. I, S. 19), whose figures are so often to be skeptically regarded, states that, in the Italian War of 1850, among 8.500 wounded Austrian*. 345 cases of wounds of the back and buttock were observed, or 4 per cent.; and among 8,595 wounded French, there were 170 eases of lesions of the back or buttocks, or 2 per cent. Fischer (H.) (Kriegschir. Erfahrungen, 1872, S. 28) tabulates 20 < ases of shot wounds of the back in a total of 875 wounded before Jletz. or 2.2 per cent. MOUAT (Med. and Surg. Hist, of Nc:o Zealand War, in the Britisn army medical report for '815. p. 474) gives 17 cases of " wounds of muscles of the back '' in a total of 415 wounded, or 4.0 per cent. BlASSAKOWSiCY (P.) (Statistischcr Bericht uber 1415 franzosische Invaliden des deutsch-franzosischen Krieges, 1870-71) states: " Ninety-three cases of injuries of the pelvis were observed, of which fifty-six (or 4.9 per cent.) were injuries of IU>' external soft parts, all implicating the buttocks, and in four instances perforating the latter from side to side. Some cases of large loss of substance from lacerations by shell fragments were worthy of mention. Four of these were really remarkable, for, notwithstanding the magnitude of the lesions, there was little general constitutional disturbance. I saw no instance in which the wounds had entirely healed, though cicatrization was rapidly going on in all. In four cases, the sciatic nervo was injured, with paralysis ofthe parts supplied by it.'' Stein- berg (Die Kriegslazarethe und Baracken von Berlin, 1872, S. 146) tabulates 8,531 cases of wounds treated in the Berlin Hospital in 1871-72, of which number 823. or 9.6 per cent., were flesh wounds of the trunk. It is fair to conclude that about one-half of these, or 4.8 per cent., were flesh wounds of the posterior parts. * In a Consolidated Statement of Gunshot Wounds (Circular No. 9, S. G. O., July 1, 1863), Surgeon J. 11. Brixton, U. S. V., records the oases of shot flesh wounds of the Trunk, treated in the U. S. A. General Hospitals for the last four months of 1862, as 2,190 in number. Of these wounded, 91 died, 220 were discharged, 50 deserted, 76 were furloughed, 12 were exchanged, 686 were sent to duty, and 1,055 remained under treatment. The regions ofthe trunk implicated in these cases were not specified. The unpublished Consolidated Statements for the quarter ending March 31, 1863, give 2.280 " gunshot flesh wounds of the trunk,'' of which 40 were fatal. Of these wounded, 559 were sent to duty, and 187 were discharged; 617 are accounted for by furlough, transfer, and desertion, and 877 remained under treatment. The Consolidated Statements for the quarter ending June 30, 1863, present 2,060 cases of shot wounds of the trunk, with 50 fatal cases, 84 discharges, 574 transfers, furloughs, or desertions, 381 cases only cured and returned to duty, and 971 cases remaining under treatment. It is obvious that more than a third of the cases in these numerical statements were liable to be counted over again in each quarterly return. The totals were, for the three quarters, 20,930, 23,627, and 25,331, and the percentages 10.4, 10.0, and 8.1, and, if half of the cases referred to the posterior part of the truuk, a proportion closely approximating that deduced from other sources is reached. 428 FLESH WOUNDS OF THE BACK. ICIIAP. VIII. On the classified returns of wounds and injuries, on the form printed on page XV of the Introduction to the First Surgical Volume, returns made with approximate complete- ness during the last year of the War only, about six per centum of the aggregate1 of cases were entered as "flesh wounds of the back and hips." Extracts from the greater number of these returns are consolidated in the following table : Table X. Paitial numerical Statement of Shot Wounds of the Back and Hips, in the Field or Primary Hospitals in various Campaigns, during the last Year of the War ofthe Rebellion, 1864-65. Battle, Action, or Series of Engagements. Names or Dates. Wounds of the Back and Hips. Cases. Missiles. shot, shell, and bomb frag- ments, grape, and canister. Small pn.ier- tiles, mu;k.t, pistol balls and small mis- siles from shrapnel and canister. Or; ^ O o S m 3 f\ o ^ " «-* O PnjSPO 6.38 + 5.73+ 3.96+ 5.93 + 4.74 + 3.22+ 5.63+ 8.19-1- 7.80+ 0.71+ Army of the Potomac from May 4 to August 31, 1864.............................. Armies of the Cumberland, Tennessee, and Ohio during the campaign to Atlanta, from May 4 to September 8, 1864............................................... Armies of the Cumberland, Tennessee, and Ohio, and Cavalry, during General Hood's invasion of Tennessee, from October 25 to December 31, 1864..................... General Sherman's campaign in 1865 through the Carolinas........................ Armies of the James and Ohio, etc., from Fort Fisher to Goldsboro', N. C, 1865...... Army ofthe West Mississippi during the siege of Mobile, from March 26 to April 9,1865. Army of the James during General Grant's campaign against Petersburg, from May 4, 1864, to April 9,1865........................................................ Engagements in the Shenandoah Valley, May 4, to Aug. 20,1864.................... Campaign in the Shenandoah Valley, Aug. 21 to Dec. 30, 1864..................... Army of the Potomac from Sept, 1, 1864, to April 9, 1865.......................... 2,485 1,336 143 91 51 68 180 589 741 318 32 1 2 2 1 14 2 11 12 180 10 72 79 2,120 1,116 116 88 30 41 696 76 507 596 38,944 23,308 3,610 1,533 1,075 2,111 16,120 2,196 7,542 10,407 Aggregates. 6,593 108 891 5,386 106, 846 6.17+ The total number of cases of shot wounds of the back (not implicating the spine or thoracic or abdominal cavities) reported are summed up in the following table : Table XL Tabular Statement of Twelve Thousand Six Hundred and Eighty-one Cases of Gunshot Flesh Wounds of the Back. SEAT OF INJURY. Returned as flesh wounds of the back, without other specification Specified as over posterior thoracic region...................... Specified as over lumbar or posterior abdominal region.......... Returned as wounds of hips, buttocks, nates, or gluteal region ... Aggregates. Cases. 3,486 990 698 7,507 Died. Discharged. Duty. Unknown 172 51 51 526 383 162 125 1,056 1,726 2,641 724 495 5,297 9,157 290 53 27 628 998 The returns conform closely to what might be inferred a priori, from the extent of surface exposed, as to the frequency of shot wounds of the fleshy parts of the thoracic, 1 The conclusions in the preliminary surgical reports in Circular No. 6, S. G. O., 1865, were based on an analysis of 87,822 cases of wounds and injuries. Of these. 5,195 cases were classified as " gunshot wounds of the back." The aggregate of cases of shot wounds treated during the War of the Rebellion, now tabulated on the registers of the Surgeon General's Office, with some approximation to precision, numbers 253,142, of which 12,681 are tabulated as gunshot wounds ofthe back, the percentage of cases referred to this category being five and three-quarters and five in the two counts. SECT. I.] STABS, OUTS, AND SHOT LACERATIONS. 429 lumbar, and gluteal regions of the back. Flesh wounds of the back, other than those inflicted by shot, and enumerated in the table, were uncommon. Punctured and Incised Wounds of the Back were exemplified by fifty-six instances, of which twenty-one were cases of bayonet stabs, thirteen of sabre cuts,1 and twenty-two of punctures or incisions by sundry weapons. None of these cases are recorded as term- inating fatally, though in six the result has not been ascertained; forty-five were sent to duty, and five were discharged. Several of these cases were examples of severe, though not dangerous, sword wounds.2 Shot Wounds of the Back involving only the soft parts3 were seldom mortal unless pyaemia or tetanus supervened, or some maltreated arterial bleeding. As the men were often ordered to lie down under artillery fire, large lacerations of the dorsal region were not infrequent. Commonly they healed rapidly: Cask 1223.—Private Frederick S------, Co. A, 149th Pennsylvania, aged 19 years, was wounded July 13, 1864, in the entrenched lines before Petersburg, on the Fifth Corps front, by a large shell fragment, which tore away the dorsal integuments over a space at least six by eight inches, and severely lacerated the subjacent muscles, without injury, however, to the ribs or spine. Surgeon W. R. DeWitt, U. S. V., rendered the first attention to the patient. There was no bleeding, and the shock was comparatively slight, and, after taking was in a condition to be transferred fig. 360.—Laceration of the back by a shell fragment. northward, and entered the Whitehall Hospital, at Bristol, Pennsylvania, on August 15, 1834. Cicatrization progressed rapidly, and Assistant Surgeon W. H. Forwood, U. S. A., reported that the patient was furloughed on September 12th, and readmitted on October 4, 1864, fairly con- valescent. On January 23, 1865, this soldier was sent for modified duty in the Veteran Reserves, and on June 24, 1865, he was mustered out of service. From the pension record, it is inferred that neither this man nor his relatives have made applica- tion for pension. The accompanying wood-cut (Fig. 380) is copied from the drawing by Stauch. Sometimes, on the contrary, the reparative process was very slow after such lacer- ations, as would be anticipated from the nature of the vascular supply in this region. 1 Of the thirteen reported cases of sabre wounds of the back, twelve were received iu action, as follows: Pt. T. O'Rourke, K, 6th Pennsylvania Cavalry, Brandy Station, August 1st; duty, August 18, 1863. G. Radebaugh, H, 13th Pennsylvania Cavalry, Winchester, June 15, 1803; duty. Pt. J. Barber, K, 1st Colored Troops, September 30. 1864 ; duty. Pt. J. Jones, H, 11th Pennsylvania Cavalry, near Richmond, October 17,1864 ; discharged. Pt. W. H. Cheeny, H, 5th Connecticut, Savannah, December 10, 1864; duty. Corporal II. H. Brownsmiller, H, 1st Pennsylvania Cavalry, Jettersville, April 5, 1865; discharged. Lieut. J. M. Corns, E, 2d West Virginia Cavalry, Five Forks, April 1st; duty, April 22, 1865. Pt. T. Gray, F, 2d West Virginia Cavalry, Five Forks, April 1st; duty, April 18, 1865. Pt. P. Gallagher, I, 9th Massachusetts, Gettysburg, July 2d; duty, September 8, 1863. Serg't T. Taylor, B, 10th New York Cavalry, Brandy Station, June 9th; duty, August 16, 1863. Pt. T. Dewyer, 4th Michigan, Fort Donelson ; duty. Pt. C. A. Woods, A, 1st Pennsylvania Artillery, Petersburg, July 1, 1804; discharged, The bayonet stabs appear to have been inflicted, for the most part, by sentries or provosts' guards, or in brawls, or through accident. One example only is specified as a wound received in action, and in this single case it does not clearly appear that the wound was inflicted by the enemy. 2 Sabre wounds of the back are seldom referred to. Bilguer (Chir. Wahrnehmungen, 1763, S. 493) gives an instance in the Seven Years War (1756-63): A cavalryman, J. R-----, retreating and leaning over his horse's neck, received two severe sword-cuts in the lumbar region. Morgagni (De sed-. etcaus., 1765, Ep. LIII, p. 270) records an autopsy in a case of sabre-thrust in the back. A report by Surgeon S. W. Gross, U. S. V. (Am. Med. Times, 1864, Vol. VII, p. 136). of a sword-stab in the left flank, penetrating the descending colon, has already been alluded to on page 70 ante. 3 Stromeyer (Maximen der Kriegsheilkunst, 1855, S. 670) observes: " Shot wounds ofthe soft parts of the back have not an especial tendency to suppuration. But in long seton wounds it frequently occurs that they heal, and reopen after months and form a fluctuating tumor, which must be opened, as the thick skin of the back is only slowly perforated by the serous substance. Many surgeons err in trying to relieve the ailment by several small incisions or even punctures parallel to the spine; these afford no relief, and it is absolutely necessary to make an incision of several inches in length at a right angle to the spinf." 430 FLESH WOUNDS OF THE BACK. [CHAP. VIII. There were some curious instances of long circuitous ball tracks, and among tho fatal cases were noted several in which the projectiles had lodged under the scapula. Other conditions being equal, flesh wounds in the flanks and buttocks had more gravity than those in the upper dorsal region.1 In cases where large portions of muscles were torn awav,2 cicatrization was sometimes protracted for years: Case 1-220.—Private John E Tucker, Co. E, 17th Maine, aged '20 years, was Avounded, by the explosion of a shell, at the battle of Chancellorsville, May 3, 1803. The integuments over the gluteal and lumbar regions were torn away, and, on the right side, a large portion of the gluteal muscles was removed. He was treated by Surgeon E. L. Welling, 11th New Jersey, at a hospital of the Ninth Corps, until reaction took place, when he was sent to Armory Square Hospital, at Washington, on Mav 8th. He suffered but little pain, and his appetite was good. He was ordered the best of diet, with porter; lint wet with a disinfectant lotion to the wound and an anodyne at night. The patient did well till the forenoon of May 15th, when he complained of inability to separate his jaAvs, and of stiffness of the muscles of the neck. He took a full dose of morphia, but on the following day the trismus was more confirmed, and there was slight opisthotonos. The report makes the contra- dictory statement that there was no spasmodic action of the muscles. No trouble in deglutition or respiration. Turpentine stupes were applied to the neck, and the fourth of a grain of sulphate of morphia was given every four hours, with milk- punch. On May 18th, the jaws could be separated more, and there was less stiff- ness about the neck. On the 20th, there were frequent involuntary twitchings of the dorsal muscles. The wound was more painful. It was dressed with olive-oil on cotton batting, and, later in the day, with a solution of morphia. The internal administration of morphia was continued. On the 21st and 22d, the symptoms continued to amend. The patient could separate his jaws and protrude his tongue He had a fourth of a grain of sulphate of morphia every hour, applications of ice to the spine, and the wound was dressed every six hours with a lotion containing six grains of morphia. On the 22d. there was a dejection from the bowels. From this date the patient steadily improved. On July 10th, he received a furlough. He returned to the hospital on November 24,1803. December 5,1863, he was examined by Surgeon J. H. Brinton, U. S. V. The wound had cicatrized, except over a space the size of the palm of the hand, which surface was granulating kindly. The right buttock was flattened and wasted. The gait was feeble and uncertain. The general health appeared to be good. Very soon after the reception of the injury a colored drawing of the huge wound, which is very accurately reproduced in the chromo- lithograph opposite (Plate IX), was executed by Hospital Steward Stanch, under Dr. Brinton's supervision. This soldier was discharged December 15, 1863, and pensioned. Examiner T. H. Jewett, of South Berwick, Maine, reported, November 30, 1870: "Ashell wound over sacrum, of large extent; is not so well as formerly; the wound over the sacrum shows no disposition to heal, and in all probability will remain an open ulcer. His weight is 130 pounds, the pulse 70, the respiration normal; disability total." In 1871, the editor of these pages addressed a note of enquiry to Mr. Tucker regarding the condition of his wound. His attorney, Mr. (1. C. Yeaton, courteously responded to this letter, and transmitted a photograph and diagram ofthe cicatrix, which then bounded an irregular granulating surface three inches Avide by two inches in height. The photograph is reproduced in the wood-cut (Fig. 361). For along time the granulations on this raw surface had been indolent, and cicatrization had made no progress; there were no sinuses or fistulous tracks to indicate the existence of diseased bone or other internal cause of irritation. The invalid's general health was satisfactory. He described the discharge from the ulcer as "thick and creamy." The editor advised that M. Reverdin's plan of skin-grafting, on which Messrs. Bryant and Pollock had latterly reported so favorably, should be resorted to, but has not been informed AA'hether this advice was folloAved. The transplantation of portions of skin to facilitate the cicatrization of large granu- lating surfaces must be regarded, I think, as a very important modern advance in surgery, "rendering," as Mr. Bryant expresses it, "many cases curable that were not so previously, and facilitating the cure of as many more." 1 BECK (B.) (Chir. der Schussverletzungen, 1870, S. 448) is one of the few writers on military surgery who speak, at any length, of shot wounds of the soft parts of the dorsal region. He remarks, in substance, that when the fleshy covering of the back is injured, much depends on the depth to which the laceration of the muscles extends, the length of the shot channel, the amount of concussion (as from large shot or shell fragments), or the degree of implication of the ribs or spine. Shot wounds limited to the areolar tissues and muscles mainly were of no special interest, unless attended by exceedingly large loss of substance or by a very long seton-like ball track. Cases in which blood-vessels of the larger order and main branches of the nerves were contused or lacerated were more serious. The functions of the dorsal muscles were, in some cases, much impaired by shot lacerations. Many invalids of this class were unable to move freely, and complained of difficulty in breathing, stooping, turning tbe head; complications due, unquestionably, to cicatiiees resulting from lacerated shot wounds that had either been attended by sloughing or had required incisions to relieve deep suppuration. 2 Fischer (G.) (Dorf Fining und Schloss Versailles, in Deutsche Zeitsehrift fiir Chir., 1872, B I. S. 198) cites the case of a French soldier, who, while kneeling, was struck by a rolling cannon ball, which tore away a piece of the buttocks the size of a dinner plate. In another instance, a piece as large as a man's hand was carried away. In both cases luxuriant granulations sprung up, and complete recoveries were to be expected. Fig. 301.—Appearance, nine years subsequent to the reception of the injury, of the ulcerated cicatrix of the wound depicted in Plate IX. [From a photograph.] Hi: V _ -<1 :4 .Hi'.' -I • ■ied tothi- !(, 1:'. t: \w}\> ■' .• .. ':.ii- :i.t ■ iil\;u '". ■ i.i '" ■• ■ . '.■.!'.> \ "•!_. litlii-gu.ph (.jii^>-. ■■■ ■ • ' •• ' :\ >. '.vs'.- ■.■*<■• ■ ■sr.-ii-.-r.t Dr. Bi-iut.a's >->.(•, i ■, \-,<, . i'lns M.-l.iier v '.";.1::iy" ]'eiisi...>; i. Ex.i;:il:.e: '!' 'J. J.'vett, oi S«iv :■'.», 18"0: A -li-i! •■•■ '>!i:> ' .v er ,-.1-u^:ui, ...f !■ lVJ WOUtl'l n; -.'i if.- -' 1 .M .-.!iO\'>'s :o, ■•.':;-.■' ' ■ ; t'i-'s. ;h" ni:>- '' . ' ■ ■•>; '.r.ifioii :;.;t;i ' '>! T,i,■'::-..' ■. , ■■ 'v. .-,..-, "til,- ,r i o •■•■■ .■•■' ■ i-• ir,-i..i. ut. .v..i .■'.■■i.i .....:■ , :- • • ■ ,'.: ■ :•. ■ -d '..::> ■■ ...i- othff ' ■•!,.■ 'I >•■ '■. ■ du- :> ,. . F?--.ti. tho .!■■■.■]• -,.- '-*'..' V: ■ ' .-. '.:■• ■ ■!■ >'.-=--. ;. Jiryani mi-1 I'.-i' -H: i," ■ ' • ■ ':."'■ .ti!~ y o . ...ij j'oll'.fV/ed. .'■', Oi portion- •- 8klU t i'Oimrd'xl. I I'l'i.; I ■: •') \r< ,t involun: I"! -,;.« .'.re.- Sure Hist of tin-War of Un- Kcbrllion , Vol.11 Chap. VIII. ^w-% at.- ®4 > .* K'i|w.'' Op. p.TJr. i:;o. St audi del. TWliu&Son niron.ohlh. PLATE IX. LACERATION OFTHE BUTTOCKS BY A SHELL FRAGMENT. SECT. 1.1 ON SKIN GEAFTTNG. 431 The value of M. Beverdin's interesting discovery1 has been experimentally substan- tiated by Drs. Hodgen, Brinton, and others, in this country, and by Messrs. Pollock, Errant, and others, in England. A wood-cut illustrating one of Dr. Hogdcn's cases is copied in Figure 3C>2, and Figure 303 is borrowed from Mr. Bryant. The two last-named surgeons have published very interesting accounts of the details of the different plans of skin grafting, with ingenious observations on the best methods of establishing centres of "cutiiica- tion." Figure 3G4 represents the scissors recommended by Mr. Bryant for the removal of the sound skin. In a number of cases on the pension rolls, of indolent ulcers consequent Tn „, .... „. "" ... .„ „, . „. ..„ „„ „„„, ' x Fig. 363.—Skin grafting. [After Fig. 362.—Skin grafting. [After HODGEN.] , . n P .. n tirvavtI upon extensive loss ot tissue, there "KIAA1-J can be no doubt that this method of skin transplantation would prove invaluable. There are several examples, analogous to that detailed on the preceding page, of what would be termed healthy granulating surfaces remaining open for as long a period as ten years. lM. Reverdin made, November 24. 1869, at the Necker Hospital, in Paris, the successful experiment of transplanting two small portions of skin, taken from the right arm of a man thirty-five years of age, to a granulating ulcer on the left forearm of the same individual, the result of a laceration incurred in falling from a scaffold on October 16, 1869. The ulcer healed under this treatment, and, on December 15, 1869, SI. GrUVON, in whose service the case was treated, read to the Surgical Society of Paris an account of this brilliant achievement, under the title: Greffe ipidermique, Bull, de la Soc. de Cliir., December, 1869; Gaz. des Hop., Janvier 11, 1870, p. 15. In May, 1870, Mr. G. D. POLLOCK, of .St. George's Hospital, London, followed this novel method of treatment, in the case if a girl of eight years, with a huge indolent ulcer of the thigh, resulting from a burn. Various modes of treatment, local and general, bad been pursued, without any diminution of the unhealed surface, when the plan of transplantation of hits of skin from the abdomen was resorted to, with such signal success that a similar treatment was adopted in fourteen other cases. (The Lancet, 1870, Vol. II, pp. 6C9, C8S. 707, and Transactions of the Clinical Society, 1871, Vol. IV, p. 37.) The Transactions of the Clinical Society for 1870, besides Sir. POLLOCK'S important paper, contain a report by Mr. G. LAWSON (On the Transplantation of Portions of Skin for the Closure of large Granulating Surfaces). The practice very soon became established as a great boon in the management of ulcers. In this country, Professor Chisolm (Skin Grafting, in Balti- more Med. Jour., 18T0, A'ol. I, p. 586), Dr. J. II. Brixton (The Med. and Surg. Rep., 1871, Vol. XXIV, p. 73), Drs. POUTER and COOLIDGE (Epidermic Engrafting, in Rep. of Soc. for Med. Improvement, in Boston Med. and Surg. Jour., 1870, Vol. VI, p. 344), Dr. H. R. WILLIAMS (On Healing Ulcers by Transplantation, in New York Med. Gaz., December 3, 1870), Messrs. BELT, HANDY, and I'.Ol.LES (Cases of Transplantation of Skin, in Boston Med. and Surg. Jour., 1870, Vol. AT, p. 389), and many others, hastened to repeat M. Reverdin's experiment. Abroad, the practice was early imitated by Mr. STEELE (On Transplantation of Skin, in Brit. Med. Jour., 1870, Vol. II, p. 621), Mr. PAGE (Obs. on the True Nature ofthe so-called Skin Grafting, ibid., p. 655), Dr. MACLEOD (Transplantation of Skin, in Glasgow Med. Jour., 1870-71, Vol. Ill, p. 339). FORT (La greffe ipidermique, in Gaz. des Hop., 1870, No. 87, and Gaz. mid. de Paris, 1871, No. 41), PONCET (Des greffes dcrmo-epidermiques, Lyon Medical, 1871, Nos. 22 and 23), HOF.MOKL (Uber Uberpftanzung von Hautstucken, in Wiener Med. Presse, 1871, No. 12), IlEIiiERO und ScHULZ (Einiges uber Hautverpflanzung, in Berlin Klin. Wochenschrift, 1871, No. 10), LINDEMSAUM (Uber die Transplantation, u. s. w., ibid., 1871, No. 11), NETOLITZKY (Zur Casuistik der Hauttransplan- tation, in Wiener med. Wochenschrift, 1871, No. 34). Many other references may be found in a summary in the Biennial Retrospect, 1871, Vol. L. p. 233, of the New Sydenham Society's publications, among which may be noted papers by DonsON (Med. Times and Gaz., Oct. 29,1870, Vol. II, p. 500), GOLDIE (R. \V.) (Skin Grafting, Lancet, 1871, Vol. I, p. 47), AVOOD (SI. A.) (Skin Grafting, Brit. Med. Jour., 1871, Vol. I, p. 446), AVlLsOX (\V.) (Remarks on Skin Grafting, Glasgow Med. Jour., 1871, p. 341). Professor FRANK II. HAMILTON (Healing Wounds iy Transplantation, in The Medical Gazette, New York, 1870, Vol. V, p. 138) draws attention to a plastic operation proposed by him in 1815 (Buffalo Med. and Surg. Jour., June, 1817, Vol. II, p. 508), in the case of a lad of 15, with an ulcer of the right calf and thigh. The plan had in view the '" planting upon the centre of the ulcer a piece of new and perfectly healthy skin," taken "from the calf of the other leg (having secured the two together)." Dr. Hamilton is reported as claiming the suggestion, "whether it be regarded as good or bad, as his own, viz: the application of the plastic oper- ation to old and indolent ulcers ; yet he will postpone getting it patented until he learns how his Bcston friends get along with their other patent." No operation was done in this case; but Dr. HAMILTON refers to an instance in which he success- fully practised an operation of this nature, in 1854, in the case of Driscoll, an Irish laborer, the operation having been fully described in a paper entitled: "Elkoplasty (cKkos, ulcer, and ukaao-w); or, Old Ulcers treated by Anaplasty," in the New York Jour, of Med., 1854, Vol. XIII, N. S., p. 165. JI. OLLIER (Lyon Medical, 1872, T. IX. p. 464) regards Dr. Hamilton as having anticipated SI. Reverdin's discovery. On the other hand, Dr. John Watson (Reclamation on the Treatment of Ulcers by Anaplasty, in New York Jour, of Med., 1854, Vol. XIII, p. 360) states that Dr. HAMILTON'S proposal had been by him "antici. pated, on at least two occasions," citing an article in the American Journal of the Medical Sciences, 1844, A'ol. VIII, p. 537, and his remarks on " Metopo- plasty, or Forehead-mending," in Vol. I, p. 711, ofthe 1847 edition of Dr. TOWNSEXD'S translation of VELPEAU's New Elements of Operative Surgery. J. F. Palmer, si editor of Hunter (The Works of John Hunter, F. R. S., 1837, Vol. Ill, p. 256), cites " B.utONIO, Degli innesti animali, 1804,'' Fir.. 364.—Scissors for transplanting sound skin, devised by Dr. Maci.god. [After Buy ant.] 432 FLESH WOUNDS OF THE BACK--[CONCLUDED]. fCHAP. vm. A fraction over six per centum of the cases returned as "gunshot flesh wounds of the back" proved fatal. The proximate causes of death in the eight hundred fatal cases recorded in Table XI are specified in three hundred and eighty cases. Eighty-three of these were complicated by other wounds. Of the remaining two hundred and ninety-seven patients, twenty-seven are said to have succumbed to tetanus,1 thirty-three to secondary haemorrhage,2 and twenty-eight to gangrene. The fatal termination was ascribed to surgical or traumatic fever in seventeen cases, to erysipelas in eight, and to typhoid fever in thirty-one cases; to pyaemia or septicaemia in sixty-seven cases; to pneumonia or hepatitis (probable instances of embolism) in seventeen cases; to diarrhoea and dysentery in thirty- nine cases ; and to peritonitis in seven. In one case, the administration of chloroform was thought to have brought about the fatal result. Two patients died from diphtheria, two from small-pox, and eighteen from various intercurrent diseases due to hospitalism and unconnected immediately with the traumatic affections. Analysis of this large series of gunshot flesh wounds corroborates the conclusions stated in a foot-note on page 7 of this volume, and indicates that the mortality of these non-penetrating wounds has been over- estimated by some European writers of acknowledged authority in matters pertaining to surgical statistics. Making every allowance for errors, and admitting that the aggregate may have been swelled by the admission to hospital of trivial cases of wounds of the integuments, the percentage of mortality remains much lower for this group of injuries than has been heretofore represented.3 in testimony of the successful transferronoe of portions of integument from one part of an animal to another. In connection with JOHN HUNTER'S well- known experiments, Mr. POLLOCK and M. G. Martin (De la durie et conditions d'adherence des restitutions et transplantations cutanies, Paris, 1873, No. 41) refer to the experiments of this Italian (Baronio (G.) (Ricerche intorno alcune riprodazioni che si operano negli animali cosi detti a sangue caldo, e nulVuomo, Milan, 1818). A highly interesting disquisition on the transplantation of animal tissues was published, ten years ago, by Dr. P. BERT (De la greffe animate, Paris, 1863), an imperfect bibliography being appended to the paper. Consult further: Morales (R.) 01 Successful Case of Transplantation, in New York Med. Rec, April 15, 1871); HOWARD (B.) (Theory of Cure of Ulcers by Skin Grafting, in Proc. of Med. Soc. of the Countyof New York, New York Med. Jour., 1871, Vol. XIII, p. 466); Bartlett (S. C.) (Removal of Entire Scalp; Wound healed by Skin Grafting, in Am. Jour. Med. Sci., 1872, Vol. LX1V, p. 573); Hodsen (J. T.) Cell or Skin Grafting, in the St. Louis Med. and Surg. Jour., July 10,1871, p. 289); Trader (J. W.) (A Case of Skin Grafting, St. Louis, 1871); Woodman (J.) (Notes on Transplantation or Engrafting of Skin, London, 1871); Barloav (\V. H.) (On the Practice and Rationale of Skin Grafting, in the Manchester Med. and Surg. Rep., October, 1871); Bryant (T.) (The Practice of Surgery, 1872, p. 431); Czerny (Haut-Transplantation, in Wiener Med. Presse, 1871, Jahrg. XII, No. 17, S. 439); MARDUEL (P.) (Des greffes cutanies, in Lyon Med., 1872, T. X, p. 76 et seq.); HOUZE DE L'AULNOIT (Quelques essais d'anaplastie d, Vaide de greffes muqueuses, etc., in Gaz. hebd., October 11, 1872, p. 662); PERCY (Article Ente animate, in the Diet, des Sci. Mid., 1815, T. XII, p. 339). 1 The date of the fatal termination is recorded in twenty-four of the twenty-seven cases. Excluding the two cases of Corporal J. Cantelon, Co. H, 4th Cavalry, and of Private J. Trainor, 2d Infantry, who survived fifty-four and forty-two days, respectively, the mean duration of life after the recep- tion of the injury, in the twenty-two cases, was nearly twelve days. One patient, a soldier of an Alabama regiment, wounded at Gettysburg, died in four days ; several died on the eighth day after the reception of the injury. Surgeon I. MOSES, U- S. V. (Am. Jour. Med. Sci., 1864, Vol. XLVIII, p. 354), has published abstracts of several of these cases in his Surgical Notes of Cases of Gunshot Injuries occurring near Chattanooga. 2 Some of these cases would, with more precision, be described as instances of intermediary haemorrhage. Of the thirty-three, in thirty-two the fatal bleeding came on from the third to the eightieth day, the mean period being the thirtieth day. In the thirty-third case, that of Private W. H. Marsh, Co. K, I3th Illinois, wounded at Vicksburg, in 1862, there was a persistent fistula after a shot wound of the buttock, and, three years subsequently, the report states that uncontrollable venous haemorrhage occurred, and proved fatal in twenty-four hours. It seems more probable that a gluteal or ischiatic aneurism gave way. 3 Consult, on this subject: Benson (O) (Article Muscles of the Back, in The Cyclopsedia of Anat and Phys., Vol. I, 1835, p. 368); Petit (Article Dos, in the Diet des Sci. Mid. 1814, T. X, p. 150); MORGAGNI (De sedibus et causis morborum, Patavii, 1765, Epist. LIII, art. 12, p. 270); BlLGUER (J. U.) (Chir. Wahrnehmungen, 1703, S. 493); COLE (J. J.) (Military Surgery, 1852, p. 75); MATTHEW (T. P.) (Med. and Surg. Hist, of the British Army in the Crimea, 1858, Vol. II, p. 336); CHENU (J. C.) (Camp, d'Orient, I. c, 1865, p. 186); Stromeyer (Maximen, 1655, S. 670); DEMME (Studien, 1861, B. II, S. 189); Birkett (J.) (in Holmes's System, etc., 2d ed., 1870, Vol. II, p. 708); Neudorfer (J.) (Die Schussverletzungen der seitlichen WeichtheiU der Wirbelsaule. in Handbuch, I. c, 1872, S. 1743); Fischer (H.) (Ruckenwunden, in Kriegschir. Erf., 1. c, 1872, S. 114); and BECK (B.) (Von den Verletzungen des Biickens, in Chir. der Schussverletz., 1872, S. 448). CHAPTER IX WOUNDS AND INJURIES OK THE UPPER EXTREMITIES. The comprehensive title prefixed to this Chapter is adopted in order to conform to the plan commonly pursued by systematic writers; yet it is not designed to enter upon all the branches of the subject, but only to present a summary of the facts reported regarding sword and bayonet and other cuts and stabs, and shot wounds. Such information as has been communicated respecting the various other injuries to which the upper extremity is exposed, such as bruises and sprains, burns, scalds, and frost-bites, luxations, and fractures from other causes than shot, it is purposed to set forth in the Third. Surgical Volume. Some particulars regarding the comparatively small proportion of reported cases of punctured, incised, and miscellaneous wounds and injuries, will be specified in succeeding subdivisions of this Chapter; but attention will be invited mainly to the facts recorded respecting shot wounds of the upper extremities, a group of great importance, comprising, numerically, one-third, or perhaps more,1 of all the cases of wounds received in action that came under the care of the hospital surgeon, and requiring, to a large extent, operative interference by excisions, amputations, or ligations of blood-vessels. Reserving the account of the accidents and injuries not inflicted by war-weapons, the materials will be arranged, as* far as practicable, on that generally accepted principle of classification of traumatic affections which bases the principal divisions on regional, and the subdivisions on structural, characters.2 The detailed facts reported of punctured, incised, and shot wounds of the upper extremities will be distributed in eight subdivisions, treating, respectively, of flesh wounds, shot fractures of the clavicle and scapula, wounds 1 The justification for this statement is found in the statement in Table XII, on the next page, compiled from the reports of .the statistical writers who have paid most attention to the relative frequency of wounds in warfare according to region, and, at the same time, have had access to large groups offsets. It is, of course, impracticable to obtain anything more than an approximation to the total number of wounds received in action; yet the comparative ratios may be as accurate as if exact enumeration was approached. 21 have no hesitation in stating that on most points I fully concur in the high estimate that Professor T. LONGMORE (On the Classification and Tabulation of Injuries and Surgical Operations in Time of War, in Med. Chir. Trans., 1871, Vol. LIV, p. 201 et seq.) has bestowed on the plan of classification proposed, in lH.'rfi. bv Inspector-General J. It. Taylor, C. B. This plan, subject to some modifications suggested by experience, has long been favorably regarded by army surgeons in this country. In 18ii4, when new forms of surgical record books were issued to the hospitals (Circular Letter, 8. (.}. O., January 20, 1864—see Prefatory, p. IV, First Part, Med. and Surg. Hist, of the Rebellion), a form, copied substantially from Iuspeotor- General Taylor's classification, was printed in each register, and commended to the surgeons "as a guide to them in recording the diagnoses of surgical cases," with the injunction that: "By following its general arrangement as closely as possible, it is believed that greater accuracy will be insured in the preservation of surgical data for consolidation, and opportunity will be afforded of comparing the surgical results obtained in this War with those arrived at during the Crimean and otlier campaigns." It was not the eulogy of the British classification that I have taken exception to in the notes on p. XXVI of the First Surgical Volume, and on p. 7 of this volume, but to what I regarded as grave misrepresentations of the nature of the American surgical statistics and of the mode of dealing with them. Surgeon-General Loxgmore has latterly (Am. Jour. Med. Sci., 1873, Vol. LXVI. p. 584) declared that his statement regarding the number of persons engaged in collating and arranging the surgical statistics of the American War was an " unintentional mistake," which he very much regrets, and I cheerfully accept this interpretation. The unguarded expression on page 6 of the preliminary report of Circular 6 is quite open to misapprehension, what was simply a list of books of record being termed a "classification." I have explained elsewhere (Am. Jour. Med. Set, 1868, Vol. LVI, p. 128) the circumstances under which that report was published a few months after the termination of the War, all pretension to completeness being repeatedly disclaimed.—G. A. O. 55 434 INJURIES OF THE UPPER EXTREMITIES. [chap. ix. of the shoulder joint, shot fractures of the shaft of the humerus, wounds of the elbow joint, fractures of the ulna and radius, wounds of the wrist joint, shot fractures of the metacarpus and phalanges. Yet no rigorous adherence to classification will be attempted, and matters allied to tho several subjects discussed, that it is desirable to place on record, will be intercalated in the different sections and subsections, as convenience may dictate. So-called accidents are subject to fixed laws, and the remarkable uniformity in the proportion of injuries of the upper extremities to the aggregates of casualties on various battle-fields, as indicated in the following table, is not surprising: Table XII. Collated Returns, indicating the Relative Frequency of Shot Wounds of the Upper Fxtremity, in the Aggregates treated in Hospitals. July, 1830, days in Paris and Lyons, etc. (SERRIER's table) Crimean War ( Matthew's return)...................... Crimean War (Cmenu's return).......................... Italian War of 1859 (ClIESU's return)..................... Italian War of 1859 (DEMME's estimates)................. Danish War of 18G4 (Loeffi.er's tables)................. American War of the Rebellion (S. G. O. returns)......... Franco-German War (consolidated returns')............... Totals........................................ Aggregate Wounded. Wounds OF Upper Extrem- ities. 784 7,660 34,306 19, 672 17,095 3,558 253,142 24,788 361, 005 233 2,189 10,648 6,721 6,047 927 84,718 7,916 119, 399 29.7 28.5 31.0 34.1 35.3 26.0 33.4 31.9 33.0 The main subject of this Chapter will be the shot fractures of the bones of the upper extremities, with the complications and operations thereby involved; but there will be much to be said also of the injuries implicating the soft parts, which were often followed by diffuse suppuration,2 by disquieting haemorrhages requiring ligation of the principal arterial trunks, by paralyses and pareses, and by other complications, which, in no incon- siderable number of cases, were treated by the extreme resource of amputation. It has been impracticable to do more than to approximate the relative frequency of shot wounds of the soft parts and of fractures of the upper extremities, and the distribution of the injuries, numerically, in the arm, forearm, and hand.3 1 These 24.788 cases are collected from the following authors: MACCORMAC (W.) (I. c, p. 128), 610 cases; BILLROTH and CZERXY (I. c, p. 208), 277; RurPRECHT (I. c, S. 8). 361; Muhlbauer (Erfahrungen aus dem Feldzuge, etc, in Bayerisches arztliches Intelligenzblatt, 1871, No. 31, S. 374), 1,899; Steinberg (I. c, S. 146), 8,531; Goltdammer (Bericht uber die Thdtigkeit des Reserve-Lazareths des Berliner Hiilfsvereins, in Berliner Klin. Wochenschr., 1871, S. 139), 639; Heyfelder (O.) (Bericht uber meine Wirksamkeit am Rhein, in Petersburg med. Zeitsehrift, 1871, No. 1), 226| SOCIX (A.) (I. c, p. 8), 643; MUXDY und MoSETIG (Service mid.-chir. de I'ambulance du Corps ligislatif, ,Gaz. des Sop., 1871, No. 149), 136; BECK (B.) (Chir. der Schussv., 1872, S. 160), 4,344; Fischer (H.) (I. c, S. 28), 875; KlRCHXEU (C.) (^Erztlicher Bericht, u. s. w., im Palast zu Versailles, Erlangen, 1S72), 2.099; Gl'.AF (E.) (Die Konigl. Reservelazarethe zu Dusseldorf, Flberfeld, 1872), 2'JS; SCHULLER (M.) (Kriegschir. Skizzen, Hannover, 1871), 491; GROS (F.) {Notice sur I'hopital civil, etc., de Strasbourg, Gaz. mid. de Strasbourg, 187-', No. 17), 148; Berthold (Deutsche Mil.-arzt. Zeitsehrift, 1872. B. I, S. 42P), 1,804; and 5I0S3AK0WSKY (P.) (Deutsche Zeitsehrift fiir Chir., 1872, B. I, S. 324), 1.415. 2Loeffler (F.) (Generat-Bericht uber den Gesundheitsdienst, Berlin, 1857, S. 145), in diffuse suppurations after shot wounds of the upper extremities, insists on the early opportune employment of the knife and syringe. He rebukes "the miserable custom of squeezing out pus, not yet entirely banished, though seldom observed," among the surgeons of the Danish War. Another abuse reprobated by Herr LOEFFLER in this connection is the carelessness of assistants in employing sponges, which he would gladly see superseded by some form of irrigating apparatus, in all traumatio case?: because, apart from the liability of septic infection, there is the liability of doing harm in passing sponges over tender granulating surfaces. i The statistics being 59.5, 27.7, and 12.8 per cent., respectively. 8KCT. l.| FLESH WOUNDS. 435 Section I. FLESH WOUNDS OF THE UPPER EXTREMITIES. Tire cases of this category were too numerous to permit any satisfactory analysis. Over fifty thousand cases,1 or about a fifth of all the wounded reported by name, were returned as shot flesh wounds of the upper extremities. A minute examination of the individual cases in such a series could not be attempted ;2 yet it was practicable to check the lists in various ways, to eliminate duplicated cases and such as should have been returned as fractures, to select for printing many attended by important complications, and to have warrant for some general deductions of interest. Thus, in examining two series, each consisting of one thousand carefully verified cases, taken in their order on the registers, it was found that the wounds of the left upper extremity slightly predominated, in the proportion of about six or seven per cent.3 The cases specified as wounds of the shoulder constituted over one-sixth, those of the arm one- third, those of the forearm nearly one-fifth, and those of the hand more than one-fourth of the total number of shot wounds of the upper extremities.4 Punctured and Incised Wounds.—There were sixty-nine examples of bayonet wounds of the fleshy parts of the arm, or forearm, or hand, and forty-four cases of similar injuries by other pointed weapons. There were eighty instances of sabre-cuts of the upper extremity, not involving the bones, and one hundred and sixty-four other cases of incised wounds of this region of sufficient gravity to be reported by name, and to require the confinement of the patient to hospital. About three-fourths of the patients with sword and bayonet wounds were early returned to duty,5 and among the remainder there were no examples of fatal results traceable to the injuries. Among the cases of punctured and incised wounds not inflicted in battle, a number required the ligature of the principal arterial trunks, and several of these resulted fatally. 1 The number of cases of shot flesh wounds of the upper extremities recorded on the registers of the Surgeon General's Office that are referred to this category at present (July, 1874) is 54,729, or about two-thirds of the total of 84,718 cases of shot wounds of the upper extremities. This aggregate of 54,729 cases is reached by summing up all cases of shot flesh wounds of the upper extremities entered by name, and taken from field reports and casualty lists, from the regular hospital reports, and from special reports. But it is known that a considerable number of this group of cases, recorded on the regular quarterly surgical reports from the hospitals, have not been transcribed en the registers, because it was impracticable to afford the clerical labcr requisite for comparison and entry of the cases without multiplication. In the aggregate of 87,6:22 oases of war injuries published in Circular 6, 21,248, cr about 24 per cent., were recorded as shot flesh wounds of the upper extremities. The ratio of the 54,729 cases here referred to that category to the aggregate of 253,142 registered cases is about 21 per cent. The reduction in the ratio is probably duo to the subtraction of cases of fractures and penetrating wounds. 2 The readers of these volumes are, doubtless, for the most part, conversant with muster-rolls and other statistical work, and it is hardly necessary to remind them that the advantages likely to accrue from such a critical analysis would not justify the clerical labor it would involve. The indices to the registers of shot flesh wounds of the upper extremities record 977 names of soldiers distinguished from their comrades by the name cf Smith, and Brown and Jones and other familiar patronymics appear almost as frequently, so that it was a task of magnitude to make a list of these cases, avoiding reiterations. '■> In tl.c first thousand cases, 401 were of the right and 5"4 of the left side, and 5 cf both sides ; in the seoond thousand counted, 471 were of the light, 522 of the left side, and in 7 both extremities were wounded. i The counts in the two series of a thousand cases, in which the part injured was specified, were as f.illows: Shoulder, 176 and 19G, or 18.6 per cent.; arm, 337 and 340, or 33.8 per cent.; forearm, 207 and 187, or 19.7 per cent.; hands, 280 and 277, or 27.8 per cent. 6 Of the C9 patients with bayonet stabs, 48 were returned to duty, 13 were discharged, 1 died in Andersonville prison from causes foreign to the injury, and in 7 instances the result was not ascertained. Of the 80 patients with sword-cuts, 58 went to duty, 17 were discharged, 1 died of phthisis while on furlough, and in 4 cases the termination was unknown. 4-3H injuries of the upper extremities. [chap. ix. Ligation of the Brachial Artery.—In two instances of punctured wounds of ihe arm implicating the brachial artery, the orthodox plan1 of ligating the vessel above and below the wound was successfully practised : Case 1230.—Private Welcome David, Co. D, 107th Illinois, aged 23 years, was accidentally wounded, August IS, 1861. Surgeon A. M. Wilder, U. S. V., states, in a Report of cases collected during the Campaign in Georgia, that this man received '"a bayonet thrust at the bend of the left elbow, cutting the brachial artery. The vessel was ligated above and below the wound." The patient was sent to Nashville, and tlience to Louisville, Jeffersonville, and Quincy, where Surgeons Chambers, Goldsmith, and Brinton noted his convalescence and discharge, July 2, 18(15. The second case was reported by Assistant Surgeon J. W. S. Gouley,2 who mentions the ocular demonstration of recurrent distal haemorrhage presented in the course of his operation :3 Case 1231.—"Private J. Williams, Co. A, 6th Pennsylvania Cavalry, aged 26 years, of intemperate habits', while in a Btate of intoxication resisted arrest and attempted to use violence, and one of the men of the provost guard stabbed him with his sword in the upper part of the left arm, corresponding to about the lower third of the coraco-brachialis muscle. Profuse haemorrhage followed, and was arrested by the corporal of the guard, who applied a handkerchief tightly above and another below the wound. This was so cleverly done that the patient lost no blood until the dressing had been removed two hours subsequently, September 20, 1862, when he was conveyed to the hospital for treatment. On careful examination, it was ascer- tained that the brachial artery had been wounded, and without any further delay an incision was made as for ligature of the brachial artery, and the vessel secured above and below the wound, and the portion between the two ligatures cut out. The vena? comites were also tied by reason of their having been injured at the time of the accident. With the exception of consid- erable oedema of the forearm and arm, which was controlled by bandages, the case progressed well, both ligatures having come off on the eighth day. On October 16, 1862, the patient was ordered to report for duty, entirely well. The first ligature having been applied, the wound was carefully sponged and red blood distinctly seen jetting out of the mouth of the vessel from below, and that with considerable force, showing that the application of a ligature to the artery above the wound only would have been an insufficient, incomplete operation." Ligation of the Ulnar Artery.—A single instance was reported of ligation of the cubital artery,4 remarkable because of the failure of restoration of circulation in the little finger: Case 1232.—Private S. H. Davidson, 2d Iowa Battery, aged 19 years, was wounded March 24, 1864, near Memphis, by a bowie-knife. Surgeon J. G. Keenon, U. S. V., reported that there was "an incised wound of the right wrist, opening the joint and dividing the ulnar artery. The vessel was ligated, and the wound brought together by sutures, prior to the patient's admission to the Adams Hospital. The patient was faint from loss of blood on admission. Pounded ice was applied over the wound. The operator's name was unknown." On his next quarterly report, Dr. Keenon continues the history of this case: "Dry gangrene had occurred, and a line of demarcation had formed, in the case of the patient whose ulnar artery was ligated on March 22d, and, on April 13, 1864, Surgeon Keenon amputated the right little finger and head of the corresponding meta- carpal bone. The patient rapidly convalesced, and was returned to duty June 8, 1864." Ligation of the Radial Artery.—There was a single instance, likewise, in which this vessel was ligated on account of an incised wound : Case 1233.—Private L. Pump, Co. I, 1st Mississippi Cavalrj', aged 39 years, was admitted into Adams Hospital, Memphis, July 21, 1884. Assistant Surgeon J. M. Study, U. S. V., reported an "incised wound of the anterior aspect of the left forearm, severing the radial artery; inflicted by the patient during a fit of delirium tremens. The tendons of the flexor muscles protruded. Acting Assistant Surgeon R. W. Coale ligated the radial artery. Gangrene set in thirty-six hours after the operation, and the patient died July 28, 1864." In wounds of vessels of the calibre of the radial, ligation is commonly deemed indis- pensable, yet in an instance reported by Assistant Surgeon Frantz, bleeding from an incised wound of the radial is reported to have been controlled by pressure : Case 1234.—Private 0. Jeffers, Co. B, 20th New York Cavalry, aged 18 years, was wounded at Portsmouth, Virginia, January 25, 1864. Assistant Surgeon J. H. Frantz, U. S. A., reports his admission into Balfour Hospital, from regimental hospital, February 6th, with "an incised wound of the left wrist, the radial artery severed, the haemorrhage controlled by pressure. Transferred to New York, April 26, 1864." Assistant Surgeon Warren Webster, U. S. A., reports this man's admissi.m to DeCamp Hospital, and death from intermittent fever, May 28, 1864. 1 Guthrie (G. J.), The Diseases and Injuries of Arteries, with the Operations required for their Cure, London, lr30, p. 254. 2 The portion of the artery exsected was sent to the Museum, and was numbered 854 in the Catalogue of Surgical Specimens of 1863. The specimen had disappeared on the revision of the Catalogue in 18G6. Dr. J. A. Lidell has already published this case. 3 S 'HOLLER (Kriegschir. Skizzen, lt-71, S. 33), in a case of shot flesh wound of the arm, on the appearance of intermediary hemorrhage, on the sixteenth day, successfully ligated the brachial artery high up, after an unsuccessful attempt to tie the vessel in loco. Bleeding recurred from the distal orifice of the vessel, but was controlled by compression. 4 Compare M. Fakaueuf's Pricis de Manuel Opiratoire, Ligatures des Artires, Paris, 1*72, p. 45, of which Dr. J. D. Jackson, of Danville, has printed an excellent English version: Ligation of Arteries, Philadelphia, 1874, p. 69. SECT. I.| PUNCTURED AND INCISED WOUNDS. 4:>7 There were one or two cases in which the reports convey intimations that stabs in the arm, implicating the brachial artery, proved fatal from malpractice—compression and stvptics having been resorted to instead of ligation.1 Wounds of the Palmar Arches.—There were no special reports of such cases from the Union Army,2 but an instance was found in a series of clinical reports from a Confed- erate hospital in Petersburg, transmitted by Surgeon AV. L. Baylor: Case 12:55.—"Private C. W. Iui/iwhls, Co. H, 3d Arkansas. Incised wound of superficial palmar arch and some small arteries in the palm. The bleeding was profuse and was stopped by pressure. An oblong compress reaching half-way to the elbow was laid over the track of the radial artery, commencing at the wrist, and one also over the ulnar. These were confined in place by bandage, the wound filled with lint, and the whole secured by a splint from the elbow to the point of the fingers; cerate dressings were used. The bandage was readjusted on the third day, tbe lint in the wound remaining. Tbe bleeding ceased entirely on the sixth day, and most of tbe lint was removed from the wound, which was improving. The arm was kept in a sling until about (September 24th, at which time the wound had healed, with some contraction of the palmar fascia." The treatment of wounds of the superficial and deep palmar arches3 often suggests very embarrassing questions, on which surgeons of the highest authority differ in opinion.4 The subjects of such injuries are very unfortunate if they have not the services of a surgeon possessed of the requisite skill and courage to' thoroughly explore the wound at the outset.5 In the three hundred and fifty-seven cases referred to, of this group of punctured and incised wounds of the upper extremities, there were four deaths, and forty patients were discharged for disabilities resulting from their wounds. Two of the deaths weiv from neglected arterial bleeding, and two from causes foreign to the injuries received. The disabilities of the majority of those discharged were from contractions or adhesions conse- quent on diffuse abscesses or the division of muscular or tendinous tissues. 1 For accounts of punctured and incised wounds of the upper extremities in American journals, compare: Smith (A. G.) (Operation for Aneurism of the Axilla, in Western Medical Gazette, Cincinnati, 1833, Vol. I, p. 319); White (O. H.) (Successful Ligature ofthe Subclavian Artery, in Am. Jour. Med. Sci., 1838. Vol. XXIII, p. 3»1); Weidf.xstraxdt ( Wound of Forearm; Division of the Radial Artery; Ligature; Erysipelas; Cure, in the New Orleans Med. Jour., 1844-5, Vol. I, p. G37); POST (A. C.) (Wound of the Axillary Artery and Plexus of Nerves, in New York Jour, of Med., 1845, Vol. IV, p. 171); WOOD (P. G.) ( Wound ofthe Brachial and Ulnar Arteries, Ligation, Cure, in The Stethoscope and Medical Reporter, ]85,i, Vol. I, p. 489); CtlEEVEU (D. W.) (Punctured Wound of the Wrist, in Boston Med. and Surg. Jour., 1868, Vol. I, p. 282); Gay (G. II.) (Wound of Arm with Injury of Large Vessels, in Boston Med. and Surg. Jour., 1873, Vol. X, p. 273). 1 There were but two cases of punctured or incised wounds of the palm specially reported, viz: Lieutenant J. S. Russell, 20th Missouri, treated at the Officers' Hospital at Lookout Mountain from November 14 to November 53, 1864; and Private J. W. Sowers, Co. F, 152d Pennsylvania, treated at Grant Hospital, New York, from March 10 to May 8, 1865. Evidence of troublesome arterial bleeding appears in neither case. 3 AwxoTT (C. D.) (On the Treatmentof Wounds of the Palmar Arch, in The Lancet, 1855, Vol. II, p. 141) remarks: "The principle I wish to inculcate is. that under no circumstance?, in haemorrhage from the palm, is deligation of the arterial trunks on the cardiac aspect to be deemed necessary or attempted. I am aware this will ut present hardly find general favor. I am, however, certain of my fact, and, therefore, state it boldly." 'Professor VOX PlTHA (Die Krankheiten der Extremitaten, in V. PlTHA und BILLROTH, Handbuch, u. s. w., 1868, B. IV, Abth. I, Heft II. S. 116): "I saw several cases of exceedingly rebellious bleeding from cuts and stabs of the palm ; two of these were brought to me, after numerous ineffectual attempts to stop the bleeding, in a profoundly anaimic condition, yet I was never forced to practise ligation, as the bleedings ceased, on removal of coagula, completely and permanently. * * The first thing to be done in such cases is to freely expose the bleeding vessel by enlarging the wound, and to boldly clear away all coagula. The irritation caused by the sponge and the admission of cool air frequently induces the gaping arterial wound \o retract. The wound should not be immediately closed, but should be kept under close observation fjr some time." 6Professor GltOSS (System, etc , I. c, 5th ed., Vol. I, p. 808) and Dr. AGXEW {Med. and Surg. Reporter, Philadelphia, 1873, Vol. XXIX. p. 3C7) advise that the general rule for the treatment of wounded arteries shall not be deviated from here, and that in recent punctured or incised wounds of the palmar arches the wound should be enlarged and both ends of the bleeding vessel tied, and the editor, for one, heartily applauds this advice. Mr. Bryant (The Practice of Surgery, 1872, p. 223), while sanctioning such practice in wounds of the superficial arch, believes that in deep wounds "it is neilher expedient nor justifiable to explore the palm for the purpose." But the neglected cases are those that present the real ditficulties, aud in these, as Velpeau (Nouveaux Elimens de Mid. Opir., 1839, T. II, p. 173) remarks, " tout riussit et tout eohoue contre elles"—compression, cauterization, acupres- sure, the ligation of the radial or ulnar or of both, and the ligation ofthe brachial, have all been employed, with reported successes and failures. VKl.rr.AU, at the place quoted, cites many references on this subject, which it would be superfluous to recapitulate; but the student may bo reminded, in addition, of JListox's observations (Elements of Surgery, 2d ed., 1840, p. 486); of an important paper by BOECKEL, in the Gazette Midicale de Paris, 1862, No. 3; of another by C'ltOLV (G. H.) (Wounds of Arteries in the Vicinity of the Wrist and Foot, 18(58); and of one Strasbourg and four Paris theses, viz: Balaxsa (Deshimorrh. traumat. de la main, 1852); DROUET (Desplaies et des himorrh. traumat. de la main, 1855); PlREYRE (Himorrh. artir. traum. de la main, Paris, 1863); Legueiix (Plaies de lapaume de la main, Paris, 1864); NAIL (Des himorrh. traum. de la main, Strasbourg, 1860); and of the following additional references: COOPER (A.) (Lectures, 1829, Vol. Ill, p. 195); Berard (A.) (Plaies de la main, in Diet de Mad., 1808, T. XVIII, p. 527); Aknott (D. C.) (Tlie Lancet, 1858, Vol. II, p. 445); SKEY (C.) (Report of a Case of Wound of the Palmar Arch, in The Lancet, 1850, Vol. I, p. 574); Savory (Wound of the Palmar Arch, in The Lancet, 1855, Vol. I, p. 653); Nelaton (Slim, depath. chir., 1859, T. V, p. 911); Horteloup (P.) (Du traitement des himorrhagies de la main, in Gazette hebd., March 27, 1868, p. 194); Caradec (L.) (Blessures et plaies de lapaume de la main gauche par des fragments de vcrre, etc., in Gazette hebd., 1868, T. V, p 2G4); Levy (E.) (Hf.morrhagics de la paume de la main arrities au moyen de Veponge priparie. 1869); Middeldoupf (Die percutane Ligatur, in Preuss. Milit. Zeitung, 1862, S. C); M.viaix (G.) (Eludes sur les plaies artirielles de la main et de la partie infirieurede Vavant-bras, in Gaz. des Hop., 1870, No. 2). A sensible discussion of the treatment of these difficult cases maybe found in the Boston Med. and Surg. Journal. 1847, Vol. XXXVI, p. 169: ELL6WORTH (P \V.) (Wound of the Palmar Arch). 438 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. Shot Wounds.—Of the vast number of cases included in this category, many were complicated by injuries of the trunk. Projectiles perforating the soft parts of the arm often wounded the thoracic or dorsal parietes or penetrated the chest, and wounds of the forearm and hand were frequently associated with superficial or deep wounds of the abdomen. Only the wounds limited to the soft parts of the upper extremity will be considered here.1 Perhaps the most interesting of these were the cases attended by lesions of the larger arterial or nervous trunks, cases that possibly cannot be strictly denominated flesh wounds, yet are conveniently classified under this head. There were numerous cases, however, in which the bones and the principal vessels and nerves escaped, that were attended by such destruction of skin, muscle, tendon, or ligament, as resulted either fatally or in very serious disabilities; and there were cases complicated by gangrene or by tetanus, and even instances in which amputation was practised for complicated injuries involving only the soft parts. Instances of each group will be cited. False Anchylosis?—Contraction and rigidity of the parts was an almost constant result of serious shot injuries of the soft tissues of the upper extremity, frequently attended by distortion of the limb, often by disordered sensation, and always by impairment of motor power. The following are examples : Case 1236.—Sergeant C. Newbert, Co. F, 2d Missouri, was wounded at Stone River, December 31, 1862, and was treated in hospitals No. 1, Murfreesboro', and No. 19, Nashville. Surgeon J. W. Foye, U. S. V., noted: "Gunshot wound ofthe left arm near the shoulder; loss of use of the elbow joint; atrophy." This soldier was discharged May 21, 1833, and pensioned. Examiner J. B. Colegrove, of St. Louis, reported, May 28, 1863: "Gunshot wound ofthe left arm four inches from the shoulder joint, the ball passing through the soft parts without injuring the bone, destroying the deltoid muscle, the injury resulting in almost total loss of use of the arm and partial anchylosis at the elbow joint." Examiner W. M. Chamberlain reported, July 20, 1883 : *'Nearly the whole of the deltoid muscle was cut out by a cannon ball; the joint is anchylosed by contraction of the soft tissues, and the upper arm is useless." The pensioner was paid to March 4, 1874. Case 1237.—Corporal J. S. Stevenson, Co. K, 20th Indiana, aged 23 years, was wounded at Gettysburg, July 3, 1833, aud was admitted to Satterlee Hospital on July 5th. Surgeon I. I. Hayes, U. S. V., noted: "Ball entered in front of the radius at the wrist joint and passed upward, traversing the fascia, and lodged at the inner side of the elbow joint." Stevenson was transferred to the Veteran Reserve Corps December 31, 1363, and discharged the service July 15, 1834, and pensioned. Examiner G. W. Moars, of Indianapolis, reported, July 15, 18j4 : "Ball entered anterior and inner surface of the forearm just above the wrist, and, ranging upward, made its exit on the anterior and outer surface of the arm at the elbow joint, iu its progress slightly injuring the lower end of the radius, otherwise making an extensive flesh wound; this is now healed, but the arm is still weak and slightly flexed at the elbow." Examiner T. Blakeslee reported, September 5, 1873: "The ball traversed the entire length of the forearm ; there now exists partial anchylosis of the elbow joint and slight contraction of the flexor muscles over the wrist; disability one-third." Hippocrates nearly approached the truth, probably, when he asserted that the more highly organized tissues after injury were repaired, but were not regenerated or reproduced as they were before;3 yet his doctrine was forgotten for centuries, until revived by Fabre 1 Socix' (A.) (Kriegschir. Erf, 1872, S. 101) says : "It is an error to believe that such wounds might be left in inexperienced hands, or that they heal without careful treatment. When a shot track passes through several superimposed layers of muscles, care is to be had that the injured parts do not displace themselves and obstruct the suppurating canal. Such displacements are of advantage only at the moment of injury, when, in some instances, they may prevent the admission of air and preclude all suppuration. Such examples of primary healing, although not extremely rare, are yet excep- tional, and it is preferable to see from the start that the entire shot track remains open. Primary prophylactic draining of all long flesh shot tracks, even, may well be justified. If this be not done, and should hardships of all kinds, such as bad quarters, tedious transportation, cold during the first days, and so forth, exert injurious influences, the results will be acute inflammatory cedema, ichor, progressive suppuration along the fascia, and fever with pyEemic chills, and the slightly wounded man' will become 'an extremely sick patient' before he reaches the reserve hospital. An early deep incision into the abscesses that have formed, and a suitable position, combined with absolute rest of the injured part and a complete disinfection cf the wound, will generally avert the threatening perils. But suppuration may continue for months. The frequent presence of various foreign bodies, such as small pieces of clothing, contribute to defeat a favorable result. The injuries inflicted by the so-called tabatiere ball of large calibre appear to be especially liable to such complications. I found them comparatively frequent in the muscular tissues; their heavy weight ('!."> grammes), and perhaps the construction ofthe altered Snider gun. from which they are fired, are perhaps the causes of their low propulsive power. The missile has a large cavity, usually filled with a pasteboard wad, which separates from the missile, remains lodged, becomes impregnated with wound secretions, and causes extremely fetid pus-forma- tions. It also frequently occurs that this very blunt projectile carries with it into the wound large pieces of clothing." 2 Prom ay/ciiAos, crooked, curved (ayth, placed upon a water-bed and ordered nourish- ing diet, iron, quinine, and wine. The patient continued to mend until six o'clock a. m., September 1st, when haemorrhage occurred from the subclavian artery, and before assistance could be rendered the man died from loss of blood. Seclio cadaveris twenty hours after death : A neat dissection was made of the artery with its anastomosing branches. A plug, about one inch and a quarter in length and to all appearance well organized, was found at the proximal side of the ligature; the ligature camu away by making slight traction. The haemorrhage was found to have come from a small branch on the distal side of the liga- ture, which freely anastomosed with the supra-scapular branch of the thyroid axis. Pressure had been made on the proximal side of the ligature without stopping the haemorrhage. A specimen preserved to be forwarded to Washington," was not received. Cask 1248.—Sergeant K. O. Gates, Co. iM, 1th New York Artillery, aged 22 years, was wounded at Cold Harbor, June 4, 1864. lie was sent, June 7th, to Fairfax Seminary Hospital, and thence, on June 10th, to Mower Hospital. Surgeon J. Hopkinson, U. S. V., reported: "A shot wound at the upper third ofthe right arm, the ball passing antero-postoriorly; the wound sloughed, .and secondary haemorrhage from the brachial ensued June 25th. The patient was placed under chloroform, and Acting Assistant Surgeon W. P. Moon ligated the axillary artery. The patient did well until June 30th, when slight bleeding recurred. This was arrested by compression. On .July 1st, haemorrhage arose from the axillary, the artery having sloughed at the point of ligation. Acting Assistant Surgeon T. G. Morton enlarged the wound made for ligating the axillary, and tied the subclavian high up in the axilla; no anaesthetic was used; the patient was ensanguined, having lost about thirty ounces of blood, and, though stimulants were freely used, died in one hour after the operation." The specimen (FlG. 365) is "a wet preparation of the brachial, axillary, and subclavian arteries, the two latter ligated for secondary haemorrhage." (Cat. Surg. Sect, A. M. M.. p. 454.) It was contributed by Acting Assistant Surgeon W. Scott Hendrie. Only the subclavian and axillary portions of the vessel are shown in the wood-cut, the distal end of the preparation being disorganized to that extent that it is difficult to determine what of the lesions and ligatures should be dated as ante mortem, and what were due to the dissector or anatomical preparer. The abstract of the fourth, and perhaps the most interesting, of the cases of ligations of the subclavian for shot wound unattended by fracture, is relegated to a future chapter, wliere the instructive illustrations belong- ing to it can also appear, in connection with other important observations of traumatic axillary aneurism1 afforded by the experience of the War. It will avoid iteration to refer here cursorily to the treatment and literature of wounded arteries2 as related to shot injuries of the axilla. In this work, the lower margin of the first rib is regarded as the line of demarcation between the subclavian and the axillary trunks. The reader who has consulted the twenty-five abstracts of cases of ligation of the subclavian in the First Surgical Volume need not be reminded that several might have been classified3 with injuries of the soft parts of the upper extremities with as much propriety as with wounds of the chest. A summary of all of the ligations of the sub- clavian reported during the War will be presented further on. Fig. 365.-Prepara- tion of the right sub- clavian ariery and branches, ligated in the continuity. Spec. 2545. 1 .Socix (Kriegschir. Erf, 1S72, S. 49) gives three interesting c;ises of shot flesh wounds ofthe upper extremities with injuries of the blood-vessels, all terminating fatally. In the first, a shot perforation through the axillary folds, primary bleeding ceased spontaneously. On the eighth day there was no radial pulse. On the tenth day there was secondary bleeding, which was checked, but recurred during the night; digital compression of the sub- clavian was maintained for twenty-two hours ; then ligation of the axillary above and below the injury was practised. Gangrene supervened, and the case terminated fatally on the seventeenth day after the injury. The second case was likewise a shot perforation of the axilla, with intermediary b&morrhages on the fifteenth, sixteenth, and seventeenth days, when the subclavian was tied outside the scaleni. Bleeding recurred five days subse- quently, and, though temporarily arrested, proved fatal on the twenty-sixth day after the injury, the ninth after the ligation. The third case was an example of consecutive traumatic aneurism. A ball passing through the scapular fold of the axilla and the upper arm injured either the axillary or brachial high up. Long afterward axillary aneurism supervened, and four months aud a half from the date of injury the radial pulse disappeared. The subclavian was then tied. Tliere was recurrent haemorrhage on the twelfth and thirteenth days after the operation, and death on the fourteenth. 2 An interesting Report of a Case of Axillary Aneurism, by Surgeon C. McDorOAl.E, I1. S. A., was communicated in 1841, by Acting Surgeon fleneral II. L. HEISKEIX, to The Maryland Medical and Surgical Journal, 1811, Vol. II, p. 52. Dr. McDougai.i. tied the left subclavian of Private J. Kane, aged 24, of Co. K, 4th Artillery, for complication attending a shot wound of the axilla. The case terminated fatally a week subsequently. The late Dr. Norr, of Mobile, has recorded the case of C. L. Church, the left subclavian tied November 27, 1838, for false consecutive axillary aneurism ; the patient lived till April, 1841—(NOTT, J. C, Ligature of Subclavian Artery for the. Cure of Axillary Aneurism caused by Gunshot Wound, in Am. Jour. Med. Sci., 1841, N. S., Vol. II, p. 111). The student will of course consult Herr KOCH'S table (Ueber Unterbindungen und Aneurysmal der Arteria subclavia, in Laxgexheck's Archiv fiir Klinisehe Chirurgie, Herlin, 18(>9, P>. X, .S. IIT>). Dr. G. XV. Nonius's statistics (Contributions to Practical Surgery, 1873, p. 222), the paper (in Guy's Hospital Reports, 1870, Vol. XV, p. 47) by the lamented POLAND, and the Report by Drs. PARKER, NORMS, Akmsijv, and Missey, in the eighteenth volume of the Transactions of the American Medical Association, 1807, p. 239. Other references to shot wounds in the axillary region without fracture, with ligation of the subclavian, are those of MOTT (V.) (Case in which the Right Subclavian Artery was tied just as it passes the Scaleni Muscles, for an Aneurism of the Axilla, from a Gunshot Wound, in New York Jour, of Med.. 1845, Vol. IV, p. 16); WATSOX (J.) (Case of Gunshot Wound in Left Axilla—Ligature of Left Subclavian, and, subsequently, Ligatures of Brachial and Subscapular Arteries, in Am. Jour. Med. Sci.. 1851, N. S., Vol. XXI, p. 294). 3On p. 539 et seq. of the First Surgical Volume, Cases 4, 7, 10, 12. 13, 14, 15, 1G, IP, 19, 20, 21, 22, of the series of cases in which the subclavian was tied, were instances in which the soft parts only were implicated, soft parts referable indifferently to the chest or upper extremity. 56 412 INJURIES OF THE UPPER EXTREMITIES. [CM A P. IX. Ligations of the Axillary Artery.—There were fifteen ligations of the axillary because of shot flesh wounds of the upper extremities—with three recoveries and twelve deaths. It is noticeable that it was the right axillary that was thrice successfully tied, and that of the twelve fatal cases, eight were operations on the left axillary. One fatal case was a ligation on the right side, and in three cases the seat of ligature was not recorded : Case 1249.—Corporal P. Yoho, Co. F, 116th Ohio, aged 30 years, was wounded at Winchester, September 19, 1864. Surgeon D. Baguley, 1st West Virginia, reported a gunshot wound of the arm and back, and the patient's transfer to McClellan Hospital on September 27th. Acting Assistant Surgeon R. E. Brown reported : "A gunshot flesh wound of the middle and outer side ofthe left arm and left side ofthe back, by a mini6 ball. The wound was in a sloughing condition at the time of his admission. He had intermediary hasmorrhage on Octo- ber 4th, 5th, 6th, and 7th. The total quantity of blood lost was supposed to amount to thirty- six ounces. The first three haemorrhages were controlled by a saturated solution of alum and persulphate of iron, and compresses of lint. The last hsemorrhage was so great that it became necessary to use the tourniquet to control it; during the day the entire arm and hand became excessively congested and inflamed, and the parts being in such a condition as to endanger the life of the patient, it was concluded, at the suggestion of Acting Assistant Surgeon E. Harts- horne, that Acting Assistant Surgeon W. L. Wells should ligate the left axillary artery at its third portion, which was done in a successful manner. The constitutional state of the patient was not good at the time of the operation; he was subject to intermittent fever, and was much debilitated. He seemed to progress favorably, and the wound began to look healthy until one week after the date of operation, when pyaemia set in aud the discharge from the wound became very vitiated. The appearance of the wound became more abnormal, and the man gradually sank, dying on October 22, 1834. Examination proved that death was caused by pyaemia. The pleural cavity of the right side was literally filled with pus, and three small abscesses were found in the right lung." The specimen (FlG. 335), contributed by Surgeon Lewis Taylor, U. S. A., is a wet preparation of the left axillary artery, ligated in its third portion for secondary hsemorrhage. The artery is patulous, having been cut through by the ligature, which came away after death. Case 1230.—Corporal S. Richards, Co. M, 11th Pennsylvania, aged 25 years, was wounded at Ream's Station, August 25, 1884, and, on the 29th, was admitted into Mower Hospital, Philadelphia. Surgeon Joseph Hopkinson, U. S. V., noted: "Gunshot wound ofthe middle third of the left arm; the ball entered at the inner side of the arm, passed upward, and was extracted from the axillary space, on the field. The wound sloughed and secondary hsemorrhage occurred; and on September 5th the patient had lost about fifteen ounces of blood. On that date, Acting Assistant Surgeon W. P. Moon ligated the axillary artery in its continuity, using chloroform as an anaesthetic. The patient was in good condition at the time, and reaction was prompt. Simple dressings were applied to the wound, and stimulants administered freely. Profuse haemorrhage set in on the 11th, due to sloughing of the artery at the point of ligation; the patient was very weak, and almost pulseless, from loss of blood. The wound was at once enlarged and the axillary ligated farther up. On September 14th, diarrhoea set in with violence; from that time the man failed rapidly, and died September 18, 1884." The bleedings which necessitated these ligations were, in most cases, intermediary, occurring in the second or third week after the reception of the wounds. In three only of the series of fifteen cases1 was the interval from the date of injury to that of hsemorrhage greater than thirty days. Case 1251.—Lieutenant-Colonel M. M. Dawson, 100th Pennsylvania, aged 38 years, was wounded at Petersburg, June 17, 1884. Surgeon M. K. Hogan, U. S. V., reported, from a Ninth Corps hospital: "A shot wound of the left arm and left side of thorax; the ball extracted, and the patient sent to "Washington June 19, 1834." From Armory Square, Surgeon D. W. Bliss, U. S. V., reported: "A gunshot wound of the left shoulder, with contusion of the right breast. On June 27th, secondary haemorrhage occurred to the amount of thirty ounces. The operation of tying the axillary artery was performed. After ligating the proximal extremity, haemorrhage continued. The distal extremity was then secured by tying the brachial. A few hours after, haemorrhage burst out afresh, and finally the patient died." CASE 1252.— Sergeant F. Oldfield, Co. D, 10th Michigan, aged 33 years, was wounded at Atlanta, July 22, 1864. Not until August 7th was he received at Cumberland Hospital, Nashville. Surgeon B. Cloak, U. S. V., reported: "A wound of the upper third of the left arm. On August 10th, Acting Assistant Surgeon James C. Thorpe ligated the axillary artery just above the anterior circumflex. At the time, the parts were gangrenous and the patient was suffering from irritative fever. Nitric acid was effectively employed for the removal ofthe gangrenous parts. Tonics and stimulants, with good diet, were given, but with little benefit. The patient succumbed, from irritative fever, August 16, 1884." Fig. 366.—Preparation of an axil- lary artery a fortnight subsequent to ligation. Spec. 3G79. 1 The bleedings were on the thirty-second, thirty-fourth, and thirty-ninth days, in these three cases; in the remaining cases, the haemorrhages occurred from the seoond to the twentieth day, viz , in 15, 12, 10. 19, 7, 20, 17, 5, 6, 10, 11, and 2 days. SECT. I.] SHOT PLESH WOUNDS. 443 The two following abstracts are gleaned from the scanty reports of the Confederate hospitals, filed in the War Department: Case 125;?.—Private If. C. Moon. Co. A, 26th Georgia, was wounded in May, 1881 (probably at Spottsylvania), and was admitted to a Confederate hospital in Charlottesville. Professor J. L. Cabell recorded: ''Gunshot wound of the left arm. On May li'lh, secondary haemorrhage occurred, and the axillary artery was ligated. Gangrene supervened, and the arm was amputated at the shoulder joint on May 23d. The patient died on the same day." Case 1254.—Private W. A. Uaggs, Co. K, 20th Georgia Cavalry, wounded in June, 1884 (probably at Cold Harbor), was sent to Charlottesville. Professor J. L. Cabell recorded: "A gunshot flesh wound of the arm. On June 23d, secondary haemorrhage from the axillary artery supervened, recurring at intervals on the 24th, and, on the 25th, the artery was ligated. This patient died June 28. 18.14." In a seventh case of ligation of the left axillary for shot wound interesting the soft parts, disarticulation at the shoulder was resorted to unsuccessfully: Case 1255.—Private J. Lightfoot, Co. E, 25th Massachusetts, aged 28 years, was wounded at Petersburg. August 10. 1884. Surgeon J. B. Morrison, U. S. V., reported, from an Eighteenth Corps hospital, "a shot wound of the left shoulder.'' On August 17th, this patient \v:is sent to Satterlee Hospital. Acting Assistant Surgeon L. K. Baldwin described the injury as resulting from " a musket ball, which entered the edge of the pectoral muscle, passed through the axillary space, and emerged near tbe edge ofthe scapula. The wound, at the time of admission, was apparently very slight and doing well. He continued to improve until August 27th, when a slight secondary haemorrhage occurred from the wound of entrance, easily controlled by compression. Another haemorrhage, of a much more serious nature, occurred on the 29th, also controlled by compression of the subclavian. An aneurism now began to form in the axillary and in front of the shoulder, which increased gradually until September 17th, when the shoulder and parts in front of it were increased to more than twice their natural size. Great pain was also experienced from the tension of the parts and from the pressure on the axillary plexus of nerves; the arm was entirely paralyzed. After a careful examination, it was deemed advisable to lay open the parts and to ligate the injured vessel. An incision was made over the line of the axillary artery, which revealed, as soon as the tissues were divided, an immense clot, containing more than a half gallon of blood, which was turned out, exposing the artery for nearly its whole length. Au opening was found in the artery, near its middle, caused by one side of the artery having been injured by the ball in its passage, having afterward ulcerated through. Ligatures were placed on the artery both above and below the seat of injury. The patient rallied well after the operation and continued quite easy for several hours; but the arm being deprived of its source of nutrition, very soon began to show signs of gangrene, and, at the same time, to become quite painful. Things continued to grow worse, and forty-eight hours after the artery was ligated the arm was covered with blebs and was in a state of mortification, and it was deemed advisable to amputate it at the shoulder joint. This was done on September 19th, forty-eight hours after the ligature of the artery. The patient rallied after the operation, but sank and died at eleven o'clock that night. No autopsy was made." Specimen 3630 (Cat. Surg. Sect, p. 459) is reported to have been derived from this case. It is a wet preparation, "showing great loss of substance from sloughing." The preparation as dissected and mounted is uninstructive. The abstracts of the next three cases, of ligations on the cardiac side of wounded arteries, may be recorded for instruction rather than for imitation. The administration of stimulants to bleeding men is a wretched substitute for the observance of Guthrie's excellent precepts ■} Case 1256.—Corporal F. Hurd, Co. F, 8th Maine, aged 24 years, was wounded at Fort Darling, May 16,1864, and sent to Mower Hospital. Surgeon J. Hopkinson, U. S. V., reported that: ''The ball entered the biceps and passed obliquely upward and inward, under the humerus, and'emerged about two inches below the axilla. May 21st, wound sloughing; secondary haemorrhage occurred from the left brachial artery, eighteen ounces of blood being lost. The patient was much prostrated from excessive discharge and loss of blood. Acting Assistant Surgeon W. P. Moon enlarged the anterior wound and ligated the proximal end ofthe brachial artery. * * The wound still continued to slough, and, on June 1st, haemorrhage recurred from the brachial artery above the ligature, thirty ounces of blood being lost. Acting Assistant Surgeon 8. II. Jamar administered ether and ligated the axillary artery. There was no reaction, and the patient died June 1,1864, eight hours after the operation." Case 1257.—Private Emanuel D. Miller, Co. F, 90th Pennsylvania, was wounded at Bull Run, August 30, 1862, aud was forwarded to Washington, where he was received into Mount Pleasant Hospital on September 1st. Assistant Surgeon C. A. McCall, U. S. A., noted: "Gunshot flesh wound of the arm. Secondary haemorrhage from the brachial artery September 5th. Ligation of axillary artery September 6th. No recurrence of haemorrhage. Collateral circulation established. Brandy and quinine administered. Death from exhaustion, at seven o'clock P. n., September 12, 1882." Case 1258.—Private F. Friedeboldt, Co. F, 5th Michigan, was wounded at Fair Oaks, May 31, 1852. On June 4th, he was admitted into Judiciary Square Hospital, Washington. Acting Assistant Surgeon C. G. Page reported: "The ball passed through the posterior portion of the upper arm without injury to the bones—extensive ecchymosis. June 10th, a free arterial haemorrhage occurred; on removing the clots, extensive disorganization ofthe soft parts was found. The wounded brachial was not accessible. The axillary artery was tied high up. The subscapular was found very far forward, and was tied to prevent subsequent trouble. June 21st, both ligatures came away ; feeble pulse detected in the radial artery. June 23d, a very profuse haemorrhage occurred from the brachial, which was stopped by compression by a pad in the axilla Troublesome haemorrhages occurred on July 12th and 13th, and the patient died July 14, 1862." ■GUTHRIE, Commentaries, etc., 5th ed., 1855, p. 242 and p. 252, and Dis. and Inj. of Arteries, 1830, passim. ■144 INJURIES OF THE UPPER EXTREMITIES. [CH.\I\ IX. Bcrard has well pointed out1 that there is a wide discrepancy in the anatomical and surgical acceptations of the limits of the subclavian and axillary trunks. Hence a con fiii-ion of language, and a necessity to choose between the nomenclature of the anatomists and that of the surgeons. Berard decides to follow the former; but it would appear more just that the opinions of practitioners on the living subject should prevail. Case 1259.—Private D. Smith, Co. C, 6th Pennsylvania Cavalry, aged 29 years, was wounded at Trevillian Station, June 12, 1854. Surgeon W. H. Rulison, 9th New York Cavalry, reported from a Cavalry Corps hospital, "a gunshot wound ofthe left arm; serious." On June 21st, the patient was admitted into Finley Hospital, Washington. Surgeon G. L. Pancoast, U. S. V., noted, "a gunshot wound of the left arm; ball not extracted. Transferred June 28th." On June 29th, this soldier was admitted into Cuyler Hospital, Germantown. Assistant Surgeon H. Schell, U. S. A., reported: "A gunshot flesh wound of the left upper arm, apparently slight. The wound of entrance healed, that of exit nearly so ; arm very painful, and enlarged at its upper third. July 16th, a traumatic aneurism of the left brachial artery had formed, which was first perceived about July 10th; the arm was greatly swollen and very painful, of a dusky hue, and threatened with gangrene. A superficial abscess had formed spontaneously. The patient was feverish and irritable from pain produced by rapid swelling of the arm. Acting Assistant Surgeon J. M. Leedom administered chloroform and ether, and ligated the brachial artery by the 'old operation' for aneurism, the sac being freely laid open, the clots turned out, and the vessel tied above and below its opening into the sac; haemorrhage twenty ounces; extent of incision four and a half inches. The patient had a pysemic rigor on July 17th, which did not recur. The wound was suppurating profusely. On July 21st a copious haemorrhage took place, twenty-one ounces of blood being lost. The bleeding was treated precisely as a secondary haemorrhage from a wound, the vessel being freely exposed and ligated above- and below the bleeding point by Dr. Leedom. July 25th, patient much worse; slight delirium; pulse 102; urine drawn off by catheter. July 26th, patient quite delirious. Sphincter relaxed, and involuntary discharges. Erysipelatous blush over arm and clavicular region. Ligatures all came away this morning. July 29th, consciousness fully restored; wound doing well. Bed- sore on inner condyle; the bone exposed. The haemorrhage recurred on July 29th, aud again on July 31st, and August 2d and 3d, sixteen ounces of blood being lost. On August 3d the artery was again ligated in the axillary space. August 5th, bleeding to the extent of six ounces. Patient exhausted and depressed by repeated haemorrhages and by suppuration; sloughing abscesses following erysipelas Assistant Surgeon H. S. Schell amputated the left arm at the shoulder joint—flap from deltoid. The ligature of the 3d instant w;is left on the axillary artery. August 6th, haemorrhage to the extent of eight ounces. Stump opened; blood apparently oozing from the tissues, and was checked by pressure and Monsel's salt. August 7th, ligature came away from the axillary artery at twelve o'clock M., a gush of blood following. The artery was immediately tied again, by Dr. Ashhurst, about three-fourths of an inch higher up, the incision being extended toward the clavicle. Haemorrhage again occurred at eleven o'clock P. M. The vessel was again tied by Dr. Rohrer. August 8th, six o'clock P. M., ligature again became detached from the axillary artery, which was now tied still higher up, in fact almost up to subclavian region. The patient survived about two hours. The constitutional treatment employed throughout was profound quiet, with nutriment and stimulus graduated according to his condition." Ligation of the axillary artery was only an incident in the next terrible case of pyaemia with pus formation in various large joints: Case 1260.—Private W. Raper, Co. G. 5th North Carolina, was wounded at Williamsburg, May 5, 1862. On May 9th, he reached Hygeia Hospital. Surgeon R. B. Bontecou reported: "Admitted with amputation of the right leg and a gunshot wound of the right arm, the ball entering at the outer border of the biceps in the lower third and emerging behind its inner border. The leg stump looked sloughy and was attacked with erysipelas. He was removed to a separate room in a distant portion ofthe building. Recovering from this, he was returned to one of the surgical wards in the early part of June, and soon complained of an abscess occupying the anterior of the right shoulder. There was little pain except on motion of the arm, but the swelling was large when my attention was called to it, and although the integuments were not discolored, yet fluctuation was so apparent and the walls so thin, I opened it, and a very large amount of pus, eight ounces, escaped. Three days after this, the assistant surgeon on duty enlarged the opening, and pus flowed again freely, and in few a hours quite a smart haemorrhage occurred, which was repeated. I enlarged the opening, which was a little to the outside of the long head of the biceps, and could not find the bleeding point. Carrying my finger down the arm, I discovered a sinus suppurating, which led beyond my reach. This I iu'stantly laid open and followed to its apparent termination, about one inch from the gunshot wound of the arm, which had long since healed externally. Failing to find any wounded vessel, I ligated the axillary as high up as I could reach it, and the haemorrhage ceased. Death ensued the day following (June 14, 1882), from exhaustion, and the post-mortem revealed an ulceration of the brachial artery at the situation of the bullet wound, in the lower third, communicating with the abscess above by a sinus along the edge of the biceps. The whole joint was disorganized and denuded of its cartilage; the scapula seemed to float in an inner abscess: the periosteum throughout its whole extent was nearly separated from it. This was likewise the case with the left scapula and joint, and the hip joints, each, were distended with pus." In ten of the twelve foregoing cases of ligation of the axillary, proximal ligatures only were applied. In three of the cases consecutive amputation was resorted to unavail- inglv; but this resource was successfully employed in one of the three succeeding fortunate cases. References to the copious literature of wounds of the axilla are omitted here. ■B^RAKD (P. H.), Article Vaisseanx Axillaires. in Dictde. Mid., 1833. T. IV, p. 48.x SECT. l.| SHOT FLESH WOUNDS. 445 Tlie reports of pension examiners give some details of the three cases of recovery in this series.1 In the iirst, a proximal ligature was applied twelve days after the reception of the injury; in the second, proximal and distal ligatures wore placed one month after the shot perforation in the axilla; in the third, a proximal ligature was placed a week after the injury, and, hoemorrhage recurring, the arm was amputated: Case 1201.—Private W. Sobliee, Co. G, 61st Pennsylvania, aged 29 years, was wounded near Fort Stevens, July 12, 1 flJ4. Assistant Surgeon C. A. McCall. U. S. A., reported that "this soldier was received, July 13th, at Mount Pleasant Hospital, with a shot fleeh wound of the right arm, a perforation of the fleshy parts, hy a minie ball, from before backward and inward- On July 23d and 24th, luvmorrhage from the brachial artery supervened. Weeding recurred four times, at least twelve ounces of blood heing lost. On July 24th, Acting Assistant Surgeon A. Transne attempted to tie the brachial artery, which was found in such a condition as not to admit of ligature. The incision was extended in the axillary space, and the axillary artery was ligated. The incision measured three and a half inches. The arm was much swollen from compression by a tourniquet." The patient was transferred to Satterlee Hospital on August 9th, and was discharged November 10, 1884. Captain C. H. Bewley certified, January 30. 1869. that "the ball severed the main artery,'' and that "a handkerchief was tied immediately above the wound to stop the flow of blood." Examiner J. Cummiskey reported, April 24, 1869: "Wounded by a ball passing through the upper portion of the right arm, making a flesh wound only, but injuring the brachial nerve. The limb is very weak, and at times he sutlers considerable pain." The Pension Examining Board at Philadelphia reported, September 13, 1^73: " Shot wound of the right arm, inner side, at upper third. Ligation of the brachial artery. No pulsations in either radial or ulnar. Hand numb in cold weather." Cask 1262.—Private A. E. Williams. Co. B, 7th Michigan, aged 27 years, was wounded at Gettysburg, July 2, 1863. Surgeon D. W. Maull, 1st Delaware, reported, from a Second Corps hospital, a "shot wound of the right shoulder," and Surgeon A. J. Ward, 2d Wisconsin, noted the patient's transfer to Mower Hospital on July 7th. Surgeon J. Hopkinson, U. S. V., reported: "Flesh wound ofthe upper third ofthe arm. On August 4th, there was haemorrhage from the axillary artery, which was ligated deep in the axilla, both ends being tied.'' The ward case-book furnishes the following notes: "Wounded in the middle third of the left arm and in the left side by a musket ball; a flesh wound. On July 7th, the discharge was profuse and offensive. The wounds were touched with creasote and wetted by a lotion of sulphate of copper. Good diet, iron, and brown stout were ordered. On July 21st, the entrance wound in the arm continued to discharge and looked badly. * * At ten o'clock at night, on August 3d, haemorrhage commenced from the brachial artery, which was taken up. On August 4th, the patient was transferred, at the ward surgeon's request, to surgical ward No. 35." This soldier recovered, and was returned to duty Apri] 25, 1864. and discharged July 7, 1834, and pensioned. In the declaration of the pensioner, made June 22. 1868, he states that he " was shot in the under side of the left arm," and "that about a month afterward the main artery of the arm became severed by sloughing off, when said artery was taken up. The arm, in consequence of said wound and the severing of the large artery, is very weak, nearly useless, and partially paralyzed; having but little sense of touch or feeling." Dr. M. S. Downer certified, June 14, 1869. that he had treated the pensioner: "The deltoid muscle is severed from the bone and the axillary artery is sloughed off. There is no pulse in the wrist whatever; the arm is partially paralyzed, the fingers are stiff, and in consequence of said wound the arm is nearly useless." Examiner D. F. Alsdorf, of Corunna, reported, September 5, 1873: "Ball entered the left side just below the scapula and passed through the posterior part of the axilla and through the fleshy part of the left arm. The wound was followed by extensive gangrene of the arm, which destroyed tbe muscles and left a large cicatrix with adhesions. The three lesser fingers are a little numb and not strong, and tbe arm weak and painful if used for hard labor." Case 1263.—Private T. Vancellete, Co. D, 3d Vermont, aged 21 years, was wounded at Lee's Mills, April 16. 1862. and was sent to Fort Monroe. Surgeon R. B. Bontecou, U. S. V., reported : "Admitted here with a gunshot wound of the middle of the right arm, the bullet entering the outer side of the biceps, and passing between that muscle and the humerus, escaped poste- riorly through the triceps. There was great swelling of the arm and forearm, with exceedingly feeble pulse at the wrist in that arm. The wounds of the integuments and fascia did not at all correspond, aud the fascia was distended with decomposing clots from the axilla to the elbow. To this circumstance, perhaps, the man owes his life, fatal haemorrhage being prevented by the condition of the orifices. Free incision of the fascia on either side of the arm gave great relief, and the tumefaction and oedema of the forearm subsided in a great measure, and the pulse at the wrist became more distinct. Simple wet dressings were used. and supporting treatment. Haemorrhage occurred twice, on April 18th and 23d. The axillary artery was tied, because the tissues below were greatly disorganized. Haemorrhage again took place on April 25th, and amputation ofthe arm high up was made. The man was for many days in a very critical state, fainting on the slightest exertion, having lost great quantities of blood by the previous bleedings. He was well supported, and, notwithstanding some sloughing ofthe integuments covering tbe stump, he recovered, and was sent north about June 1st. I shall not soon forget the trouble experienced in finding the artery when search was made for it from the posterior wound. In fact, the tissues were so disorganized that the artery could not be distinguished by the eye, and the heart's action was so feeble that the pulsation could not be felt. The parts were so extensively denuded that the ligature was placed upon the axillary in sound tissues. Examination of the arm after the amputation showed absence of the brachial, for two inches of its course, by ulceration or wound; the haemorrhage was from the distal end, near the bend of the elbow." This soldier was sent to New Haven, June 9, 1852, and Surgeon P. A. Jewett, U. S. V, recorded his discharge January 13, 1853. He was pensioned, and was paid March 4, 1874. ' Compare, on this subject, Lariiey's famous narrative of the case of General Dulong, shot through the right axilla, in Poland, in 1807; HOLLO- WAV (.1. M.) (Consecutive and Indeterminate Hemorrhage from large Arteries after Gunshot Wounds, with a Report of Cases treated by different Methods, Appreciation, in Am. Jour. Med. Sci., 1865, Vol. I, p. 350); Brinton (J. H.) (Ligation of the Axillary Artery in the First Portion of its Course, in Am. Jour. Med. Sci., 1866, Vol. LII. p. 101); LlDELr. (J. A.) (On the Wounds of Blood-vessels, etc., op. cit, 1870, p. 64). \u\ INJURIES OF THE UPPER EXTREMITIES. [CIIAI*. IX. Ligations of the Brachial Artery.—This operation was resorted to, on account of shot flesh wounds of the arm, in at least seventy-six instances. A few cases will be detailed, and all reported will be tabulated. The right brachial was interested in thirty- eight, and the left in thirty-seven cases; in one case this point was not mentioned. Con- secutive amputation was resorted to in nine cases, with success in only three of the nine. Twenty-one cases, or 27.6 per centum, terminated fatally, a terrible mortality. The bleedings for which the ligations were done were primary in thirteen cases; in thirty-three they occurred in the first fortnight after the reception of the injury, and, in some cases of sloughing, as late as the seventy-second day; the mean was about eighteen days:1 Case 1264.—Private J. A. Heminger, Co. H, 67th Ohio, aged 18 years, was wounded at Fort Darling, May 20, 1864, and was treated in a Tenth Corps field hospital until the 23d, Surgeon J. J. Craven, U. S. V., recording a "gunshot wound of the elbow." The patient was then sent to Hammond Hospital, Point Lookout. Surgeon A. Heger, U. S. A., noted: "Gunshot flesh wound of the lower third of the right arm. The wound became gangrenous, destroying the continuity of the artery and causing secondary haemorrhage, during which there was a loss of eighteen or twenty ounces of blood. On July 24th, Surgeon Heger ligated the brachial artery above and below the wound." The soldier was discharged June 28, 1835, and pensioned. Examiner E. D. Peck, in February, 1867, described "a ball entering the right arm at the elbow and injuring the joint, so that he is unable to perform full labor." Examiner F. W. Firmin, in September, 1873, reported that "the ball passed through the right elbow; joint slightly necrosed, and motion impeded." The reports of the pension examiners imply some osseous lesion which must have been of a secondary nature. The great difficulty of exact diagnosis in old injuries in the vicinity of the elbow joint is familiar to all practical surgeons. Cask 1265.—Private M. Gillard, Co. K, 16th Mississippi, aged 27 years, was wounded and captured in an engagement on the Weldon Railroad, August 24, 1864. He was sent to Washington four days subsequently, and Dr. J. C. McKee reported, from Lincoln Hospital: "A shot flesh wound through the biceps muscle, with secondary hsemorrhage. On September 7th, Acting Assistant Surgeon J. Morris ligated the brachial artery about the middle third, and also a muscular branch,,applying two ligatures to each. The brachial vein being found to be ulcerated, ligatures were applied above and below the opening. At the time of operation the parts in the vicinity of the wound were gangrenous, and the general condition of the patient was not very good." This prisoner recovered, and was transferred to the Old Capitol Prison, for exchange, on February 5, 1855. Case 1265.—Private A. Gilboa, Co. C, 8th Michigan Cavalry, aged 27 years, was wounded near Knoxville, January 29, 1864. Surgeon L. D. Griswold, 103d Ohio, reported a ''flesh wound of the left arm." The patient was sent, February 11th, to hospital No. 1, at Nashville. Surgeon C. W. Hornor reported that: "The ball entered the flexure of the left elbow joint one inch above the external condyle of the humerus, passed through the soft parts, and emerged at the upper and inner border of the forearm. The patient had had a haemorrhage from the wound, on his journey from the battle-field, the night before admis- sion, and another bleeding of six ounces occurred soon after his arrival at the hospital. The wound was discharging ichorous pus. The septum between the two openings was divided, and the bleeding found to be from the brachial artery, which was lacerated in two-thirds of its calibre. It was ligated above and below the seat of injury by Acting Assistant Surgeon H. C. May. The track of the ball was lined throughout with black sloughing shreds of decomposed tissues. The hsemorrhage did not recur, but much trouble existed below the joint from swelling of the tissues; and the wounded man being a very impatient person, perfect rest of the limb was impracticable, and a partially anchylosed joint was the result. On June 11, 1834, the patient was transferred to Louisville." This soldier was subsequently treated in Totten, St. Mary's, and Harper Hospitals, and discharged November 14, 1834, and pensioned. Examiner M. L. Greene, , for contraction of the biceps muscle," and was pensioned. Examiner E. Bradley, of New York City, reported, December 2, 1855 : "Musket ball lacerated externally the soft tissues ofthe middle third ofthe right arm. Atrophy of the biceps and partial atrophy of the forearm and hand from diminished vascular and nervous supply has resulted. The limb has little strength, and is comparatively useless." Examiner Charles Phelps, August 9, 1857, noted: "Wound of right arm by musket ball; the orifice of entrance was enlarged and the brachial artery tied. Pulsation is distinct in the superior profunda artery, which is much enlarged, but is feeble in tlfe radial. Nutrition of the arm is well maintained, but in the hand it is much impaired, and the fingers have little strength in flexion." This pensioner is reported to have died October 30, 1870, from disease not referable to the injury. The more important facts of the nine foregoing, and of sixty-seven other cases, are grouped in a tabular statement on the two following pages. Us INJURIES OF THE UPPER EXTREMITIES. (HAT. IX. Table XIII. Summary of Seventy-six Cases of Ligation of the Brachial Artery for Hcemorrhage from Shot Lnjuries unattended by Fractures. Name and Military DKsCUIPTIOX. Babcook, P., Sergeant. M, 6th Illinois Cavalry, age 21. Bergner, P., Private, B, 121st Pennsylvania, age 21. 3 Bettenhauser. C., Pt., I. 61st New York, age 22. 1 Beverly, W. J., Pt., C, 17th Maine, age 27. Bowman, (i. W., Pt., C, 107th Illinois, age 22. 6 ■ Branagan, T., Private, B, 22d Massachusetts, age 19. 7 Brooks, 67., Private, I, 9th Vir- ginia. 8 Caden, L., Pt., C, 8th New Jersey, age 19. 9 Carroll, J., Pt., E, 39th New York, age 28. Cline, C R., Pt., D, 7th West Virginia, age 23. 1 Clark, Oscar A., Pt., D, 21st Ohio, age 31. 12 Coyle, Dan. O., Pt., K, 1st Wisconsin Cavalry. 13 Davis, J. H., Pt., K. 39th U. S. C. T., age 21. 14 Davis, Wm., Pt., E. 3d U. S. Artillery, age 24. 15 Daniels, Lewis, Pt., B, 69th New York, age 26. 16 Downey, J. N., Pt., 6th Maine Battery, age 21. 7 Donnelly, J., Pt., D, 16th Mas- sachusetts, age 41. 8 Duffy, Hugh, Lieutenant, D, 155th New York, age 46. 9 Donnelly, E.. Pt., C, 51st New- York, age 29. D Ellis, Wm.. Pt., K, 9th New York Cavalry, age 20. 21 Estes, 11., Pt., H, 11th Ken- tucky, age 18. Fisher, A., Corporal, G, 36th Massachusetts, age 18. 23 Plewellin. A., Pt., I, 29th In- diana, age 20. 24 Fritzchey, Win., Sergeant, M, 12th Pennsylvania Cavalry, age 24. Frank, Ph., Pt., D, 5th Minne- sota, age ~7. 26 Gilboa, A., Pt,, C. 8th Michi- gan Cavalrv, age 27. 7 Girbach, A., Pt., B, 5th Penn- sylvania Cavalry, age 26. Gillard, M., Pt., K, 16th Mis- sissippi Regiment, age 27. 29 j Grady, James, Pt., K, 164th New York, age 47. 0 Greaf, A., Corporal, D, 46th New York. 1 Hayward, R. G., Pt., B, 4th Vermont, age 19. 32 Heminger, J. A., Pt., H, 67th Ohio. 3 i Hereford, J., Pt., L, 6th Kan- sas Cavalry, age 18. 34 Heliker. R., Pt., G, 65th Ohio, age 25. 35 I Hatmaker, J., Corp'l, B, 51st I Ohio. 36 I Herring. I., Pt., C, 53d Ga..... 37 Henderson. D. D.. Pt., I, loth Mississippi, age 21. 38 , Howard. G.. Pt.. H, 8th New- York Artillery, age 20. Date of Injury. Feb. 21, 1864. May 25, 1864. July 2, 1863. May 5, 1864. Aug. 6, 1864. June 18,1864. Aug. 26,1864. June 16,1864. May 6, 1864. June 1, 1864. July 9, 1864. July 27,1862. July 30,1864. Feb. 20,1864. Mar. 28, 18(15. June 18,1864. May 12, 1864. June 3, 1864. Sept. 17,1862. Aug. 1, 1863. June 9, 1863. June 22,1864. April 6, 1862. Mar. 21, 1865. Dec. 16,1864. Jan. 29, 1864. June 25,1864. Aug. 24,1.864. June 16,1864. June 18,1864. Dec. 13,1862. May 20,1864. Oct. 22, 1864. Nov. 25,1863. Nov. 24, 1863. Nov. 25,1863. Feb. 12,1865. June 3. 1864. Date of h.euoruiiacf. June 15,1864. Aug. 12,1863. May 23 and 24. 1864. Aug. 6, 1864. July 20 and 24. 1864. Sept. 5, 1864. July 2, 1864. May 12, 1864. June 15,1864. July 24,1864. July 31,1864. Mar. 7, 1864. April 5,1865. May 24, 1864. June 13,1864. Oct. 3d, 5th. and 6(h, 1862 Aug. 11 and 12, 1863. June 13,1863. April20,1862. April 23,1865. Feb. 11,1864. Sept. 5 and 14, 1864. Sept. 7, 1864. July 2 and 4, 1864. July 23,1864. Dec. 31, 1662. July 24,1864. Oct. 22, 1864. Dec. 6, 1863. Nov. 24,1863. Nov. 27,1863. Feb. 24, 1865. June 29,1864. Probable source of Hjemorkuage. Palmar arch .. Brachial artery, Brachial artery. Brachial arterv Brachial artery, Brachial artery, Profunda minor, Brachial artery. Brachial artery, Brachial artery. Interosseou: artery. Brachial arten-. Brachial artery. Brachial artery. Brachial artery. Palmar arches. Palmar arch... Brachial artery, Brachial artery. Ulnar artery... Brachial artery. Radial artery.. Brachial artery. Brachial artery. Brachial artery. Date of Operation. Mar. 14, 1864. June 15,1864. Aug. 12, 1863. May 24, 1864. Aug. 6, 1864. July 24, 1864. Sept. 5, 1864. July 2, 1864. May 12, 1864. June 15,1864. July 24, 18S4. July 27, 1862. July 31, 1864. Mar. 7, 1864. April 5, 1865. July 6, 1864. May 24, 1864. June 13, 1864. Oct. 6, 1862. Aug. 12,1863. June 13 and 19, 1863. June 22, 18G4. April 21,1862. April 23,1865. Dec. 23, 1864. Feb. 11, 1864. Sept. 15, 1864. Sept. 7, 1864. July 4, 1864. July 23, 1864. Jan. 1, 1863. July 24, 1864. Nov. 27, 1864. Brachial artery. Dec. 6, 1863. ................I Nov. 24,1863. ............... Nov. 29, 1863. Brachial artery.) Feb. 24, 186.3. Brachial artery. I June 29,1864. I Operation and Operator Brachial ligated by A. A. Surgeon A. Sterling. Brachial ligated above and below by A. A. Surg. E. DeWitt. Proximal end ligated in wound.... Brachial ligated above and below by Ass't Surg.G.A.Mursick, U.S.V. Brachial ligated by Surg. A. M. Wilder, U. S. V. Proximal end ligated in wound; A. A. Surg. H. Sanders. Ligated above and below wound; A. A. Surg. T. J. Dunott, Brachial tied in wound by A. A. Surg. W. Hooper. Ligated at junction of axillary and brachial arteries by Acting As- sistant F. G. H. Bradford. Brachial ligated. Arm amputated June 21, 1864, by A. A. Surgeon H. D. Vosburg. Brachial ligated by A. A. Surg. A. H. Hoy. Brachial ligated just above elbow.. Left brachial ligated by incision in upper third of arm. Brachial ligated in middle third by A. A. Surg. J. T. Kennedy. Both ends of brachial tied......... Brachial tied by A. A. Surg. G. E. Brickett. (See Case 1267 ante.) Brachial tied above and below for violent bleeding, patient having lost 2 qts. of blood in 3 minutes. Ligation of brachial. Arm ampu- tated June 21, 1864, by Surg. D. W. Bliss, U. S. V. Brachial ligated above and below; Ass't Surg. W. M. Notson, 1 \S. A. Oct. 7, 1862, amputation of arm. Brachial ligated by A. A. Surgeon J.E.Smith. (See Case 1268ante.) Ligation of radial. Ligation of bra- chial by A. A. Surg. E. L. Green. Ligation of brachial on field....... Ligation of brachial. Brachial ligated at middle third by Surg. J. B. Lewis. U. S. V.; bleed- ing recurred May 4, 10, and 14. Arm amputated May 14, 1865. Brachial ligated.................. Brachial tied by A. A. Surg. H. C. May. (See Case 1266 ante.) Ulnar ligated Sept. 5th; brachial Sept. 15th, by Ass't Surg. J. W. Meriam, U. S. V. Brachial artery and vein ligated above and below by A. A. Surg. J. Morris. (See Case 1265 ante.) Right brachial tied above and below by Ass't Surg. H. S. Schell, U. S. A. (See Case 1272 ante.) Ligation of brachial above its bifur- cation—radial had been ligated previously. Brachial ligated.................. Brachial ligated above and below by Surg. A. Heger, U. S. A. Brachial ligated at cardiac and distal end bv Surg. A. C. Van Duyn, U. S.V. Brachial ligated above and below by Surg. A. M. McMahon, 64th Ohio. Brachial ligated on field........... Brachial ligated in middle third--- Lilt brachial Uprated at upper third by Surg. B. 15. Breed, U. S. V. Brachial ligated above and below by A. A. Surg. E. L. Duer. Dutv,Julyl3, 1864. Duty.June 30, 1864. Vet. It. Corps, May 13,1864. Died July 2, 1864. Disch'd April 11, 1865. Duty, Jan. 18, 18 ■;.■>. Died Sept. 16, 1864. Duty, Jan. 12, 1865. Deserted July 28, 1864. Died June 25, 1864. Discharged. Disch'd Oct. 25, 1862. Deserted Jan. 19, 1865. Duty, April 24, 1864. Died April 12, 1865._ Disch'd June 3. 1865. Disch'd Jan. 18, 1865. Disch'd Oct. 13, 1864. Died Novem- ber 7, 1862, of pyaemia. Duty, Oct. 10, 1863. Disch'd Jan. 16, 1864. Disch'd Dec. 23, 1864. Disch'd May 15, 1863. Disch'd June 25, 1865. Duty, Sept. 4, 1865. Disch'd Nov. 14, 1864. Disch'd May 16, 1865. Sent to Old Capit'lPris'n Feb. 5, 1865. Disch'd Feb. 6, 1865. Died July 25, 1864. Disch'd Oct. 30, 1863. Disch'd June 28, 1865. Disch'd July 6, 1865. Disch'd Oct. 6, 18:i4. Disch'd Oct. 4. 1864. Recovery.' Died July 1, 1864. ' Compare HOLLOWAY (J. M.). in American Journal of the Medical Sciences, 1865, Vol. L, p. 342. sECT. I.] SHOT KLF.SII WOUNDS. 449 Najif, am> Military description. Unlin, II.. Lieut., K, 44th Illinois, age 24. Ilurd, V., Corp'l, V, 8th Maine, age 24. Hurlev, R., Pt., H, 150th New York. Johnson, O., Pt., C, 33d Iowa.. Marshall. H.. Pt.. P. 1st Mich- igan Cavalry, age 20. McAllister, Wm , Sergeant, F, 9tith Pennsylvania, age 30. Melntire. A . Pt., M. 2d New York Artillery, age 22. Moore. A. A., Pt.. C. .".3d In- diana, age 21. Morgan, L., Pt., D. 14th Mich- igan, age 22. Morris, R.. Pt., A, 149tb Penn- sylvania, age 2.3. Myers, H., Sergeant, A. 23d Illinois. Owens. E.G..Pt., H, 13th West Virginia, age 19. Parett. \V. B., Pt.. D, 5th Iowa, age 21. Parmenter. R. B., Pt., A. 21st Michigan, age 32. Pierce. Geo. \\\. Pt., D, 20th Indiana. Potter, E , Pt., H, 86th New- York, age 29. Price. E„ Corp'l, B, 39th New Jersey, age 22. Quinn, J., Pt., C, 18th U. S. Infantry. Rea, J. K., Pt., H, 102d Penn- sylvania, age 17. Roberts. J., Pt., H, 24th New- York Cavalry. Sanoni. C, Pt., I, 9th New Hampshire, age 23. Shuck, J. L., Pt.. G, 27th Ohio, age 21. Sipes, J., .Serg't, K, 32d Ohio, age 24. Smith, Ph., Pt., E, 84th Penn- sylvania, age 33. Smith, v., Pt., C, 15th Iowa, Smith, T. J., Pt., E, 6th Iowa, age 22. Smith, D., Pt., C, 6th Penn- sylvania Cavalry, age 29. Sweeney, P., Pt., 2d New York Artillery, age 40. Torbet, C. L., Serg't C, 2d Alabama, age 18. Tuttle, P. M., Pt.. B, 44th niinois, age 23. Vanderslice, J , Pt.. D, 96th Pennsylvania, age 40. Waite, *\V., Pt., E, 53d Ohio... Walker, II. H., Pt., A, 27th New York. White, A. 15 , PL, D, 1st D. of C. Cavalry, White, E. P.. Pt., F, 19th Maine, age 21. Williamsm, J..Corp'l. C, 111th Illinois, age 26. Winnemore, E., Mus.. K, 88th Pennsylvania, age 21. Wolfe, P., PL, N, 9th New York Artillery, age 28. Date OF I N.I CRY. June 27,1864. May 16, 1864. Sept. 19,1864. July 4, 1863. May 28, 1864. May 10, 1864. June 3, 1864. July 21, 1864. Mar. 20. 1865. Oct. 27, 1864. May 3, 1863. Oct. 19, 1864. Sept. 19,1862. Dec. 16, 1862. Aug. 30,1862. May 6, 1864. April 2, 1865. Dec. 31,1862. May 5, 1864. June 17,1864. Sept. 13,1864. July 4, 1864. July 16,1865. Oct. 1, 1864. Aug. 14,1864. April 6, 1862. June 12,1864. Aug. 14,1864. April 9, 1865. June 27, 1864. June 3, 1864. May 31,1864. June 27,1862. June 17,1854. Mar. 31, 1865. Dec. 13,1864. June 26,1864. Oct. 19, 1864. Date oi H.E.MOURIlAilE June 27,1864. May 21, 1864. Sept. 27 and 28, 1861. Aug. 4 and 5, 1863. June 19 and 24, 1864. May 21, 1864. June 15,1864. Oct. 1, 1864. April 8, 1865. Nov. 13, 1864. May 3, 1863. Oct. 27, 1864. Oct. 3, 1862. Sept. 9 and 10, 1862. May 17, 1864. April 6, 1865. Dec. 31,1862: Jan. 10 and 22, 1863. May 14, 1864. June 28, 1804. Oct. 10, 1864. July 11,1864. July 17,1865. Oct. 12, 1864. Aug. 14,1864. April 24,1862. July 16,1864. Sept. 17,1864. April 17 and 25, 1865. July 17, 1804. June 14 and 28. 1864. May 31, 1864. Aug. 2, 1862. July 6, 1864. April 12,1865. Jan. 2, 1865. Aug. 8, 1864. Oct. 29, 1864. PltOllABLE SOl'HCK OK II.K.YlOKIUIAliE Brachial nrtcry Braehial artery. Brachial artery Radial, ulnar, and brachial. Ulnar, radial, and brachial. Brachial artery, Radial artery. Left brachial .. Radial artery.. Brachial artery. Brachial artery. Brachial artery. Palmar arches. Brachial artery. Ulnar artery... Brachial artery, Brachial artery. Brachial artery Brachial artery. Brachial artery. Brachial artery. Brachial artery. Brachial artery Brachial artery Brachial artery. Brachial artery. Brachial artery. Brachial artery. Brachial artery. Brachial artery Brachial artery. Brachial artery Brachial artery Ulnar and bra- chial arteries. Ulnar artery... Brachial artery Date or Operation. June 27, 1864. May 21, 1864. Sept. 28, 1864. Aug. 5, 1863. Juno 19, 1864. May 21, 1864. June 15,1864. Oct. 1, 1864. April 8, 1865. Nov. 13, 1864. May 3, 1863. Oct. 27, 1864. Oct. 3, 1862. Sept. 10,1862. May 17, 1864. April 6, 1865. Jan. 23, 1863. May 14, 1864. June 28,1864. Oct. 10, 1864. July 11, 1864. July 17, 1865. Oct. 12, 1864. Aug. 14,1864. April 24, ? 862. July 16, 1864. Sept. 17,1864. April 17.1865. July 17 and 19, 1864. June 14, 1864. May 31, 1864. Aug. 2, 1862. July 6, 1864. April 12, 1865. Jan. 2, 1865. Aug. 8, 1854. Oct. 29, 1864. on:ration and Operator. Ligation of brachial in wound on iield hy Surg. II. E. Hasse, 24tli Wis., and W. P. Pierce, SMIi III. Brachial ligated hy enlarging the Wound hy W. P. Moon, A. A. Surg. June 1st, axillary ligated by A. A. Surg. J. H. .Lunar. 1'uachinl ligated at upper third. Arm amputated helow el bow Oct. 9, 1864, hy A. A. Surg .Maury. liight brachial ligated............. liight brachial ligated June 24th, arm amputated at upper third by A. A. Surg. E. B. Harris. Brachial ligated just above bifurca- tion. June 6tii, religatedin mid lliirdbySurg.lv Beiitlev, U.S.V. (See Cash 1200 ante.) Right brachial ligated by Surg. T. U. Crosby, U. S. V. Brachial ligated by Surgeon J. C. .Morgan, 20th Missouri" Left brachial ligated at both ends.. Right brachial ligated by Surg. N. R. Moseley, U. S. V. Brachial ligated by A. A. Surgeon J. Kirker. Brachial ligated in wound by Surg. S. W. Gross, U. S. V. Brachial ligated.................. Brachial ligated.................. Brachial ligated ................. Brachial ligated at middle third by Ass't Surg. W. Thomson,U.S.A*. (See Case 1271 ante.) Ulnar ligated at 4 A. M.; brachial at 1.30 P. M.. by Ass't Surg. H. Allen, U. S. A. Left brachial ligated at upper third. Left brachial ligated. May 17th, arm amputated by Surgeon C Page. U. S. A. Brachial ligated.................. Brachial ligated in wound; one ligature; A. A. Surg. J. Sweet. Brachial ligated.................. Brachial ligated by Surgeon R. R. Taylor. U. S. \'. Brachial ligated. Oct. 21st, bleed- ing recurred, and subclavian li- gated. (See CASE 1240 ante.) Brachial ligated on field, in upper third. Brachial liga'ed ................. Brachial ligated; religated July 21st: axillary ligated Aug. 3d. Amputation of arm at shoulder joint Aug. 5th. Bleeding recur red. and axillary ligated Aug. 7th, and still higher on Aug. 8th. (See Casf, 12."0 ante.) Brachial ligated just above the crossing of the median nerve ; Surg. N. R. Moseley , P. S. V. Brachial ligated by -Surg. A. M. McMahoii. U. S. V. Ligation of ulnar; ligation of bra- chial; Surg..1.11. Ludlow.U.S.V. Brachial ligated by A. A. Surgeon D. Kennedy. Brachial taken up by Surg. I. N. Barnes. 116th Illinois. Brachial ligated by Ass't Surgeon W. Thomson. U. S. A. Brachial ligated bv A. A. Surgeon J. M. McGrath. ' (Sec Cask 1270 ante.) Brachial ligated by A. A. Surg. W. H. Ensign. Ligation of brachial; religated same clay. Amputation of arm, upper third, Jan. 7th, by A. A. Surg. H. Leamon. Brachial ligated by A. A. Surg. W. P. Moon. Both ends of the brachial tied--- aVd Dec 1804. Died June 1, 1864. Disch'd Mar. 29, 1805. Died Aug. 13, 1803. Died July 11, 1664. Disch'd Oct. 13, 1864. Mustered out in Dec, 1864. Disch'd May 11, 1805. Died April 13, 1865. Disch'd April 26, 1865. Disch'd July 24, 1805. Tr. toV.R.C. Mar.20,1865. Disch'd Jan. 7, 1803. Died Jan. 1, 1863. Disch'd Feb. 7, 1863. Disch'd May 12, 1865. Disch'd July 27, 1865. Vet. R. Corps, July 8, 1863. Died Dec. 1. 1864. Died July 8. 1804. Died Nov. 13, 1864. Disch'd May 25. 1865. Disch'd Sept. 27, 1865. Died Nov. 22. 1864. Disch'd July 24. 1805. Disch'd Mar. 10, 1863. Died Aug. 8, 1S64. Disch'd Feb. 3, 1865. Released on June 23,1865. Disch'd Feb. 28. 1865. Died July 16. 1804. Disch'd May 12. I860. Died Aug. 3. 1802. Disch'd Dec 20, 1864. Disch'd June 20, 1865. Died Fob. 1 1865. Disch'd Jan. 13. 186." Died Nov. 14, 1864. 57 450 INJURIES OF THE UPPER EXTREMITIES. [chap. ix. In one of the cases enumerated in the preceding table, a preparation of the ligated brachial was preserved and transmitted to the Museum. Specimen 950 of the Surgical Section (Cat, p. 461) is also an example of ligation of both extremities of the brachial for shot injury; but, unfortunately, the history of the case has not been identified. The other preparations of ligature of the brachial in the Museum are from cases of amputation: Case 12715.—Corporal A. Greaf,.Co. D, 4(ith New York, aged 37 years, was wounded at Petersburg, June 18, 18(i4, and was treated in a Ninth Corps hospital, thence transferred to Harewood, and, on June 28th, to Satterlee. Acting Assistant Surgeon W. B. Corbit reported: "Gunshot flesh wound of the upper third of the right forearm. A minie" ball entered about three inches below the external condyle ofthe humerus, on the dorsal surface, and emerged opposite; no bones were involved. The wound was in a sloughing condition, the patient anaemic and despondent. Nitric acid was applied to the wound and followed hy flaxseed poultices, and extra diet was prescribed. By July 20th, gangrene had ceased to spread and healthy granulations had arisen, but the patient's despondency continued. On July 23d, a profuse hsemorrhage occurred from the radial artery, which was ligated. The surrounding tissues being very much disorganized and the bleeding still continuing, a ligature was put around the brachial just above the bifurcation. Stimulants, beef-tea, and tonics were freely given. Several minor haemorrhages occurred next day, and the patient died, apparently from exhaustion, July 25, is;i4." The specimen (FlG. 367), forwarded by Dr. Corbit to the Museum, is a wet preparation, showing the radial artery ligated just below, and the brachial artery just above, the bifurcation. It is remarkable that all of the thirteen cases of ligation for primary hsemorrhage were successful.1 In the series of thirty-three intermediary cases,2 those in which the interval between the injury and recourse to ligature did not exceed fifteen days, there were nine deaths. Eleven of the twenty-nine secondary cases,3 in which the interval from the date of injury to the date of ligation of the brachial ranged from sixteen to eighty-two days, terminated fatally. In one fatal case, the date of the ligation was not given. Four of the consecutive amputations belong; to the intermediary, and five to the secondary group. In Pic..367.-Prep- " & J tit Tii l .1 aratiou showing eight of the twentv-one fatal cases, ligatures were applied above and below the ligations of the O J ° L L cwaiarteries". wounded point, and hsemorrhage recurred in one instance only. Bleeding Spec' recurred in at least seven of the thirteen cases of proximal ligation. The reported causes of death in these twenty-one fatal cases were: in seven cases, pyaemia; in eight, "exhaustion" from repeated bleedings; in two, gangrene; in one, intercurrent colliquative diarrhoea; in one, phthisis; and in two cases this point was not reported. The seat of ligation was indicated in sixty cases, and unmentioned in twelve of the successful and four of the fatal cases. The artery was tied in the upper third in thirteen cases, with four deaths; in twenty-four cases, of which six were fatal, it was secured in the middle third; and in twenty-three cases, with seven fatal terminations, ligatures were applied near the bend of the elbow.4 The surprisingly large mortality of the cases of ligation at the lower third is partly explicable by the fact that there are included in this category several instances of complicated wounds of the hand or forearm, and ligature of the brachial was but one of a series of operations. Of shot lesions of the brachial, much the larger proportion are attended by fracture of the humerus, with which the artery is in such close relation through the greater part of its course. 1 See Cases 5, 12, 13, 22, 33, 35, 36, 39, 49, 56, 61, 63, and 70 of TABLE XIII. 2 Cases 7*, 9, 10*, 11, 14, 15*, 17, 18, 20, 21, 23, 25, 26, 28, 34, 37, 40*, 41, 44, 45, 50, 51, 53, 54, 55, 57*, 58*, 60, 62*, 67, 69*, 73, 76*; the fatal cases are indicated by asterisks. *Cases 1, 2, 3, 4*, 6, 8, 16, 19*, 24, 27, 29, 30*, 31, 32, 38*, 42*, 43*, 46, 47*, 48, 59*, 64, 65*, 66, 68, 71*, 72, 74*, 75. 4 The instructions given by Malgaigne (Manuel de Medecine Opiratoire, 7me ed., 1861, p. 149), by Dr. J. H. PACKARD (A Handbook of Opera- tire Surgery, 1870, p. 157), and by other systematic writers, for tying the brachial, leave nothing to be desired. Unless the arm is greatly tumefied, the vessel can be felt throughout its whole course, and only a very clumsy surgeon could miss it. At the lower third, the median basilic veiu running parallel to it, and the internal edge of the tendon of the biceps, are almost certain guides, and, higher up, the inner edges of the biceps and coraco- brachialis afford indications not less sure. Many interesting details regarding ligations of the brachial may be found in M. L. TlUFIEK'S article Brachiale, in the Dictionnaire Encyclopedique des Sciences Midicales, 1869, T. X, p. 447. SECT. I.] SHOT FLESH WOUNDS. 451 Ligations of the Ulnar Artery.—Ten instances were reported of ligations of the ulnar artery for shot wounds unattended by fracture. Three of these cases terminated fatally. One of the ligations was done for primary bleeding, three for early intermediary haemorrhages incident to sloughing. The right forearm was interested in seven, and the left in three cases. Brief notes of eight of the cases are subjoined; the ninth has been already mentioned in the enumeration of cases of ligation of the brachial artery; and the tenth will be referred to among the ligations of the radial. CASES :—1274. Corporal J. X. Freeman, Co. H, 58th Virginia, aged 36 years, was wounded at Winchester, September 19, 1864. Surgeon F. V. Hayden, U. 8. V., reports: " Shot fiesh wound of the right arm, severing ulnar artery. Ligation of ulnar artery, September 19th, by Surgeon C. W. Todd, 13th Virginia." This soldier was subsequently treated at West's Buildings Hos- pital, Baltimore, and was transferred, October 25, 1864, to Point Lookout for exchange.—1275. Sergeant G. L. Bell, Co. E, 10th Connecticut, was wounded at Kinston, North Carolina, December 15, 1862. Surgeon E. I'. Morong, 2d Maryland, reported from Foster Hospital, New Berne: " Flesh wound of the right forearm ; haemorrhage on December 27th, sixteen ounces of blood being lost. The artery was cut down upon just above the bend ofthe elbow and ligated; the artery tied was the ulnar, there being high division of the brachial." [The hemorrhage was not arrested by the ligation, since Dr. Morong states in another column of this report that] " the arm was amputated at its lower third, December 2.7, 1802. The patient lived seventy-four days after the operation, doing well up to within fourteen days of his death. At this time he learned that another had been appointed to the second lieutenancy of his company, to which he was himself entitled by right of promotion. His disappoint- ment was great, aud was, I believe, the immediate cause of his death, March 11, 1863."—1276. Private G. W. Booth, Co. F, 1st Michigan, aged 2o years, was wounded in the engagement on the Weldon Railroad, August 21, 18o4. He was sent from a Fifth Corps hospital' on the 27th, to Fairfax Seminary. Assistant Surgeon H. Allen, U. S. A., recorded: " Gunshot wounds of left forearm. A conoidal ball entered the outer side of the middle third of the forearm, on the anterior surface, passed trans- versely inward, and made its exit on the inner side. September 6th, at midnight, * * bleeding from the ulnar artery to the extent of eight ounces occurred, and recurred on the following morning, when an ounce of blood was lost. * * The track of the ball being exposed, by uniting the wounds of entrance and exit by a transverse incision, Dr. Allen turned out the clot and tied the ulnar artery above and below the aneurismal sac." The patient was transferred to Harper Hospital, Detroit. " He was discharged and pensioned, February 28, 1855." Examiner J. W. Falley, of Hillsdale, reported, May 20, 1874, "that he can neither open nor close the three outer fingers, and that the hand has been growing more and more useless."—1277. Private J. Carter, Co. D, 11th Connecticut, aged 22 years, was wounded at Drury's Bluff, May 16, 1834. Assistant Surgeon W. Webster, U. S. A., reported from DeCamp Hospital: '"A mini(3 ball passed through the right forearm at its middle third. There was phagedenic sloughing and haemorrhage from the ulnar artery, on June 2d, to the extent of twelve ounces. Acting Assistant Surgeon O. W. Peck ligated the ulnar artery." This soldier was discharged December 21, 1865, and is not a pensioner.—1278. Sergeant G. W. Shaw, Co. H, 85th Pennsylvania, aged 42 years, was wounded at Bermuda Hundred, May 20, 1864. He was shot through the left forearm, and bleeding coming on, the ulnar artery was tied, June 12th, by Acting Assistant Surgeon Pryer. Discharged November 12, 1864, and pensioned. Examiner F. C. Eobinson, of Uniontown, reported, September, 1866: "The muscles and tendons of the arm are so extensively injured that he is unable to open or close the hand, three of the fingers being permanently contracted and immovable, and the index finger and thumb can only be moved partially, and possesses but a slight degree of power."—1279. Private J. A. Clapper, Co. G, 43d New York, aged 22 years, was wounded July 12, 1864. He received a shot perforation ofthe middle third ofthe left forearm, and was sent to Mount Pleasant Hospital, and thence, on July 20th, to Satterlee. Acting Assistant Surgeon M. Lampen reported that: "The wound measured three inches by four and was gangrenous. The patient's general health was tolerably good. A solution of permanganate of potassa was applied to the wound, which was dressed also with sugar. On August 2d, the slough was removed completely and the wound was healthy. On August 8th, the wound was sloughing again, and the patient was feeble, and sugar was applied as before, tonics being given internally. On August 10th, haemorrhage occurred from the ulnar artery to the amount of six or eight ounces, and Acting Assistant Surgeon \Y. F. Atlee ligated the artery in the wound at both extremities. By August 20th, the slough was all removed, the wound was looking healthily, and the patient's health improving. On August 30th, he had a severe chill followed by fever. August 31st, haemorrhage occurred from a small artery and was arrested by compression. He had a chill during the night, and again on September 1st. Sulphate of quinia was given freely during the intermission. September 7th, the wound was sloughing again, and there was slight haemorrhage, which was arrested by compression, and he had a chill in the morning. Chills recurred on the 8th and 9th. On the 11th, there was again a slight haemorrhage, which was arrested as before ; the patient was sinking rapidly; tonics and stimulants were administered. The next day he had a chill. On the 14th, hsemorrhage occurred from the ulnar artery to the amount of five ounces. The patient being too much exhausted to bear any operation, the tourniquet was applied to the arm to arrest the haemorrhage, and was allowed to remain until the time of his death, which occurred at one o'clock "P. m., September 14, 1864."—1280. Private G. Harbison, Co. L, 2d Pennsylvania Artillery, aged 32 years, was wounded at Chapin's Farm, September 29, 1864. Surgeon J. C. Fisher, U. S. V., reported, from Camp Parole : " Shot wound ofthe lower third of the right forearm; haemorrhage November 1st, from the ulnar artery. Assistant Surgeon W. St. G. Elliott, U. S. V., tied the proximal end of the artery November 2d, and, haemorrhage recurring, a ligature was placed upon the distal end on November 3d. The patient recovered, with partial contraction of the index and middle fingers, and was transferred to Philadel- phia February 8, 1865." Surgeon J. Hopkinson, U. S. V., reported that this soldier was discharged from Mower Hospital May 18, 1865, on account of " shot wound of the right wrist, with sloughing of the flexor muscles." He was pensioned, and on September 16, 1873, Examiners A. G. McCandless and J. W. Wishart reported : " The middle, ring, and little fingers of the right hand are closely contracted in the palm and cannot be opened, and there is but little power in the first finger and thumb. Ir)2 INJURIES OF THE UPPER EXTREMITIES. [chap. ix. The hand is wasted from want of use."—1281. Private W. D. Wartenbee, Co. D, 100th Ohio, aged 21 years, was wounded at Wilmington, February 20, 18fio. Surgeon St. J. W. Mintzer reported from the hospital at York: "Shot flesh wounds of the anterior surface ofthe right forearm, followed by extensive sloughiug March 26, 1865. There was hsemorrhage from the ulnar artery ; twenty ounces of blood lost. Acting Assistant Surgeon G. Byers tied both ends of the artery in the wound. The haemor- rhage did not recur." Discharged July 5, 1865. Not a pensioner. In five of the ten cases, the artery was tied above and below the seat of injury. One of the patients died from pyaemia. In three instances, a proximal ligature only was applied. Two of the three patients died, one having undergone consecutive amputation ; the third recovered, after consecutive ligation of the brachial. In the two remaining successful cases it is not stated whether one or two ligatures were applied. Ligations of the Radial Artery.—The reported cases in which it was specified that the radial artery was tied on account of shot wounds unattended b}?- fracture, numbered twenty. Eighteen will be briefly noted here—two, in which the brachial was tied consec- utively,1 having been already mentioned. Proximal ligatures were applied in eight, both proximal and distal ligatures in nine, while in three cases this point was not specified. Two were cases of primary, fifteen of intermediary, and three of secondary bleeding.2 It is noticeable that in the four fatal cases proximal ligatures only were applied : Cases.—There were two instances of ligation for primary bleeding: 1282. Private W. C. Tate, Co. B, 56th Illinois, was wounded at Corinth, October 4, 1862, and sent to Mound City October 14th. Surgeon E. C. Franklin, U. S. V., noted: " Gunshot wound of the middle third of the right forearm, severing the radial artery and tendons of the supinator longus muscle. Ligation ofthe radial artery on the field. Returned to duty November 14, 1862." Tate is reported to have been lost on the steamer General Lyon, off Cape Hatteras, on the way to Illinois for muster out.—1283. Private G. Smith, Co. H, 64th Ohio, was wounded at Marietta, June 16, 1864. Surgeon W. P. Peirce, 88th Illinois, recorded: "Gunshot wound of the left arm ; radial artery divided. Ligation by Surgeon S. J. Young, 79th Illinois." The patient was subsequently treated iu Cum- berland Hospital and at Camp Dennison, and was discharged December 3 1865, and pensioned. Examiner W. Loughridge, of Mansfield, Ohio, reported, July 3, 1872, that the radial nerve as well as the artery was wounded in this case, and that the extensors ofthe thumb and first two fingers are liable to spasmodic contraction from slight irritation.—1284. Private D. Brown, Co. I, 7th West Virginia Cavalry, aged 18 years, was wounded at Wyoming, November, 1864. The radial artery was ligated five days after the reception of the injury, and the patient returned to duty in about a month. He was mustered out August 1, 1865, and re-enlisted December 11, 1866, in Co. K, 1st Infantry. Assistant Surgeon H. E. Brown noted " a deficient vitality in the left hand; he suffers from cold in it, and loss of power. The cicatrices from the wound and the operation are plainly visible." Not a pensioner.—12ro. Private Wm. Thompson, Co. E, 1st Maryland Legion, aged 24 years, was wounded at Cold Harbor, June 3, 1864, and sent to Alexandria June 9th. Surgeon E. Bentley, U. S V., reported: "Gunshot flesh wound of the left forearm, the ball passing anterior to the bones. The radial artery was perforated, and from it considerable haemorrhage occurred twenty-four hours previous to the operation. The tourniquet was applied at the time of hsemorrhage. On June 12th, the radial artery was ligated at wound, both ends of the artery being tied. Patient did well, and was returned to duty September 19, 1861." Not a pensioner.—1286. Corporal J. A. Grundy, Co. F, 98th New York, aged 21, was wounded at Chapin's Farm, September 29, 1864. Surgeon J. J. Van Rensselaer, 98th New York, noted, "a gunshot wound of the left forearm," and the patient't: transfer to Hampton Hospital on October 2d. The hospital register refers to " hsemorrhage from the radial and interosseous arteries to the amount of four ounces on October 9th; on the 10th, there was bleeding of five ounces, and on the 13th, of five ounces, checked, on each occasion, by compression and persulphate of iron and cold-water applications. On the 16th, the radial artery was ligated in the wound, one end only being tied. There had been no recurrence of the haemorrhage after the 13th. The patient died, on October 26th, from irritative fever."—1287. Private L. Hathaway, Co. I, 25th Massachusetts, aged 24 years, was wounded at Cold Harbor, June 2, 1864. Surgeon S. A. Richardson, 13th New Hampshire, reported "a shot flesh wound ofthe upper fourth of the left forearm." The patient was sent to Alexandria, and on June 13th the radial artery was tied high up, by Surgeon Edwin Bentley, U. S. V. The parts were swollen, cedematous, and dark colored. The ease progressed favor- ably, and the patient was discharged October 22, 1864, and pensioned. Examiner V. 0. Taylor, of Athol, reported, September, 1873, " lameness of the arm not improved since last examination.''—1288. Corporal J. Mclsaacs, Co. G, 5th Michigan, aged 21 years, was wounded at Spottsylvania, May 10, 1864, sent from a Second Corps hospital to Mount Pleasant, and thence, on May 20th, to Cuyler Hospital; the case was recorded by Assistant Surgeon H. S. Schell, U. S. A., as a gunshot flesh wound of the left forearm. May 21st, profuse hsemorrhage from the radial artery; eight ounces of blood lost. x\cting Assistant Surgeon W. R. Dunton enlarged the wound and tied the radial artery above and below. The slough had not been discharged, and the surrounding parts were perfectly healthy. Haemorrhage did not recur; ligatures came away on the 26th. Returned to duty August 12, 1864.—1289. Private H. Greenly, Co. K, 34th New York, was wounded at Oak Grove, Virginia, June 20, 1862. Surgeon T. A. McParlin, U. S. A., reported from Annapolis, July 4, 1862 : " Shell wound in right wrist. The wound sloughed and involved the radial artery, and, on July 10th, haemorrhage to the amount of eighteen or twenty ounces took place. The 1 C.\si> 21 and "0, in Taiilk XIII—of Pt. H. Estes, Co. II, 11th Kentucky, and Corp'l A. Greaf, Co. D. 4Gth New York. Casf. 1073. p. 4.v0 ante. * A godU statistical table on wounds ofthe radial is contained iu M. Gusiave MaRTIX's Etude sur les Plaies arlirielles de la Main et de la Partie infirieure de VAvant-bras, Thdse de Paris, 1870, No. 104. p. 3 et seq. SECT. I.] SHOT FLESH WOUNDS. 453 bleeding was arrested by cold, pressure, and styptics. < )n the 1 *th, the radial artery was ligated above the wound. The ligation was difficult on account of loss of blood and feeble pulsation. The wound healed, with a large cicatrix and contraction of the flexor muscles." Returned to duty October 29, 1862, and discharged the service .January 10, 1833, and pensioned. Examiner H. B. Cole, of Wisconsin, reported, July 22, 1870, "partial anchylosis of wrist joint, and partial loss of use of thumb and index finger, with rheumatism of forearm."—1290. Private J. Thomas, Co. G, 75th Illinois, aged 22 years, was wounded at Perrvville, October 8,1862. From New Albany Hospital No. 4, Acting Assistant Surgeon J. Sloan reported, October 14th : " Flesh wound of the middle third of the right forearm. October 20th, secondary haemorrhage from the radial to the amount of twenty four ounces; both ends ofthe artery were tied at the wound ; no recurrence ofthe haemorrhage. Discharged from service December 7. 1862."—1291. Private M. O'Brien, Co. I, 169th New York, aged 24 years, was wounded at Petersburg, June 30,%1864. At Hampton Hospital tliere was noted: "Gunshot wound of the left forearm. July 14th, haemorrhage to the amount of a quart from the radial artery. The artery was ligated in the wound July 15th; being tied above and below the bleeding point, just beyond the bifurcation of the brachial. Hamiorrhage recurred July 20th ; loss of blood, two quarts; wound exposed to the air, and haemorrhage ceased. Operator, Assistant Surgeon Edward Curtis, U. S. A. On August 2d, Acting Assistant Surgeon H. B. White amputated the arm at the middle third. * * The patient was transferred, October 6, 1864, to New York," and treated at Grant Hospital until February 11, 1855, when he was discharged and pensioned. The examiner's report, December 4. 1873, mentions no details of interest.—1292. Private I. Miller, Co. K, 97th Pennsylvania, aged 25 years, was wounded in a skirmish in Virginia, May 20, 1864. Surgeon J. R. Everhart, 97th Pennsylvania, reported that the patient was sent from a Tenth Corps hospital to Hammond Hospital with a "shot wound of the left forearm ; the ball passing through the radial side." The register of the Point Lookout Hospital states : "June 12th, Acting Assistant Surgeon T. Liebold ligated the radial artery above and below the wound. The patient recovered, and was transferred to the Veteran Reserve Corps April 12, 1885." Not a pensioner.—1293. Private S. Hulse, Co. I. 84th Pennsylvania, aged 27 years, was wounded at. Cold Harbor, June 3,1*64. Surgeon 0. Everts, 20th Indiana, at a Second Corps hospital, reported: " Gunshot wound ofthe right forearm. The patient was sent to Hammond Hospital." The register states : " Haemorrhage occurred from the radial on June 26th, with loss of nearly ten ounces of blood. The artery was ligated in its continuity above and below the point of haemorrhage by Acting Assistant Surgeon J. Evans. Patient recovered sufficiently to go on furlough." He was transferred to Satterlee Hospital on August 16th, and deserted October 18, 1*64.—1294. Sergeant A. Knock, Co. B, 84th Illinois, aged 24 years, was wounded at Marietta, June 27, 18;i4, and sent to Nashville, to Cumberland Hospital, and thence transferred to hospital No. 1 on July 14th. Surgeon B. B. Breed, U. S. V., noted: '■ Severe gunshot flesh wound of the left arm. On July 22d, haemorrhage occurred from the radial artery to the amount of twelve ounces, and the artery was ligated in the wound, the proximal end only being tied. Gangrene . supervened, involving the whole anterior aspect of the forearm and wrist joint, and, on July 24th, Surgeon R. L. Stanford, U. 8. V., amputated at the lower third ofthe arm. Death ensued, from exhaustion from diarrhoea and suppuration, October 11, 18.i4."—129C. Sergeant H. M. Beach, Co. C, 5th Minnesota, aged 31 years, was wounded at Nashville, December 16, 1864, and treated in Cumberland Hospital until the 18th, and then sent to No. 4, New Albany, Indiana. Acting Assistant Surgeon S. J. Alexander noted : "The ball entered immediately above aud within the outer condyle of the right humerus, passed downward, backward, and inward, injuring both the radial and ulnar arteries, fracturing no bones, and making its exit just below the internal condyle ofthe humerus. On January 10, 1835, haemorrhage, of from sixteen to twenty ounces, took place from the radial and ulnar arteries. On the same day both arteries were ligated at the seat of injury, on the cardiac side, only one ligature being applied to each artery. The operation was performed by Acting Assistant Surgeon J. Sloan ; haemorrhage did not recur. The patient died January 2$. 1*65. Death was not the result of exhaustion, but was owing to the jaundiced and typhoid condition of the system."—1296. Private R. Fisher, Co. K, 121st New York, aged 18 years, was wounded at Spottsylvania, May 10, 1864. Surgeon E. F. Taylor, 1st New Jersey, reported, from a Sixth Corps Hospital, a " shot wound of the lower third of the right forearm, nearly exposing the radial artery." The patient was sent to Armory Square, and later to Satterlee, where the register notes: "June 7th, secondary haemorrhage from the radial; loss of blood, four ounces. The radial artery was tied at the upper and lower edges of the wound by Acting Assistant Surgeon A. A. Smith. Wound was sloughing from the effects of the contusion, some two and a half inches of the artery having been destroyed. Progress favorable; no recurrence of the haemorrhage. Deserted December 1, 1864."—1297. Sergeant G. H. Wrightman, Co. L, 6th Michigan Cavalry, aged 23 years, was wounded at Hanovertown, May 28,1864, and sent to Emory Hospital June 4th. Surgeon N. R. Moseley, U. S. V., noted: " Shot wound of the right radial artery; ligation June 27th. Secondary haemorrhage June 28th, amounting to six ounces ; radial re-ligated in the wound at one end, with favorable result. Furloughed August 19, 1864. Deserted October 11, 1864." Not a pensioner.—1298. Corporal W. C. Wright, Co. F, 107th New York, aged 21 years, was wounded at Atlanta, June 20, 1864, and sent to Nashville. Surgeon J. E. Herbst, U. S. V., noted, at hospital No. 2: "Gunshot flesh wound of the right forearm; rupture of the radial artery ; wound gangrenous. August 5th, artery tied, by enlarging the wound, by Acting Assistant Surgeon S. Blackwood." Dot}', July 13, 1865. Not a pensioner.—129D. Private D. Ray, Co. I, 5th Connecticut, aged 22 years, was wounded at Dallas, May 25. 1864. Surgeon C. N. Campbell, 150th New York, reported, from a Twentieth Corps hospital: "A shot wound of middle third of left forearm; ball passing directly across, beneath the skin and fasciae, slightly wounding the muscles." The patient was sent to Joe Holt Hospital, Jeffersonville. Surgeon H. P. Stearns, U. S. V., reports that on July 22d haemorrhage to the amount of ten ounces, probably from a muscular branch of the radial, took place. The radial artery was ligated in the wound, both ends being tied. The patient recovered, and went to duty January 26, 1865. Not a pensioner. The side injured was specified in each case, and the injuries were equally distributed, ten on the right and ten on the left side. Four cases terminated fatally; five patients were discharged; eight returned to duty; and three deserted. In two cases, a second ligation was practised, and, in two, resort was had to consecutive amputation. The bleed- ings were either primary or as late as the fifty-eighth day; the mean was nineteen days. 1)4 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. Ligation of the Lnterosseous Artery1 for shot flesh wound of the forearm is represented in the reports by a single instance: ('asm 1300.—Private J. A. Forsyth, Co. G. 9th Maine, aged 21 years, was wounded near Petersburg, June 25, 1864. He was sent from a Tenth Corps hospital to Hampton Hospital. Assistant Surgeon E. McClellan, U. S. A., recorded: "Shell flesh wound ofthe left forearm. July 19th, haemorrhage occurred from the interosseous artery, with loss of two ounces of blood. Both ends of the bleeding artery were ligated in the wound, on July 20th, by Assistant Surgeon E. Curtis, U. S. A. Hoemorrhage recurred on August 13th, and the patient died, from exhaustion, on the same day." A' Ligation of the Superficial Palmar Arch for shot wound was reported. The hospital and pension reports disagree regarding the complication of the injury of the soft parts by lesion of the bones : Cash 1301. Private R. D. Roberts, Co. F, 72d Illinois, aged 49 years, was wounded opposite Island 18, Mississippi River, March 9, 1864. He was sent to Adams Hospital, Memphis, on March 12th, from the steamer Hillman. Assistant Surgeon J. M. Study, U. S. V., reported that "a revolver ball entered about the centre of the right hand. On March 19th, the track of the ball was slit up. On March 27th, ligation of the superficial palmar arch was practised." Surgeon J. G. Keenon, U. S. V., reported "a revolver shot of r-ight forearm, the ball entering about the centre ofthe palm ofthe hand and emerging at the upper third of the forearm. There was bleeding to the extent of eight ounces on March 22d, and, on March 27th, the superficial palmar arch was tied." This man was discharged and pensioned January 26, 1865. Examiner J. E. Ennis, of Iowa, reported, in 1866, contraction and loss of use ofthe fingers, from a "shattering ofthe radius and ulna." Examiner C. H. Lothrop, of Lyons, Iowa, reported, September 4, 1873, "perfect anchylosis of wrist joint." The pensioner stated that he had been attended at Memphis by Drs. Jessup and Hall. The second lieutenant of his company testified that while this soldier was returning to his regiment from a furlough, on the steamer Hillman, "when the boat was wooding on the Missouri shore, he was taken, and shot through his hand and wrist and arm by a guerrilla." Ligations of Branches of the axillary and brachial, and ligations of the digital arteries, were, in a few instances, made the subjects of special reports. The anterior and • posterior circumflex, the superior profunda, anastomotica magna, and the inner digitals of the index and middle fingers, are the minor arteries specified as ligatured for shot wounds unattended by fracture.2 Two of the cases of this group terminated fatally.3 Flesh Wounds involving large Blood-vessels treated without Operation.—A number of examples of shot wounds of the larger arterial trunks of the upper extremity were reported where ligatures were not applied ; and many instances of opening of these vessels by ulceration or sloughing, consequent on shot injury, in which operative inter- ference was not essayed. Nine cases of the former group were specially reported, and will be briefly recapitulated: Case 1302.—Lieutenant J. G. Miner, Co. K, 1st Kansas, was wounded at Tuscumbia, October 5,1862. Acting Surgeon A. Newman, 1st Kansas, reported, "a gunshot wound ofthe upper extremity, severing the axillary artery; death, October 5, 1862." Case 1303.—Private W. Rendrick, Co. F, 28th South Carolina, aged 22 years, was wounded May 20, 1864, and sent to a Confederate hospital in Petersburg. Surgeon W. L. Baylor reported that " a minkj ball inflicted a flesh wound of the right shoulder; the axillary artery was believed to have been wounded. Haemorrhage ensued on May 24th, and recurred on the 27th. The patient died June 1, 1834, from its effects." Case 1304.—Private C. W. Simpson, Co. B, 32d Massachusetts, aged 19 years, was wounded at Hatcher's Run, Feb- ruary 6, 1865, and was admitted to No. 1 Hospital, Annapolis, on February 17th. Surgeon B. A Vanderkieft, U. S. V., reported: "Shot wound of the left shoulder, the ball passing through the axilla and wounding the axillary artery. On the 19th, there was slight haemoiThage from the anterior opening; arrested by compression. It recurred during the evening more 1 Compare an Account of the Ligation of the Interosseous Artery, by Assistant Surgeon G. M. Sternhekg, in Circular 3, S. G. O.. 1871, p. 238, ; Cases of: 1. Private R. Yarick, G, 6th Michigan, wounded at Cold Harbor, June 3, 1864. Ligation of anterior oircumflex of left arm at seat of injury. Discharged and pensioned. In September, 1873, Examiner J. J. Lutze, of Saginaw, reported the arm "atrophied and weak." 2. Corporal A. Ward, V, loth Massachusetts, aged 25, wounded at Gettysburg, July 2, 1863. Ligation of left posterior circumflex, at Satterlee, July 13th. Trans- ferred to Veteran Reserves, and discharged July 28, 1864. 3. Corporal A. Detweiler, G. 19th Pennsylvania, aged 18, was wounded at Hatcher's Rum March 21). 1865. Ligation of right posterior circumflex artery, at Harewood Hospital, some time in April. Recovered, and was discharged June 16, 1805, and pensioned. There is a photograph of the patient in the Museum (Contributed Photographs, S. S., Vol. VII, p. 17). 4. Sergeant G. T. Zwick, . I, 27th Michigan, aged 27, wounded at Spottsylvania, May 12, 1864. Ligation of left posterior circumflex, July 2d, at Chester. Death, July 15, 1864, 5. Corporal J. Foster, K, 38th Illinois, was wounded at Chickamauga, September 19, 1863. Ligation of the right anastomotica magna, September 29th. Death, October 9, 1863. 6. Private L. G. Williams, H, 84th Illinois, was wounded at Chickamauga, September 20, 1863. Proximal ligation of the left inferior profunda, October 8th. Discharged and pensioned February 28, 1865. Examiner W. E. CltAIG, of Illinois, reported, September, 1873, that the wound had implicated the humeral artery, and that the motor powers of the hand were much impaired. 7. Private Z. Gantt, G, 27th North Caro- lina, was wounded at Petersburg, June 15, 1864. Ligation of the third digital artery by Assistant Surgeon E. CURTIS, V. S. A., July 20, 1864. 8. Pri- vate J. XV. Turner, I, 126th Ohio, age 24, wounded at Spottsylvania. May 12, 1804. Ligation of second digital artery by Surgeon N. R. MOSELEY, TJ. S. V., May 22d. Transferred to Veteran Reserves January 17, 1865. 3 Cases of Zwick and Foster, 4 and 5 ofthe preceding note. SECT. I.] SHOT FLUSH WOUNDS. 455 profuselv. 'Ihe anterior and posterior openings were then enlarged, the clots removed, and fresh compresses, saturated with a solution of persulphate of iron, were applied and partially controlled the haemorrhage; but it continued to weep until the <;l)th, when the patient became delirious, and continued so until the time of bis death, February 22, 1H65. Loss of blood thirty-two ounces. Supported throughout by beef tea and brandy." In a fourth case, reported as a wound implicating tlie axillary, the bleeding probably arose from the subscapular artery: ' Case 1305.—Private J. Shelley, Co. D, 107th Pennsylvania, was wounded at Fredericksburg, December 13, 1862, and was sent from a First Corps hospital to Washington, aud admitted to Mount Pleasant I [ospital December 21 st. Acting Assistant Surgeon I. P. Myer reported: "The ball entered the arm on the internal side, about two inches below the head of the humerus, passed obliquely backward and slightly downward, toward the anterior border of the scapula, and was probably lodged in the axillary space. Tliere was a collection of pus in the axilla, to which egress was given. On December 23d, secondary hemor- rhage supervened. Tliere was haemorrhage also on the subsequent evening. On December 26th, the patient was in a feeble, debilitated condition : pulse very frequent and weak; lips pallid from the repeated hsemonhages; respiration quick and nervous. The blood and pus had burrowed beneath the muscles and tissues as far as the seventh rib and formed a large sac, from which a quantity of clotted blood aud discharges of an offensive character were pressed out. The patient was too much prostrated to sit up a sufficient length of time to permit his wound to be dressed, being constantly bathed with perspiration. On January 2d, he was attacked with severe rigors; had a troublesome cough, with gelatinous sputa mingled with blood; and fine crepitant rales through the lower portion of the right lung; pulse 100. A bistoury was passed into the huge fluctuating tumor, but the discharge consisted chiefly of clots of blood, only a very little pus escaping. January 3d, the wound was dressed and the sac emptied as near as possible of its contents, and the chest firmly bandaged. Tliere was a return of the bleeding; checked by compresses. At eight o'clock that evening it recurred profusely; pressure upon the subclavian checked it. The wounds were then stuffed with charpie, sprinkled with powdered persulphate of iron, and the bleeding was controlled. January 4th, the patient was e.heri;;ed, and a thorough examination of the wound was made. The finger was passed along the course of the wound, and pulsation was felt in the brachial artery; and through the incision in the axilla pulsation was recognized in the axillary artery; there was also pulsation in the radial. It was then inferred that the subscapular artery must be the source from which the haemorrhage arose. The wound was again filled with charpie, over which compresses were placed, and in this condition the patient was allowed to remain undisturbed until January 7th, when the dressings were removed and the wounds cleared, and a large quantity of healthy pus entirely free from clots gushed forth; by gentle pressure the sac was effectually emptied, and a bandage was thrown tightly about the chest; pulse 100, and appetite improved. The sac was daily evacuated of its contents, and the bandaging continued. January lllli, while dressing the wounds this morning, a hard substance wns discovered at the dependent portion of tlie sac, over which an incision was made, and a conical ball was extracted, that, no doubt, had lodged in the axilla, and had followed the burrowing blood and pus. It was extracted a little forward of a line dropped from the inferior angle of the scapula, and from the interspace of the seventh and eighth ribs. From this period the pulse began to diminish in frequency and the discharge to decrease in quantity. January 13th, to-day he sat up for several hours, for the first time siuce his illness. The discharge from the wound now amounts only to about two drachms during the twenty-four hours; pilseS?: appetite good; quite cheerful. January 24th, there is no more discharge; the patient is convalescing favor- ably." 8helley was discharged August 4, 1883, and pensioned. Examiner T. B. Smith, of Washington, reported, August 5, 186.5: "Numbness, coldness, and loss of power of index and middle fingers and thumb of right hand, owing probably to nervous injury. Extension of arm imperfect through long rest." This pensioner died October 19, 1864. The cause of death is not known a: the Pension Bureau. Two cases were reported as instances of spontaneous healing of the brachial after shot injury. The evidence, however, is inconclusive: Cash 1305.—Corporal T. Munroe, Co. K, 9th Illinois, was wounded at Chickamauga, September 20, 1S63, and was sent to Nashville November 1st. Surgeon W. M. Chambers, U. S. V., noted: "Severe gunshot wound ofthe right arm, with injury to the brachial artery and nerves, and also a shot wound of the left arm. Discharged from service January 7, 1864, for paralysis of the right forearm in consequence of a cicatrix compressing the brachial artery and median nerve." Cask 1307.—Private T. Hughes, Co. D, 1st Kansas, was wounded at Cross Bayou, Louisiana, September 14, 1863, and was admitted to Post Hospital, Natchez, Mississippi, on the following day. Surgeon B. F. Stephenson, 14th Illinois, noted: " Gunshot wound of the left arm. The ball passed beneath the radius and ulna and made its exit at the internal condyle of the humerus, severing the brachial artery. Secondary haemorrhage September 16th; bleeding suppressed by compression. Duty, October 22, 186.J." Not a pensioner. In two cases, likewise, of shot injury of the radial, the bleeding was arrested without operative interference:] Cask 1308.—Lieutenant J. Kelly, 23d Tennessee, aged 25 years, was wounded at Petersburg, June 17, 1864, by a conical musket ball. He was made a prisoner and was sent to Washington. Surgeon O. A. Judson, U. S. V., reported, from Carver Hospital, "a gunshot wound ofthe left forearm. The patient was transferred to Lincoln .Hospital July 14th." Assistant Surgeon J. C. McKee. U. S. A., reported, "shot wound of left forearm, the radial artery severed. Transferred to Old Capitol Prison July 30, 1864." 1 Guthrie (G. J.) (On the Diseases and Injuries of Arteries, London, 1830, p. 331) did not disapprove of attempts to treat wounds of the radial by compression. The shot lesion, if the artery is completely divided, is equivalent to torsion. 456 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. The next, the eighth of the series of shot flesh wounds interesting primarily the larger vessels of the upper extremity, of the cases treated without operation, was probably an example of division of the radial, with spontaneous cessation of the bleeding: Cash 1:50'.).—Captain S. M. Bawliston, Co. D, Cth Georgia Cavalry, aged 38 years, was wounded May 10, 1864, and entered Institute Hospital, Atlanta, May 19th. Surgeon D. C. O'Keefe recorded' a "gunshot wound; the ball entering the left forearm anteriorly two inches from the elbow joint, and passing obliquely upward made its exit just above the olecranon process on the back of the arm. Great haemorrhage followed the injury. There was no radial pulsation at the wrist. June 5th, the patient has done well up to this time; has had a chill, followed by fever; suppuration diminished; arm more painful; for this condition quinine was used in the forenoon; aperients and poultices to the arm were employed. June 13th, the parts around the elbow continue red, swollen, and painful; there is a free discharge of pus from the incision. From this time forward the patient steadily improved, and was furloughed July 29, 1864." A case of hsemorrhage from the right interosseous artery was followed by gangrene and amputation of the thumb: Case 1310.—Private S. Maxwell, Co. A, 122d Ohio, aged 28 years, was wounded at Winchester, June 15, 1863, and sent to Newton University Hospital, Baltimore, on June 23d. Surgeon C. W. Jones, U. S. V., reported: " The patient was wounded by a mini6 ball entering anteriorly halfway between the wrist and elbow, and passing upward between the radius and ulna, lacerating the interosseous artery. On June 24th, a slight secondary haemorrhage occurred, which was arrested by compression. On the 25th, a more marked haemorrhage occurred. The wound was dilated and unsuccessful exploration made for the ball. An effort was also made to ligate the artery at the seat of injury, hut it was so broken down that the effort proved a failure. Persulphate of iron was applied, with compression, which arrested the haemorrhage and prevented its recurrence. In all, about twenty-four ounces of blood had been lost. On July 1st, the ball was removed by a couuter opening posteriorly, just below the elbow; the wound commenced healing very soon. On July 7th, the thumb became suddenly gangrenous, probably from obliter- ation of the interosseous artery, and a generally congested state of the arm interfered to a great extent with the circulation of the hand. The thumb was amputated at the middle of the metacarpal bone. On August 8th, the hand had entirely healed from the injury resulting from the amputation of the thumb; the wound of the arm was nearly well, though the destruction of the soft parts of the forearm was very marked." The amputated thumb was sent to the Museum by Dr. Jones, and is numbered 1692 of Section I (Cat. Surg. Sect, 1866, p. 522). Sloughing involving the larger Blood-vessels.—From various causes, many of the shot flesh wounds of the upper extremity, where no considerable vessel was implicated, assumed an unhealthy action, and the larger trunks were opened secondarily by ulceration. Haemorrhage from the Subclavian or its Branches.—One instance in which the main trunk, on the left side, was supposed to have been opened, was reported, and another where one of its principal branches gave way in a sloughing shot wound: Cask 1311.—Sergeant H. Allen, Co. K, 77th New York, aged 38 years, was wounded at Autietam, September 17, 1862. He was sent from a Sixth Corps hospital to Harrisburg, probably on September 24th. Acting Assistant Surgeon J. P. Wilson reported that: "When admitted he was very weak from loss of blood; but by the use of tonics and styptics he appeared to rally until October 14th, Avhen haemorrhage to the extent of five pounds supervened. Brandy, styptics, plugging of the wound, and the actual cautery were employed unavailingly to arrest the bleeding. Ligation of the artery was not attempted, as, in the opinion of a number of surgeons who saw the case, it would have bean entirely useless under the circumstances." Case 1312.—Corporal L. Burnett, 11th Mississippi, was wounded at Gettysburg, July 2,1863. Surgeon H. Janes, U S. V., reported "a gunshot wound ofthe breast," and added that the patient "was sent to the rebel field hospital, and was transferred to Chester Hospital July 19th. Surgeon E. Swift, U. S. A., reported: "A shell wound below the left clavicle, causing great destruction of the muscular tissue. On July 22d, there was profuse haemorrhage from one of the branches of the left subclavian, which was imperfectly checked by compression and styptics. The patient died July 26, 1863, from the effects of the recurring haemorrhages." Hoemorrhage from the Axillary or its Branches.—Four cases were reported that appear to belong to this category: Case 1313.—Private E. Wilson, Co. E, 35th Missouri, aged 23 years, was wounded at Helena, July 2, 1863. He was sent to Gayoso Hospital, Memphis. Surgeon D. W. Hartshorne, U. S. V., reported: "A shot flesh wound of the left arm; haemorrhage from the axillary artery, August 1st, nearly ten ounces of blood being lost. Death, August 7, 1863." Case 1314.—Private E. J. Thompson, Co. E, 82d Pennsylvania, aged 28 years, was wounded at Cold Harbor, June 3, 1864. He was scut directly to New York from White House Landing. Assistant Surgeon Warren Webster, U. S. A., reported, from De Camp Hospital: "A gunshot wound of the shoulder. On August 16th haemorrhage set in, proceeding apparently from the axillary artery. An attempt was made to find the bleeding point, but the patient expired during the exploration, August 16, 1864." ' (»' IvEKFE (D. C-), Confederate States Medical and Surgical Journal, 1865, Vol. II, p. 30. SECT. I.] SHOT FLESH WOUNDS. 4r,7 In the next case, early bleeding from a branch of the axillary was followed by ulcera- tion and mortal hemorrhage from the main trunk: Case 1315.—Sergeant W. T. White, Co. B, 3d North Carolina, aged 22 years, was wounded at Petersburg, April 1, 1865. Treated at Sickel Hospital, Alexandria, Surgeon E. lientley, U. S. V., reported: "On admission there was slight haemorrhage from small branches ofthe axillary, which was controlled by pressure, but recurred. Loss of blood, twenty-four ounces. Pulse small; patient too feeble to undergo the operation of ligation of the subclavian, which was the only one likely to all'md relief, as the axillary artery had undoubtedly sloughed high up in the axilla. Death, April 29, 1865." The happy effects of temporary compression under certain circumstances are illustrated by the following case: Cask 1316.—Private W. H. H. Bailey. Co. F, 38th New York, aged 20 years, was wounded at Fredericksburg, December 13, 1862, and sent to Annapolis January 29, 1863. Surgeon T. A. Mcl'arlin, U. S. A., reported: "A gunshot wound, the ball passing through the front ofthe shoulder and out near the scapula. Gangrene took place at the orifice ofthe wound on January 18. 1863, and sloughing continued until February 26th. On March 9th, bleeding to the amount of twelve ounces took place, probably from injury to one of the thoracic arteries. Pressure was made by a pad and bandage over the subclavian for forty- eight hours, and bleeding was arrested." This soldier was discharged and pensioned. The Most on Pension Examining Board reported, September 8. tS73, that "the extremity was paralyzed and atrophied, the forearm two and a half and the hand a half inch smaller than their fellows." Special reports were made in several cases of bleeding from the brachial or its branches, that were treated by compression and styptics: Case 1317.—Private T. J. Young, Co. F, 20th Maine, aged 30 years, was wounded at Gettysburg, July 2, 1863. He was sent to Summit House Hospital. Acting Assistant Surgeon J. Gibbons Hunt reported: "Phagedenic ulceration ofthe lower half of the left arm followed a shot flesh wound. Haemorrhage, to the amount of sixteen ounces, took place on August 25th. It was arrested by persulphate of iron and decoction of logwood." He was discharged and pensioned September 19, 1S63. Case 131-\—Sergeant J. T. Robinson, 122d Ohio, aged 26 years, was wounded at the Wilderness, May 6, 1S64. He was sent to Washington, to Harewood Hospital. Surgeon R. B. Bontecou, U. S. V., reported: "He had a shot perforation through the right knee joint and a flesh wound at the lower third of the right uplper arm. What appeared to be a compara- tively unimportant injury proved, in the sequel, a fatal accident. Bleeding from the wound in the forearm came on June .d, as much as sixteen ounces of blood being lost. The haemorrhage was arrested by compression of the brachial, but, in the patient's debilitated condition, the bleeding was mortal; and when the surgeon arrived and prepared to tie the artery the patient was moribund. He died June 2. 1804." Case 1319.—Private D. Warner, Co. B, 170th Ohio, was wounded at Snicker's Ferry, July 18, 1864, and was sent to Sandy Hook. Acting Staff Surgeon N. F. Graham reported: "A shot wound of the left arm. Haemorrhage from ulceration of the artery, August 1, 1864; compression used. Haemorrhage recurred August 6th, and continued at intervals until death, August 12, 1864.'' Case 1320.—Colonel G. Mihalotzy, 24th Illinois, was wounded at Tunnel Hill, February 25, 1864. Surgeon L. D. Harlow, 1*. S. V., reported from the Officers' Hospital, Lookout Mountain: "A deep gunshot flesh wound of the right arm above tbe elbow. Haemorrhage, amounting to sixteen ounces, from the anastomotica magna, took place on March 2d. Solution of perchloride of iron was applied. The patient died March 11, 1864, probably from pyaemia which succeeded the haemorrhage." Case 1321.—Sergeant J. Lawton, Co. A, 13th Pennsylvania, aged 24 years, was wounded at Petersburg, June 15, 1864. Surgeon T. H. Bache, U.S. V., reported from Chester Hospital: "There was haemorrhage from the anastomotica magna to the extent of six ounces ou July 8th, consequent on a shot wound of the fleshy part of the middle third of the right arm. The bleeding was controlled by stuffing the wound with lint saturated with a solution of the persulphate of iron, and the patient recovered, ana was returned to duty November 23, 1864." Not a pensioner. Cask 1322.—Private W. Jones, Co. E, 4th Delaware, aged 24 years, was wounded at Petersburg, June 18, 1864, and sent to-Washington. Assistant Surgeon C. A. McCall, U. S. A., reported from Mount Pleasant Hospital: "A superficial shot wound of the right arm near the elbow joint. Haemorrhage occurred on July 23d and on August 9th, from a branch of the brachial artery, with a loss of ten ounces of blood. The bleeding was arrested by cold applications and compression." This soldier was returned to duty December 22, 1864. Discharged and pensioned, May 7, 1865, for muscular contraction. Case 1323.—Sergeant G. Shapleigh, Co. D, 5th New Hampshire, aged 28 years, was wounded at Gettysburg, July 2, 1863, and treated at Satterlee Hospital. Surgeon I. I. Hayes reported: "A shot flesh wound of the right arm. On July 20th, there was haemorrhage from a muscular branch ofthe brachial to the amount of six ounces; it was arrested by compression." Case 1324.—Private J. Ruhl, Co. K, 88th Pennsylvania, aged 34 years, was wounded at Gettysburg, July 3, 1863, Acting Assistant Surgeon W. V. Keating reported, from Broad and Cherry Streets Hospital, Philadelphia: "A shot wound of the right arm followed by sloughing. On August 10th, there was bleeding to the extent of ten ounces from a muscular branch ofthe brachial; the bleeding was arrested by compression." This soldier was discharged and pensioned September 10, 1863. Case 1325.—Private E. Powers, Co. C, 4th Massachusetts Cavalry, aged 30 years, was wounded at Jacksonville, Florida, March 1, 1864, and was treated at Beaufort, South Carolina. Assistant Surgeon C. E. Goddard, U. S. A., reported: "A shot wound of the upper third of the left arm. On March 15th, there was haemorrhage from a muscular branch of the brachial; treated successfully by compression." The patient recovered, and was discharged and pensioned October 4. 1864. 58 458 INJURIES OF THE UPPER EXTREMITIES. [CHAP.ix. Haemorrhage from the Ulnar Artery or its Branches.—Guthrie1 taught that bleedinf from the ulnar artery would be arrested spontaneously, if the vessel was completely severed. This is doubtless true; but a great liability to consecutive bleeding remains, and he is a rash surgeon who trusts a vessel of this calibre without a ligature, unless he employs torsion, acupressure, or some other substitute. Case 1326.—Private T. E. Curtis, Co. C, 10th Connecticut, aged 19 years, was wounded at Kinston, December 14, 1862, and was sent to New Berne. Surgeon E. P. Morong, 2d Maryland, reported: "December 25th, haemorrhage from ulnar artery to the amount of seventeen ounces; tourniquet applied to the brachial arrested the bleeding;" recovery. Case 1327.—Private H. Olsen, Co. C, 56th Massachusetts, aged 18 years, was wounded at Petersburg, June 17, 1864, and was sent to Harewood Hospital July 20th. Surgeon R. B. Bontecou, U. S. V., reported a shot wound ofthe left hand, ball entering near the pisiform bone, and emerging at the side of the wrist, about an inch below. The ball was cut out August 1st. On August 9th and 10th, there were haemorrhages to the amount of two ounces from branches of the ulnar. An incision was made for the purpose of finding the bleeding vessel, but without avail. No recurrence of bleeding. The patient did well and was returned to duty. Case 1328.—Private J. Cotter, Co. D, 11th Connecticut, aged 22 years, was wounded at Drury's Bluff, May 1(5, 1864, and sent to DeCamp Hospital on May 22d. Assistant Surgeon W. Webster, U. S. A., reported: "A shot flesh wound of the right forearm at the middle third. On June 2, 1864, haemorrhage, to the amount of twelve ounces, took place from the ulnar artery, but ceased after compression, and did not recur." This soldier was discharged December 21, 1865. Case 1329.—Private W. A. Dobbins, Co. B, 84th Illinois, aged 28 years, was wounded at Chickamauga, September 19, 1863. Surgeon C. W. Hornor, U. S. V., reported, from hospital No. 1, Nashville, Ocfober 12th: "Shot flesh wound of the upper third ofthe left forearm. On November 23d, there was bleeding from a branch ofthe ulnar, which was arrested by com- pression ofthe brachial. The bleeding recurred, however, and the patient died May 28, 1864." Lfcemorrhage from the Radial and its Branches.—Four examples were specified: Case 1330.—Sergeant J. E. Broion, Co. K, 13th Mississippi, aged 31 years, was wounded at Gettysburg, July 2, 1863, and sent to the Twelfth Corps Hospital. Surgeon H. E. Goodman, 28th Pennsylvania, reported: "A gunshot flesh wound of the forearm, with haemorrhage from the radial artery July 14th." This soldier was paroled from West's Buildings Hospital. September 25, 1863. Case 1331.—Corporal S. Lowery, Co. G, 92d New York, aged 25 years, was wounded at Petersburg, June 15, 18C4, and sent to McClellan Hospital. Surgeon L. Taylor, U. S. A., reported: "A shot flesh wound of the left forearm at its lower third. Bleeding to the amount of two quarts, from the radial artery, took place on July 7th. It was checked by persulphate of iron and compression." The patient recovered, and was returned to duty December 3, 1864. Case 1332.—Private L. D. Varney, Co. B, 106th New York, aged 22 years, was wounded at Cold Harbor, June 3, 1864, and was sent to McKim's Hospital. Surgeon Lavington Quick, U. S. V., reported: "A flesh wound of the lower third of the left forearm near the wrist. The wound sloughed, and, on July 2d, haemorrhage to the amount of one pint occurred from the radial artery; this was arrested by the application of powdered persulphate of iron, pressure, and ice." No recurrence of bleeding supervened, and this soldier was returned to duty November 28, 1864. Case 1333.—Private J. A. Campbell, Co. H, 81st Illinois, was wounded at Vicksburg, May 22, 1863. He was admitted at Church Hospital, Memphis. Surgeon G. E. Weeks, U. S. V., reported: "A gunshot wound ofthe left hand. On admission the entire palmar surface of the hand was covered with fetid sloughs, and the cavity of disorganized tissue extended nearly to the elbow. Bromine was freely applied, and the wound cleaned rapidly. On August 13th, haemorrhage to the extent of thirty ounces took place from the radial. He died the same day. The autopsy revealed thrombi in the vessels leading to and from the heart." Hozmorrhage from the Lnterosseous Artery.—Three instances were reported of serious bleeding from shot flesh wounds of the forearm, where the interosseous artery was believed to be consecutively implicated: Case 1334.—Sergeant N. Strain, Co. C, 9th Veteran Reserves, aged 28 years, was wounded at Fort Stevens, July 11, 1864. He was treated at Mount Pleasant Hospital. Assistant Surgeon C. A. McCall, U. S. A., reported: "Haemorrhage of thirty-four ounces, from the left interosseous artery, on July 23d, following a gunshot wound of the forearm. The bleeding recurred on August 3d, and again on the 12th, and was arrested by compression, a finger being introduced into the wound." The patient was returned to duty. Case 1335.—Private S. Sharpe, Co. C, 4th U. S. Colored Troops, aged 20 years, was wounded at Deep Bottom, Septem- ber 29, 1864. Assistant Surgeon J. H. Frantz, V.. S. A., reported: "A shot perforating flesh wound of the forearm. At Balfour Hospital, on October 15th, eight ounces of blood were lost; but the bleeding was arrested by cold and compression." Case 1336.—Private C. Lake, Co. H, 10th New York Artillery, aged 27 years, was wounded at Petersburg, July 3,1854. Assistant Surgeon J. H. Frantz, U. S. A., reported, from Balfour Hospital: "A gunshot flesh wound of the forearm. Bleeding to the extent of eight ounces took place on July 10th. It was controlled by compression, and there was no recurrence." 1 See his work On the Diseases and Injuries of Arteries, with the Operations required for their Cure, London, 1830, p. 225: '"In many cases of amputation at the wrist and forearm, in which I wished the patient to lose a certain quantity of blood, I have allowed either the radial or ulnar artery to bleed until it ceased." SECT. 1.1 SHOT FLESH WOUNDS. 459 Three cases of consecutive bleeding from the palmar arches,1 due to sloughing conse- quent on shot injuries of the hand unattended by fracture, were reported without details. One proved fatal. Serious results were reported from 1 Hemorrhages from sloughing wounds implicating the digrtal arteries.2 One fatal case was recorded; but the fatal termination was appa- rently due to pysemic infection. A few additional examples of haemorrhage from collateral branches, inadvertently omitted in the preceding enumeration, may be noted here. There were four reported instances of shot flesh wounds of the shoulder in which grave haemorrhage arose, as was believed, from the supra-scapular branch of the sub- clavian, or from the subscapular arteries.3 There were two examples of fatal consecutive bleeding in shot flesh wounds of the right shoulder, in which it was supposed that the haemorrhage proceeded from ulceration of the acromial thoracic artery.4 A single instance was specified of serious bleeding from the inferior circumflex branch of the axillary.5 Examples have been given already6 of haemorrhages from branches of the brachial. Special reports were made, besides, of two instances of bleeding after sliot injury of the superior profunda, one case proving fatal: Case 1337.—Private J. Johnson, Co. I, 39th Illinois, aged 18 years, was wounded at Bermuda Hundred, May 14, 1S04. Surgeon A. Heger, U. S. A., reported: "On June 23d and 24th, bleedings of from ten to twelve ounces took place from a gun- shot wound of the right axilla. The" haemorrhages proceeded from the superior profunda. Digital compression of the right subclavian was kept up night and day by the hospital assistants. There were slight recurrences of bleeding, however, and the patient died June 24. 16t>4." Another instance of bleeding from the superior profunda is noted on the succeeding page. In these lesions of the branches of the axillary and brachial, as in man}- other circumstances, a precise knowledge of the topographical anatomy will guide the surgeon to a correct treatment; but this knowledge will be unavailing, unless, at the same time, he appreciates the true principles of the management of wounded arteries. 11. Cases of Pt. J. Blanch, 122d Xew York, wounded at Petersburg, April 2, 1865; Surgeon B. B. Wilson, U- S. V., reported from Stanton Hospital, that bleeding from the right superficial palmar arch on April 11th was successfully treated by compression. 2. Of Pt. G. M. Kidd. 46tb Virginia, aged 44. In the records of the Confederate medical department, Vol. LXXIX. p. 63, it is stated that "he was wounded at Atlanta, August 4. 1861. and the left superficial palmar arch was opened by sloughing consequent on the wound, and profuse haemorrhage occurred on August 12th. but was successfully controlled by compression." 3. Of Pt. J. C. Costley, Co. II, 3d Kentucky Cavalry; was wounded at Stone River, December 31, 1 Si>2. Surgeon J. Shrady, 2d Tennessee, reported: ''A shot wound traversing the palm, forearm, and arm, the missile lodging near the spine of the scapula. Haemorrhage from the palmar arches January 12, 1863. Profuse bleeding; death, January 14, 1863." 2 Corporal E. Stewart, 1st Missouri Cavalry, aged 22, was wounded ;i1 the Wilderness, May 5, 1864. Surgeon T. H. Bache, U. S. V.. reported. from Chester Hospital, that "bleeding, to the extent of twenty-four ounces, took place on June 3d, from one of the digital arteries of the right hand. but was arrested by compression." Sergeant T. Rieger, Co. U, 119th New York, aged 28. was wounded at Gettysburg, July 2, 1863. Surgeon I. I. Hayes, U. S. V., reported: "A shot flesh wound of the left hand, with haemorrhage from a digital artery, August 5th, to the extent of two ounces. It was arrested by cold and pressure ; but pyaemia supervened, and death ensued August 19. 1863." 3 Cases: Surgeon R. M. S. Jackson, V. S. V.. reported that Pt. II. G. Whitehead, Co. G, 141st Xew York, was wounded at Atlanta, July 20, 1864, and lost forty ounces of blood, September 25th, at Lookout Mountain, from a shot flesh wound of the right shoulder. The bleeding was supposed to proceed from the supra-scapular artery. The patient died a few hours after the-bleeding. There were two deaths and one recovery in the three oases in which the bleeding was supposed to proceed from the subscapular: Surgeon L. Taylou, U. S. A., reported, from McClellan Hospital, that "Pt. J. F. Cole. Co. F, 35th Massachusetts, aged 23, was wounded at Spottsylvania, May 18, 1864. There was haemorrhage'from the subscapular artery on June 13th, following a shot wound of the left shoulder, and the patient died June 14, 1864." Surgeon H. S. Steakxs, U. R. V., reported, from Paducah: "Pt. A. Young. Co. A, 28th Louisiana, was wounded at Chickasaw Bayou, December 29. 1862, by a shot perforation of the. right shoulder. There was haemorrhage on January 14th, from the subscapular probably. Death, January 15,1863.'' Dr. Stearns also recorded a case of recovery from secondary bleeding from this vessel: " Corporal E. XV. Olney, Co. F, 13th Illinois, was wounded at Vicksburg, December 29, 1862. On January 14th, there was bleeding from the left subscapular artery. The shot track appeared to involve the soft parts only. The bleeding was arrested by the injection of a solution of perchloride of iron, and the patient made a rapid recovery.'' 4 Cases of Pt. J. V. Snyder, Co. I, 12th Iowa. Mid of Pt. T. Snowberger. Co. E, 184th Pennsylvania; the former wounded at Tupelo, and treated at Adams Hospital, Memphis; Assistant Surgeon J. M. Study, U. S. v., reporting a mortal haemorrhage from the acromial thoracic, estimating the amount of blood lost at sixty ounces. Death, August 12, 1864. The second patient was wounded at Petersburg, June 18, 1864, and died at Mount Pleasant Hospital, July 29, 1864. Bleeding from one of the right acromial arteries was temporarily arrested by stj-ptics and compression; but the patient sank the same day. 6 Case of Sergeant J. Black well, Co. E, 24th Michigan, aged 20, wounded at Gettysburg. Surgeon 1.1. Hayes, U. S. V., reported, from Satterlee: "A shot flesh wound of the right axilla, followed, August 2, 1833, by profuse haemorrhage from the inferior circumflex." Duty, March 24, 1864. 6 See Cases 1320 ct seq., p. 457. 4*30 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. In a second case of consecutive bleeding from the superior profunda, a somewhat novel haemostatic method was employed : Cask. 1338.—Private W. Getcher, Co. F, 1st Pennsylvania, aged 24 years, was wounded at Old Church, May 30, lsUl, and sent to Philadelphia. Assistant Surgeon S. A. Storrow, U. S. A., reported a "gunshot wound of the right upper arm. Haemorrhage of twelve ounces from the profunda major, June 14th. The clot being removed and the bleeding recurring, the wound was filled with subnitrate of bismuth, and compression was made by bandages from the wrist." The patient was trans- ferred to Harrisburg, June 16, 1864, for muster out of service. In a number of instances of bleeding consequent on shot wounds of the forearm, satisfactory results were ascribed to the Use of compression, styptics, and the application of cold. Surgeon J. Curtis, U. S. V., reported two cases1 to exemplify the utility of the persulphate of iron under such circumstances. Assistant Surgeon A. Ingram, U. S. A., reported an instance of haemorrhage after a shot lesion of the superficialis volse, arrested by the same means." Reliance on such measures was not always rewarded by success, since in thirteen instances, at least, bleeding from minor branches led to a fatal termina- tion. These cases will be briefly noted. But three were intermediary; in the others, the bleedings3 were later than the first fortnight after the injury: Cases 1339-1351.—Surgeon T. Antisell, U. S. V., reported that: "Major L. Schauniberger. 15th New York Artillery, was wounded at Hanover Court House, May 19, 1864, receiving a shot flesh wound of the right forearm. Profuse haemorrhage took place May 28th, and the officer died from its effects the same day."—Surgeon W. L. Baylor, of the Confederate service, reported that: ''Private A. Luscomb, Co. G, 39th Illinois, was wounded at Bermuda Hundred, May 16, 1864, and captured. He was treated at Petersburg for a gunshot flesh wound of the right arm, and died May 26, 1864, from hsemorrhage, which compression failed to control."—Acting Assistant Surgeon G. W. France reported that: "Private P. Borkvort, Co C, 19th Illinois, was wounded at Vicksburg, January 2, 1863. He was sent to Nashville Hospital No. 7, with 'a lacerated gunshot wound of the left forearm. Haemorrhage amounting to forty ounces,' on January 16th, was controlled by compression of the brachial, and a second bleeding did not occur; but pulmonary trouble set in, and the case terminated fatally February 24. 1863.'"—Medical Cadet, O. M. Pray reported and printed4 an account of the case of "John Wygal, Co. F, 11th Virginia, aged about 25 years, * * * wounded at Williamsburg, May 5, 1862," in the muscles of the right shoulder, by a musket ball. "Secondary haemorrhage occurred about May 21st, from the anterior wound. A plug and compress were used for about three days, and then removed. On the 28th, another haemorrhage took place, and again the wound was plugged. Patient Avas very weak. Slight bieiwuri-lia^e on the 29th. Death took place May 20th."'—Assistant Surgeon A. Hartsuff, U. S. A., reported that: "Private W. Bennett, Co. D, 11th Wisconsin, aged 38 years, was wounded at Fort Blakeley, April 9, 1865, and was treated, at Greenville, for a shot wound ofthe right forearm, and died from exhaustion, due to secondary haemorrhage, April 29,1865."—Surgeon J. H. Taylor, U. S.V., reported that: "Teamster B. Fuller, Sixth Corps, was wounded near City Point, July 16, 1864. He had a shot flesh wonnd of the right shoulder. Secondary haemorrhage took place August 2, 1864, and resulted in death."—Assistant Surgeon C. A. McCall, U. S. A., reported that: "Private B. Atwood, Co. C, 1st New York Dragoons, aged 24 years, was wounded at Old Church, June 11, 1864, receiving a shot perforation of the left deltoid. Death, from haemorrhage, July 2, 1864.''—Surgeon A. J. Ward, 2d Wisconsin, reported that: "Private E. Null, 53d North Carolina, was wounded at Gettysburg. A musket ball had pene- trated the fleshy parts of the right shoulder. He died, July 23, 1863, from secondary haemorrhage."—Surgeon J. G. Hatchitt, U. S. X., reported that: "Corporal A. J Ferris, Co. C, 10th Wisconsin, was wounded at Perryville, October 8, 1862, by a musket ball, which passed through the left shoulder without injuring the bones. Death, from secondary haemorrhage, November 5, 1862."—Surgeon E. S. Cooper. 83d Illinois, reported that: "Captain It. Stephenson, a Confederate officer, aged 33 years, was wounded at an engagement near Fort Donelson, February 3, 1863, and made a prisoner. A musket ball passed through the lower part of the muscular walls of the right axilla without injuring any vessels or nerves of importance. On March 3d, and again on March 5th, there was profuse haemorrhage, a thin dark-colored blood, that did not coagulate, flowing away. The bleeding continued, in spite of compression and the various other haemostatics resorted to, until the date of the death of this officer, May 6, 1863."—Assistant Surgeon E. McClellan, U S. A., reported that: "Private N. E. Sweat, Co. E, 24th Massachu- setts, aged 28 years, was Avounded at Bermuda Hundred, May 18. 1864. a musket ball perforating the right pectoral and delfoid muscles. Death, from secondary haemorrhage, June 26, 1864."—The same medical officer reported that: "Private M. Bayard, Co. C, 116th Ohio, aged 28 years, was wounded at Hatchir's Kun, Marcli 30, 1865. A gunshot flesh wound of the left upper arm was followed, on May 27th, by secondary bleeding, which resulted fatally on the same day."—Surgeon St. J. W. Mintzer reported that: "Private T. Maloy, Co. B, 66th New York, was wounded at Spottsylvania, May 10, 1864. A musket ball i perforated the left arm without fracturing the humerus. Secondary haemorrhage occurred, ai)d was checked by the application of a tourniquet; .but the bleeding recurred, and the patient deserted August 18, 1^54." 1 C.\>E of Pt. C. W. O'Key, Co. C, 6th Wisconsin, aged 23, wounded at Gettysburg, and treated at Cuyler Hospital for a shot wound grazing the right wrist. Haemorrhage, on August 3d, was arrested by the Monsel salt. The case of Pt. A. F. Muller. Co. C, 6th Wisconsin, aged 23, was identical in the reported details. * Case of Pt. J. Dnnkel, Co. D, 148th Penn., aged 33, wounded at Chancellcrsville. Haemorrhage from superficialis vote, May 17,1863. Duty. 3 The dates of hsemorrhage were, in the thirteen cases, ou the 9th, 10th, and 13th days in the three intermediary cases, and in the others the inter- vals were, respectively, 16, 20, 21 (in two cases), 22, 28, 30, 39, 57. and 111 days. 1 Rej>ort of Mill Creek Hospital, Fort Monroe, in Am. Med. Times. 1862, Vol. V. p. 76. SECT. I.] SHOT FLESH WOUNDS. 461 Flesh Wounds involving the larger Nerves—The reports specify ninety-six instances of shot flesh wounds of the upper extremities unattended by injuries of the bones or blood-vessels, but interesting large nerve trunks. The most detailed accounts of such cases are from the Christian Street Hospital, in Philadelphia, where, in May, I860, wards were set apart lor cases of traumatic all'ections of the nerves. Dr. Mitchell, Dr. Morehouse, aud Dr. Keen had charge of these wards, and have published the results of their observations in several important papers. The first1 and second2 were prepared in association by the three observers. A third monograph3 was printed by Dr. Mitchell, in 1S67, on this subject; and, with the Baconian inspiration that every debtor to his profession should also be a- help thereunto, this writer, in 187-J, printed a systematic treatise4 on 1 Gunshot Wounds and other Injuries of Xerves. by S. Weir Mitchell, M. D., GeOKGE R. MOREHOUSE, M. D., and William XV. Keen. M. D., Philadelphia, 1804. In this valuable treatise, Cask 19 (p. 90), of Pt. J. Bieswanger, Co. B, 75th Pennsylvania, was an example of "gunshot wound ot the left brachial plexus, with slight loss of sensation and paralysis of motion. Atrophy and contraction of numerous muscles, and joint lesions, due to disu>e. ensued. Case 22, of Pt. A. Lawton (p. 94), Co. A, 4th Ohio, aged 20, wounded at Chancellorsville, was an instance of "gunshot wound of the brachial nerves, with slight loss of motion and sensation, with early burning pain, diseased joints, and acid sweats." The " vinegar sweats'' are said to have "disappeared during the electrization of the arm, but probably not through its agency." Case 23 (p. 98), of B. Graham, 5th Battery, Massa- chusetts Artillery, aged 22. was a case of "shell wound affecting the musculo-spiral nerve, with trivial loss of tactility; but entire motor paralysis in the ultimate distribution of the nerve." Case 24 (p. 107), of II. Weston, Co E. 18th Massachusetts, aged 42, is the history of an ■' injury of the brachial nerves, resulting in nutritive changes and in burning and neuralgic pains." CASE 27 (p. 12G), l't. L. Monaghan, aged 2!i, wounded at Chancellorsville, May 3, 18o3; "shell bruise of right brachial plexus; slight loss of motion; tonic spasm of the flexor carpi radialis, flexor carpi ulnaris, and palmaris longus, causing violent flexion of wrist; analgesia well marked; no loss of tactility; section of tendons; relief." Case 30 (p. 131), II. Gervaise, Co. F, 1st Vermont Cavalry, aged 20, shot July 7. 1863, in the left arm, at the edge of the biceps, six inches above the internal condyle of the humerus ; exit on postero-internal face of arm ; ulnar and median nerves injured; "paralysis of motion ; slight of sensation; contraction of flexors; relaxation under treatment; atrophy; claw-hand from paralysis of interossei; stinging pain iu hand; great gain; interosseal paralysis alone remains; discharge, with prothetic apparatus." Case 31 (p. 148), Sergeant A. D. Marks, Co. C, 3d Maryland ; shot wound of left brachial plexus ; ■' paralysis of motion and sensa- tion ; muscular hyperesthesia ; intense burning in hand and arm ; contracted extensors ; relief;" discharged April 10, 1864. 2 Circular No". 6, S. G. O., March 10, 1864 (Reflex Paralysis), by S. Weir Mitchell, M. D., George It. Morehouse, M. D., and William XV. Keen, jr.. M. D. Case VII (p. 13), of Pt. M. Farrell, Co. I, 20th New York, aged 28, wounded at Fredericksburg, December 13, 18a2, is an example of , " wound ofthe deltoid; sensory and slight motor paralysis of right arm ; speedy recovery." 3 A. Flint, M. 1). (Contributions relating to the Causation and Prevention of Disease, and to Camp Diseases, New York, 1867, Preface, pp. V, VI), informs us that: "After the termination of the late War of the Rebellion, the United States Sanitary Commission resolved to publish a series of volumes * * under the immediate direction of the medical committee of the Commission, the committee consisting of Professor W.w. II. Van' Buren. M. D., Cornelius R. Agxew, M. D., E isiia Harris, M. D., Professor Wolcott Glbiss, M. D., and Professor J. S. Newberry, M. D. * * This volume is devoted tu topics pertaining to medicine. * * The transportation of the sick and wounded, together with other kindred topics, and all those which belong to surgery are assigned to other volumes." The twelfth chapter of the volume thus prefaced is a paper by Dr. 8. Weir Mitchell, On the Diseases of Xerces resulting from Injuries (pp. 412-468), containing abstracts of a large number of cases observed at the " United States Army Hospital for Injuries and Diseases of the Nervous System." It is difficult to understand why this topic was supposed to have no relevancy to surgery. Perhaps the exclusive devotion to medicine of Professors Gibbs and Newberry led them to regard the cases only in their relations to internal pathol- ogy. This important paper contains abstracts of the following "War cases " of shot flesh wounds of the upper extremities, with lesions of the nerves, unattended by injuries of the bones or blood-vessels : Case I (p. 455), J. Albaugh, Co. G, 83d Pennsylvania, aged 19, wounded at Chancellorsville, May 3, 1803; ball passing through interosseal space ofthe right forearm ; "partial loss of sensation ; immobility of fingers and wrist owing to disease and adhesion; recovery." Case II (p. 456), C. Behr, Co. K, 1st Minnesota, aged 26, shot at Gettysburg, July 2. 1863, in the left hand, between the thumb and forefiuger, ball finally entering half an inch below the clavicle; " wound of brachial plexus ; paralysis, atrophy, and contraction of numerous muscles ; burning pain until wound healed; motions limited by general stiffening of the joints." Case III (p. 457), G. T. Barnes, Co. D, 68th Pennsylvania, aged 25, wounded at Gettysburg, July 2, 1863, at the antero-superior angle of left axilla; axillary nerves injured; "extensive paralysis of forearm and band; loss of sensation ; great improvement under treatment; continued gain afterward." Case V (p. 401), R. C. Phillips, Co. C, 4th New Vork, aged 20, wounded at Gettysburg, July 2, 1863; ball entered the left chest, and lodged in the left arm on a level with the posterior border of the armpit; two hours later the missile was cut out; axillary nerves injured; " total loss of motion; extensive atrophy ; gradual gain ; partial loss of sensation ; slight causalgia and neuralgia; relief of both; tremors; great general gain." Case VI (p. 403), D. Shiveley, Co. E, 114th Pennsylvania, aged 17, shot at Gettysburg, July 2, 1813; the ball entered an inch above the sternal end of the clavicle and escaped on the posterior part of the right arm two inches below the axilla; axillary nerves injured; " paralysis of motion; slight of sensation; burning on tenth day; great atrophy and contracted muscles; subluxation of fingers; nutritive changes; eczema in both palms; great improvement; discharged." CASE VII (p. 406), of II. Gervaise, has been mentioned as Case 30, in Note 1. 4 Dr. S. Weir Mitchell (Injuries of Nerves and their Consequences, 187, cites the following instances of shot flesh wounds of the upper extremities, with lesion of the nerves : Case 19 (p. 145), a private, " shot through the brachial plexus, became wildly excited, crying murder repeatedly, and accusing those near him of having shot him. He did not fall." Case 20 (p. I45j, " An officer, shot through the right median nerve, talked some- what incoherently, * * had not the least remembrance of having been shot." Case 21 (p. 14")), a ' wagonmaster, shot through the left ulnar nerve," destroying the trunk as well as the ulnar artery, resulting in loss of sense and motion. Case 33 (p. 200), " II------, aged 39, shot July 2, 1863, through inner edge of the right biceps, half an inch above the internal condyle of the humerus; glossy skin, causalgia and neuralgia; joint disease; acid sweats; slight loss of tact; constitutional symptoms." Case 34 (p. 204), of Mouaghan has been mentioned as Case 27, in a preceding note. Case 35 (p. 207), J. D------, Co. F, 09th Pennsylvania, aged 23, shot in the left forearm behind the ulna, four and a half inches below the olecranon process ; median and ulnar nerves involved ; " paralysis of motion ; none of sensation ; rigid fingers from joint disease ; neuritis and causalgia from tenth day; relief by blisters; eruptions above the limit of causalgia; red palm." CASE 37 (p. 209), G. L------, Co. C, 1st Minnesota, aged 31, wounded July 3, 1803 ; the ball entered the right biceps three and a quarter inches above the level of the internal condyle, and made its exit three and a quarter inches directly below, wounding the main artery and the ulnar and median nerves; "atrophy and contraction of flexor muscles; atrophy of all the hand muscles; ueuro-traumatic arthritis; loss of sensation; moderate improvement; discharge.'' Case 42 (p. 252), of II. Gervaise, has already been men- tioned as Case 30, in Note 1. Case 47 (p 290), J. H. Corliss, Pt., Co. B, 14th New York Militia, aged -7. shot at the Second Bull Run. August 2), 18;i2, iu the left arm, three inches directly above the internal condyle ; " injury of median and ulnar nerves ; loss of motion ; excessive causalgia; exsection of four inches of median nerve ; no relief." Case 50 (p. 29s), A. F. Swann, Captain, Co. C, 10th Pennsylvania Cavalry, aged .34, wounded at Cold Harbor, May 28, 1864, by a minie ball, which entered the left forearm two inches below the head of the radius, and made its exit just above the inner condyle 462 INJURIES OF THE UPPER EXTREMITIES. [Ciiap. ix. injuries of the nerves, dealing largely with the results of shot lesions of the arms. The special cases referred to by these authors are indicated, in the footnotes, and it is proposed here to advert cursorily to the subject, as it must come up hereafter in connection with the shot fractures of the upper extremities, and is well deserving of separate consideration. Others have printed contributions on this subject from observations made in the Union and Confederate hospitals. The late Professor J. C. Nott, of Mobile, in a paper1 published in 1866, promised an account of cases of shot injuries of the nerves; but did not live to fulfil this purpose. Dr. W. P. Moon published2 several abstracts of cases of shot lesions of the nerves of the upper extremity unattended by fracture, one of which was an example of neurotomy for the relief of traumatic neuralgia. Drs. Mursick, Eve, Stewart, and Birdsall3 have published observations of shot flesh wounds of the upper extremities interesting the nerves. As so many histories of cases of this category are thus accessible for reference, but few will be detailed here: Case l'.i~>2.—Private J. Carroll, Co. E, 61st New York, aged "28 years, was wounded at Antietam, and was treated in a Second Corps field hospital, and afterward at Satterlee. Acting Assistant Surgeon W. S. Halsey reported: "Admitted, Septem- ber 27, 1802. with gunshot wound of the right arm, a buckshot passing under the skin just below the axilla, injuring the internal cutaneous nerve. On October 20th, I dissected carefully down to the internal cutaneous nerve, following the cicatrix, when the nerve was reached and examined. He attributed all his distress to that part. Nothing was found that resembled a foreign body; a hard and knotty substance, however, was felt along the course of the nerve, and seemed to be a part of it. This was cut out by dividing the nerve and removing about a half inch. The wound had healed up, broken out again, discharging a large quantity of pus and a piece of cloth, and again closed. He complained of great pain along the inside of the arm and elbow, and, though somewhat relieved after the discharge of the cloth, the pain was still intense. Great relief followed the operation, but all power over the forearm was lost. From this time, he complained of sharp pain near the acromial process. The wound healed, but the pain.in the shoulder continued. About December 13th, the pain in the arm and forearm gradually increased in severity. Belladonna plasters were used, and hypodermic injections of morphia in solution, giving relief for a limited period only. The cause of the pain was no doubt due to the injury to the nerve, and subsequently to the new cicatricial tissue, which bound the nerve clown to the surrounding parts and by its contraction kept up a continual strain on it. The return of the old pain was probably due to the formation of a new cicatrix, acting in the same manner." The patient was discharged the service, on certificate of disability, on February 24, 1863, Surgeon I. I. Hayes, U. S. V., certifying to "partial paralysis of right arm, and neuralgia of the same." It does not appear that he ever applied for a pension. Lnjuries of the Brachial Plexus.—Thirteen examples were specially reported of shot wounds implicating the brachial plexus, though unattended by injury of the bones or blood-vessels. Two of these have been published in detail, and are enumerated, with brief references to the eleven others, in the subjoined footnote.4 Paralysis resulted in of the humerus; " median nerve injured ; causalgia; excision of three inches of the median nerve ; entire relief." CASE 55 (p. 311), T. B. W-----, 29th Pennsylvania, aged 17, wounded at Gettysburg, July 2, 1863, by a ball, which entered the middle arm behind the brachial artery, three-fourths of an inch below the uppermost part of the axillary hollow; nerve lesions; "loss of motion and slight loss of sensation; relapse from neuritis, with contrac- tion of flexors, and ' claw-hand ;' recovery." i NOTT (J. C), Contributions to Bone and Nerve Surgery, Philadelphia, 1866. The author remarks: " I have, during the War, witnessed a num- ber of cases of neuralgia following gunshot wounds and amputations, which I may work up at some future day, aud can make room at present for but two cases, which are of unusual interest both for their novelty and practical bearings." The two examples of neuromata, for which room was made, were unconnected with war-surgery, and before the profess'r had worked up the examples of shot lesions of nerves Mors pallida overtook him. 2M00X (W. P.), Cases of Gunshot Wound of Neck, Arm, Forearm, etc., in Am. Jour. Med. Set, 1868, Vol. LV, p. 54. CASE III is that of Corporal J. Dixon, Co. F, 8th New York Artillery, a shot wound of the right forearm, in which, after an unavailing excision of a portion of the radial nerve by Dr. MORTON, amputation was practised. This report may be supplemented by the records of this Office, which show that " this man was discharged June 24, 1865, and pensioned, and was an applicant for increase of pension, August, 1874.'' 3 Ml'iisick (G. A.) (Report of a Case of Gunshot Injury of the Median and Internal Cutaneous Nerves, in New York Med. Jour., 1866, Vol. II, p. 174); Eve (P. F.) (Cases of Gunshot Wounds, in The Nashville Jour, of Med. and Surg., 1867, Vol. II, p. 224); Birdsall (S.) (Report of a Case of Wound of Median Nerve, in Philadelphia Med. and Surg. Reporter. 1866, Vol. XV, p. 434); and Stewart (J. L.) (Ibid., 1871, Vol. XXIV, p. 92). 4 The case of Sergeant G. F. Barnes, Co. D, 68th Pennsylvania, has been already mentioned in the reference to Dr. S. Weir Mitchell's paper in the Memoirs of the Sanitary Commission, 1867 (Vol. I, p. 413). The case of Sergeant J. Bieswanger, Co. B, 75th Pennsylvania, had also been adverted to in the enumeration of the cases detailed by Drs. Mitchell, MOREHOUSE, and KEE.V (Gunshot Wounds and other Injuries of Nerves, 1864, p. 90). Both of these men were pensioned. Examiner H. L. Hodge reported, April 6. 1864, in the case of Barnes, that: " On account of a gunshot wound of the left axilla the hand is perfectly useless, being without, sensation and incapable of movement." The Pension Examining B->ard of Phila- delphia reported. September 11, 1873. "' paralysis of hand, equal to loss of it." In the case of Bieswanger, the Philadelphia Examining Board reported, August 23, 1871: "There is complete paralysis of the extensor muscles of the left hand, rendering his hand almost useless. He complains of severe neuralgic pains in the arm and hand." In September, 1873, the Board reported : '' Atrophy of pectoral muscles ; contraction of ring and little fingers; thumb deformed and contracted on the palm." Information is found on the pension reports of five others discharged for disabilities resulting from shot lesions of the brachial plexus: Pt. S. R. Baker, Co. H, 38th Massachusetts, wounded at Winchester, September 19, 1864, was reported by Surgeon C. X. CHAMliEELAIX, U. S. V., from Dale Hospital, as a case of " shot injury to the left brachial plexus, with partial loss of use of arm and fingers." This soldier was discharged and pensioned, July 26, 1865. The Boston Pension Examining Board reported, September 5. 1873 : " Ho has an aneurism of tho SECT. I.] SHOT FLESH WOUNDS. 463 eight of the cases, and the patients were discharged from service, and seven were pen- sioned. Four patients recovered and were returned to modified duty. One patient died from tetanus. Lnjuries of the Circumjlex, J\[usculo-cutaneous, and jllnsculo-spiral Nerves.—Eleven instances were recorded of shot lesions of one or more of these nerve trunks. Two cases have been cited in detail. One patient succumbed from tetanus, and the record of the autopsy is appended. Other examples of the results of such lesions may be found among the cases already noted: Cask 1353.—Private H. Quigley, Co. 0, 1st Kansas, aged 28 years, was wounded at Wilson's Creek, August 10, 1861, and sent to St. Louis on August 17th. Assistant Surgeon S. M. Horton, (J. S. A., reported: "The wound was caused bya minie ball, which perforated the arm at the middle of the right biceps, emerging through the posterior portion at the junction of the middle and lower thirds. In its course, the median and internal cutaneous nerves were lacerated. The wound healed kindly; but a neuroma was formed where the nerves had been wounded, embracing the two nerves at that point. The tumor was as large as a small walnut. The neuralgia that, resulted was incessant, and of the most intense character. From one and a half to two grains of sulphate of morphia had to be given at night to afford the man any rest. Bathing the hand in cold iced-water during the day for four months afforded him very much relief, the hand feeling easy. But if the hand was permitted to become dr}- and warm, and a narcotic was not administered, the pain returned. After a furlough of thirty days, he returned in Febru- ary with the hand much less painful, the neuroma having nearly disappeared. In one month he was sent as attendant to the hospital at Jefferson Barracks." He was discharged October 10, 18(52. and pensioned. Examiner J. C. Whitehill, of St. Louis, reported, September 9, 1^1)7: "The applicant was shot through the right arm, wounding the median and ulnar nerves, whence sensation is partially destroyed. The hand is deformed from muscular and tendinous contractions, and the arm is considerably smaller than the other. He has some use of the thumb and forefinger, but the whole hand is almost useless." In October, 1873, the St. Louis Pension Board reported substantially as above, describing: "Atrophy of the arm and forearm; contraction of all the fingers of the right hand on the palmar surface." The autopsy in the fatal case of this category did not corroborate the view of some of the German pathologists,1 that proliferation of the connective tissue of the white brachial artery near the elbow joint. * * * The circulation in the hand is weak ; the fingers are very small and atrophied, but have good motion, although not much power." Pt. J. Mulhern, Co. A, 8th Kansas, aged 27, wounded at Chickamauga, September 19, 1863, is reported by Acting Assistant Surgeon S. F. Few to have received a "shot wound of the right axilla, passing through and injuring the brachial plexus of the nerves." This soldier was discharged July 27, 1864. and pensioned. The discharge certificate stated that there was "partial paralysis of the limb and contraction of the muscles." Fxaminer C. Rowland, of Brooklyn, reported, December 12, 1864, that the "disability will soon be removed." The pensioner was last paid March 4, 1866, and hence it is probable that the prognosis of the examiner was verified. • Pt.,C. F. Pearson, Co. A, 40th Massachusetts, was wounded at Cold Harbor. June 1 1814. Acting Assistant Surgeon JOHN Stearns, jr., reported, from the hospital at Readville, Massachusetts: "A severe gun- shot injury of the right brachial plexus by a musket ball. Partial paralysis of the limb ensued. The patient was discharged May 7, 1865." Examiner I. F. Galloupe reported, April 11, 1867, that: "A musket ball entered right arm three inches below the acromion, at the inner edge of the deltoid muscle, passed through the axilla, and made its exit from the back one inch from the spine, on a level with the inferior edge of the scapula. The bone was not injured. Ihe arm is partially paralyzed. The thumb and first three fingers are numb, and cau be but partially flexed with difficulty. The whole limb is iveak, easily fatigued, and painful if much used.'' Dr. Oalloupe, in two subsequent examinations, March 7, 1868, and September 9,1873, reported substantially as in the foregoing statement. Corporal C. Haynes, Co. D, 33d Massachusetts, was wounded October 29, 1863. Acting Assistant Surgeon W. E. Towxsend reported, from Mason Hospital: "A gunshot wound from the brachial plexus, causing paralysis of the arm. Discharged February 16, 1864, and pensioned." Examiner A. S. McLean', of Springfield, Massachusetts, reported, November 2, 1868: "A ball, entering near the middle of the posterior edge of the left sterno-cleido-mastoideus, emerged from the middle of the left trapezius, causing injury of the cervical plexus, and corresponding pain and weakness of the muscles supplied by some of its branches." Pt. J. XV. Hollingsworth, Co. C. 18th Indiana, aged 22, was wounded at Cedar Creek, October 19, 1864. Assistant Surgeon C. H. Ai.dex, U. S. A., reported: "A severe gunshot wound of the left arm, injuring the brachial plexus." The patient was discharged June 17, 1865, and pensioned. Examiner N. D. Thomas, of Rockville, Indiana, reported, February !>, 1866, that: " The arm and foreann have atrophied until greatly reduced in size. He states that he suffers pain in the limb nearly all the time, and that he can use the limb but little." Examiner C. Leavitt reported, March 4, 1870: "There are no contractions or adhesions, yet there is doubtless some weakness of the limb." The eighth soldier discharged for this form of injury was Pt. B. I). Libbey, Co. F, 20th Maine, aged 41, wounded at Gettysburg, July 1, 1863. Surgeon J. J. Rekse, U. S. V., reported, from Christian Street Hospital: "A gunshot wound ofthe brachial plexus, producing paralysis agitans. Discharged November 30, 1864." The four cases returned to full or modified duty were : Pt. P. O'Sullivan, Co. F, 6th New York Artillery, age 20, wounded at Cold Harbor, May 10, 1864. Assistant Surgeon C. H. Alokn, U. S. A., reported : "A gunshot wound ofthe left shoulder, injuring the brachial plexus; the patient was transferred to the Veteran Reserves October -27, 1864.'' Pt. H. C. Reynolds, Co. B, 75th Indiana, aged 20, was wounded at Chattanooga, September 21, 1863. Assistant Surgeon XV. C. Daniels, U. S. V., reported: "A ball passed through the muscular parts of the left arm, injuring the brachial plexus of nerves; causing partial paralysis." The patient was transferred to the Veteran Reserves March 7, 18f>4. The Indianapolis Board reported unfavorably on his application for pension, which was consequently rejected. Pt. T. Burns, Co. C, 69th Pennsylvania. was wounded at Mine Run, September 16, 1863. Assistant Surgeon C. H. Alden, U. S. A., reported: "A severe shot flesh wound of the right arm, with injury to the brachial plexus." The patient was returned to duty September 5, 1864. Pt. J. Dunbar, Co. F, 69th Pennsylvania, aged 23, was wounded at Gettysburg. Assistant Surgeon C. H. ALDEN, U. S. A., reported: "A severe shot wound of the right shoulder, with injury of the brachial plexus; duty March 2, 1864." The case that terminated fatally from tetanus was reported by Assistant Surgeon D. C. PKTEU8: '' Pt. H. L. Prince, Co. F, 7th Maine, aged 18, was wounded at Cedar Creek, receiving a shot laceration of the left shoulder, involving the brachial plexus. Symptoms of trismus appeared on October 24, 1864, five days after the injury, and blisters to the spine, tartar emetic, opium, and stimulants were unavailingly employed, the case ending fatally October 25. 1864." 1 Rokitaxsky (C.) (Uber das Auswachsen der Bindegewebs-Substanzen und die Beziehung desselben zur Entziindimg, Wien, 1854); Demme (H.) (Beitrage zur pathologischen Anatomic des Tetanus, Leipzig, 1859); Tiiamhayn (O.) (Beitrage zur Lehre vom Tetanus, nach den neuern Untersuch- ungen uber denselben, in SCHMIDT'S Jahrbiicher, 1861, B. 112, S. 210). HASSE (K. E.) (Handbuch der Speciellen Pathologie und Therapie, Erlangen, 1855, S. 602) expresses grave doubts of the correctness of this view. ■164 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. medullary matter of the cerebellum, medulla oblongata, and spinal cord should be regarded as the constant anatomical lesion of tetanus. The eleven cases are mentioned below.1 Case 13.">4.—Corporal J. S. Mills, Co. A, 57th Massachusetts, aged 22 years, was wounded at Fort Steadman, Marcli 25 1SG."), and was admitted to Mount Pleasant Hospital, Washington. Assistant Surgeon H. Allen, U. S. A., noted: "Gunshot flesb wound of left upper extremity. Traumatic tetanus appeared April 11th, and death ensued x\.pril 15, 1865. Sectio cadaveris Upon laying open the track of the ball, it was found that the external cutaneous branch of the musculo-spiral nerve had been wounded. The tissues were matted together, of a dark color, and filled with a bloody serum. The bone was denuded for a space as large ;is a shilling, but no fracture. All the other tissues and organs in a remarkably healthy condition. The wound had been allowed to close rapidly. The treatment consisted of morphia and brandy in large doses, counter-irritation to the spine, with liquor ammoniae; and supporting the constitution with beef essence, egg-nog, etc. There was no evidence that the patient had been exposed to cold, draughts of air, dampness, or excessive heat." Injuries of the Median Nerve.—Shot flesh wounds in which lesion of this nerve was regarded as the principal feature were reported in thirty-six instances, to three of which allusion has been made. Five of these patients were returned to duty; twenty-eight, of whom fourteen were pensioned, were discharged for disability; and three died. Three cases furnished specimens to the Museum. Two cases will be detailed, and the others concisely enumerated: Case 1335.—Private M. Hanighan, Co. I, 2d Infantry, was wounded at Gaines's Mill, June 27, 1862, and was sent to Douglas Hospital, Washington. Surgeon Peter Pineo, U. S. V., reported: "Patient entered this hospital on July 4th, with a gunshot wound of the left arm at the junction of the middle and lower thirds, involving the median nerve. The wound healed kindly, but left a neuralgic condition of the hand, which has thus far, December 13th, yielded to no treatment, either local or general. December 17th, he was operated upon by Surgeon P. Pineo, U. S. V., and one and a quarter inches of the median nerve was resected. At eight in the evening, the hand was very warm, and there was some pain; but the patient was too much influenced by ether to give a correct statement of his feelings. He was ordered half a grain of sulphate of morphia. On December 18th, he complained of soreness of the hand, with considerable pain; he had enjoyed some sleep the previous night. On December 19th, the patient complained of the sensitiveness of the hand, even to jarring catised by a person walking across the floor. On December 20th, the patient was removed to a separate room; he slept quite well last night. * * December :24th, no improvement. December 29th, his hand is more painful. After January 1, 1863, the patient thought he improved slowly, but that he would never get well if he remained in hospital, and his discharge was granted him February 14, 1833; the patient then felt quite well, and said his hand pained him less than usual, and thought he would be able to get home without any trouble. He left for Xew York at three in the afternoon of the day of his discharge. The foregoing statement is given by Dr. G. L. Sutton, who has had the'immediate charge of the case. An important point in this case is the fact that the patient always complained of pain in the extremities of the ulnar as well as of the median nerve, aud while the pain was less in the extremity of the median after the operation, it was the same in the ulnar. Another point is, that a less amount of the nerve was taken away in this case than in that of Corliss, and the pain, though manifestly less, was not so complete as when double the amount of nerve tissue was removed." The specimen, consisting of one and one-fourth inches of the median nerve, was con tributed to the Museum {Cat. Surg. Sect., p. 499, Specimen 958) This soldier was pensioned, Surgeon Pineo recording on his certificate of disability: "Gunshot wound of arm, injuring the median nerve." This man re-enlisted May 14, 1867, and was discharged March 22, 1869, his pension being resumed from that date. Examining Surgeon W. W. Potter, of Washington, reported, August 6, 1869: "A minie! ball entered the outer lateral aspect ofthe left arm three inches above the bend ofthe elbow, direction inward, passing anterior to the humerus; the exit was from the inner lateral aspect ofthe arm. The median nerve has sustained injury near the point of exit of the missile, causing hyperaesthesia. The muscles are soft and atrophied, especially those of the hand, and the extremity is carried in an extended position, flexion being painful." Examining Surgeon J. O. Stanton, September 10, 1873, reported: "Cicatrices well healed; paralysis of forearm and hand; atrophy of the muscles; has no control of the left hand; disability total." The pensioner was paid June 4, 1874. 1 CASES of: 1. Pt. H. C. Phillips, Co. C, 44th New York, cited as Case V, in Note 3, p. 461 ante. 2. Pt. W. Gray, Co. B, 140th New York, aged 20 years, wounded at the Wilderness, May 5, 1864. Surgeon R. A. Ciiiustian, U. S. V., reported, from Turner's Lane Hospital: " Severe shot flesh wound of the left arm, involving the musculo-cutaneous nerve; discharged August 16, 1864.'' Not a pensioner. 3. Pt. H. Carneil, Co. G, 29th Wis- consin, aged v.'6, wounded at Murfreesboro', April 8, 1864. Surgeon H. Culbertsox, U. S. V., reported, from Harvey Hospital: "Gunshot flesh wound on the under face of the right arm on a level with the axillary fold, anteriorly, wounding the external cutaneous nerve, and inducing paralysis of sensa- tion of the outer half of the left arm and forearm, the thumb, fore and middle fingers, with paralysis of motion of the biceps and brachialis anticus. The patient was transferred to the Veteran Reserves October 7, 1864." A fourth, Case 1352, and a fifth, Case 1353, have already been adduced. 6. Lieutenant B. S. Fitch, Co. C, 157th New York, aged 19; Gettysburg, July 2, 1863. Surgeon J. W. PETTINOS, U. S. V., reported, from Camp Parole, Anuapolis: "Gunshot flesh wound of the left forearm, involving the musculo-spiral nerve. The patient was returned to duty October 13, 1863." 7. Lieutenant S. C. Smith. Co. 1,1st Maine Cavalry; wounded at Rappahannock Station, October 3,1863. Surgeon H. W. Di cachet, U. S. V., reported: "Gunshot wound of the inner side of the right arm, with injury of the musculo-spiral nerve. The patient was returned to duty November 3, 1863. ' 8. Corporal J. F. Elliott, Co. G, 5th Wisconsin, aged 23; wounded at the Wilderness, May 4, 1864. Surgeon 11. A. Christian, U. S. V., reported: ■• Severe gunshot flesh wound of the left arm, involving the musculo-spiral nerve. The patient was returned to duty September 9, 18U4." 9. Pt. W. II. Barkey, Co. K, 149th Pennsylvania, aged 22; wounded at Spottsylvania, May 12, 1864. Surgeon It. A. CHRISTIAN, U. S. V., reported: "Gunshot wound of the right arm, involving the musculo-spiral nerve. The soldier was transferred to the Veteran Reserves October 27, 1864." 10. Pt. T. J. Orentt, Co. L, 2d New York Artillery, aged 25: wounded at Cold Harbor. June 4, 1864. Surgeon R. A. CHRISTIAN, U. S. V., reported: "Gunshot wound of the middle third of the left arm, involving the musculo-spiral nerve. The patient was transferred to the Veteran Reserves October 27, 1834. The eleventh case (Case 1354) has been given iu detail. sect. 1.1 SHOT FLKSII WOUNDS. 165 Neurotomy was resorted to in the next_ ease, which furnished several specimens' to the Museum. Notwithstanding recent experiments, this appears a surgical resource to be entrusted only to practitioners possessing more than ordinary physiological knowledge: ('ask 1356.—I'rivate B. Knox, Co. A, Isl Delaware Cavalry, aged 27 years, was wounded at F.dward's Ferry, February 1,"), lS.i."). and on the 19th was received into Armory Square Hospital, Washington. Acting Assistant Surgeon II. E. Woodbury furnished the following special report: "The patient's injuries were, 1st: A gunshot flesh wound ofthe outer aspect ofthe lower third of the left thigh; ball extracted from anterior surface of knee just above patella. Also gunshot flesh wound of right arm ; ball entered the outer aspect just below the elbow, and passed upward and inward through the biceps muscle. Point of exit about four inches above point of entrance. The ball in its course injured both the ulnar and median nerves. The wound ofthe thigh healed rapidly. A neuroma was formed on the ulnar; this I extirpated April 3, 1865, and sent tlie specimen, with history, to the Army Jledical Museum at nearly that date. Temporary relief followed, but the pain returning, on April 7th the surgeon in charge tried separating the ulnar nerve. April 10, 183 ">, the patient still suffering, at his request it was decided to amputate. The patient was put under the influence of ether, and the surgeon in charge amputated. The patient seemed to be doing well until April 22d. when he had a severe chill. From this time the symptoms of the pyaemia were well marked. Sulphite of soda, iron, and quinine were freely given, with stimulants, but the patient firmly believed he would die, and gradually sank until April 23th, when he breathed his last." Casks 13r>7-13'.)i).—Ft. R. M. Whiteside, Co. F, 40th New York, aged 23; Gettysburg, July 2, 1863; median nerve injured: discharged August 16, 1864.—Ft. J. O'Eourke, Co. E, 5th Michigan; Gettysburg, July 2, 1863; shot wound of median nerve of left arm; duty. May 7, 1864.—Pt. L. Stueker, Co. H, 75th Pennsylvania, aged 33; Gettysburg, July 2,1833; gunshot wound of median nerve; mustered out October 3,1834.—Corp. M. Irwin, Co. F, 57th Pennsylvania, aged 30; Gettysburg, July 3, 186!; shot wound of right median nerve; discharged October 31, 1834, and pensioned.—Pt. R. H. Shumway, Co. G, 5th Wisconsin, aged 29: Fredericksburg, May 3, 1863; slight flesh wound of right median nerve; discharged July 26, 1864, and pensioned.—Pt. M. Cussing, Co. F, 14th Connecticut, aged 22; Morton's Ford, February 6, 1864; shot wound of lower third of right arm; median nerve injured; discharged October 18, 1835.—Corp. M. S. Ditson, Co. K, 20th Massachusetts, aged 24; Gettysburg. July 2, 1863; shot wound of median nerve; discharged January 8. 1864, and pensioned.—Pt. M. Kennedy, Co. H, 90th Pennsylvania, aged 16; Wilderness, May 5, 1864; shot flesh wound, involving median nerve; duly, February 7, 1865.— Pt. W. A. Sturdy, Co. I. 18th Massachusetts; Bull Run, August 30, 1862; median nerve injured; discharged August 16, 1863, and pensioned.—Pt. H. Yandever, Co. A, ".th Michigan, aged 35; Williamsburg, May 5, 1862; shot wound of median nerve; discharged September 25, lv>4.—Corp. C If. Dinkias, Light Artillery, aged 31; Petersburg, July 18, 1864; injury of median nerve;2 discharged March 1. 1865.—Pt. M. Miller, Co. A, 111th Pennsylvania, aged 18; Peach Tree Creek, July 20, 133-1; median nerve severed; discharged May 31, 1865.—Pt. G. I. Grothers, Co H, 22d New York Cavalry, aged 21; City Cross Roads, October 1, 1864; division of median nerve; discharged May 18, 1865.—Pt. D. A. Pat ton, Co. E, 129th Illinois, aged 24 : Peach Tree Creek, July 20, 1864; median nerve injured; discharged January 24, 1865, and pensioned.—Pt. J. O'Brien, Co. K, 5Qd Illinois; Shiloh, April 6, 1862; shot wound of left median nerve; erysipelatous inflammation; discharged September 22, 1832.—Pt. L. Wheat, Co. I, 71st Xew York, aged 21; Bull Run, August 29, 1832; shot wound involving the median nerve; discharged June 17, 1863.—Corp. J. llossack, Co. A, 142d Pennsylvania, aged 26; Wilderness, May 5, 1834; shot wound of median nerve; discharged July 27, 1865, and pensioned.—Pt. H. Griffy, Co. F, 8th Indiana, aged 23; Cedar Creek, October 19, 1864; shot injury of median nerve; discharged July 1, 186").—-Pt. E. Bacon, Co. A, 20th Massachusetts, aged 25; Spott- sylvania, May 12, 1864; median nerve injured; discharged August 29, 1835, and pensioned.—Pt. U. Smith, Co. C, 15th Iowa, aged 23; Atlanta, August 14, 1864; shot injury of right median nerve; discharged.—Serg't W. Peohlar, Co. D, 8th Maryland, aged 34; Spottsylvania, May 12, 1834; shot injury of the median nerve; duty, October 8, 1864.—Pt. J. Rowland, Co. I, 45th Pennsylvania, aged 24; Spottsylvania, May 12, 1834; severe flesh wound of left arm, injuring the median nerve; discharged September 15, 1865, and pensioned.—Corp. T. Tucker, Co. D, 61st Pennsylvania, aged 27; Spottsylvania, May 12, 1864; shot wound of left median nerve; transferred to V. R. C., March 25, 1835.—Pt. W. H. Nelson, Co. C, 184th Pennsylvania, aged 19; Cold Harbor, June 3, 1864; shot injury of right median nerve; transferred to V. R. C, March 17, 1865.—Pt. John Repp, Co. B, 20th Pennsylvania, aged 32; Fort Harrison, September 29, 1864; shot wound of right arm and forearm, with injury of median nerve, and also shot wound of left arm, for which the arm was amputated; discharged January 29, 1836, and pensioned.— Pt. F. Eos, Co. F, 93d Pennsylvania, aged 44; Wilderness, May 5, 1864; flesh wound of right arm, involving median nerve; discharged October 17, 1834.—Corp. B. Graham, mentioned as Case 23, in note 1, on page 461 ante.—Pt. H. Gervaise, cited as Case 30, in note 1, on page 431 ante.—Pt. G. L. Squiers, Co. C, 1st Maine, aged 32; Gettysburg, July 3, 1333; injury of median and ulnar nerves; discharged April 6, is34, and pensioned.—l't. R. Macauley, Co. D, 71st Pennsylvania, aged 20; Wilderness, May 6, 1864; shot flesh wounds of right median and ulnar nerves; discharged March 17, 1863.—Sergeant A. D. Marks (see Case 31, in note 1, on page 431 ante).—Pt. J. H. Corliss,3 mentioned as Case 47, in note 4, on page 431 ante.—Pt. P. Lehman, Co B, 42d Pennsylvania, aged 22; Antietam, September 17, 1832; shot injury of the left median nerve; death, September 25, 1862.—J. H. Matthews, Co. F, 83d Illinois; wounded in the left arm, February 17, 1833; median nerve injured; traumatic tetanus; death, February 22, 1833. 1 Specimen 4038 is an oblong neuroma (Cat. Surg. Sect., p. 529); specimen 4056 (ibid) is a " wet preparation of portions of the median and ulnar nerves" * * after amputation * * '• upon each of the nerves a sliglit neuromatous enlargement is noticeable." Specimen 4095 (I. c, p. 502) shows "the soft tissues from the stump,'' in the foregoing case. 2Hallovvay (J. W.), Consecutive and Intermediate Hcemorrhage, etc , in Am. Jour. Med. Sci., 1865, Vol. L, p. 340; Case VII. Shot Injury of the Median Nerve. 3This case furnished Specimen 959, of Section I, of the Army Medical Museum, Surge.m P. Pineo, U. S. V., having exsected " tw;> inches of the median nerve, * * for excessive neuralgia of the palmar portion of the hand and fingers following a flesh wound ef the left arm at the junction of the upper thirds.''—(Cat. Surg. Sect, p. 449.) 59 •16<3 INJURIES OF THE UPPER EXTREMITIES. |('IIA1'. IX. Injuries of the Ulnar Nerve-.—Seventeen cases were reported, and ulterior informa- tion of thirteen of them is obtained from the pension reports. A plaster cast in the Museum, described at page 533 of the Surgical Catalogue, designates one of the cases.' Tlie remainder will be briefly enumerated: Case 1391.—Corporal C. Hinds, Co. A, 9th New York Cavalry, aged 28 years, was wounded at Falling Waters, Mary- land, July 7. 1833. and was left at Boonsboro' until January 11, 1834, when he was received into Armory Square Hospital. Surgeon D. W. Bliss, U. S. V., noted : " Gunshot wound of the left arm; ball entered the ulnar border of the arm three inches below the elbow joint, passed downward and outward, and made its exit four and a half inches from the point of entrance." He was discharged the service February 26, 1864, for "paralysis of the left forearm and hand from gunshot wound," and pensioned. Examiner C. S. Hurlbut, June 23, 1864, reported: "Wounded by a ball passing through the left forearm near the ulna, wounding or dividing the ulnar nerves, causing atrophy of the entire hand and paralysis of the ulnar side of the forearm and hand." This pensioner was paid March 4, 1874. Cases 1392-1408.—Surgeon D. G. Brinton, U. S. V., reported the following two cases from the hospital at Quincy: 1. " Pt. J. M. Putnam, Co. F, .r>5th Illinois, age 24; wounded at Shiloh, April G, 1832. Gunshot wound across the inner condyle of the right arm, injuring the ulnar nerve. The wound had healed on admission. The hand was partially paralyzed and the muscles of the forearm were atrophied." The patient was discharged September 4, 1832, and pensioned. Examiner G. YV. Wright, of Canton, reported, December 9, 1872, that: "The ulnar nerve was divided, and a part of the hand is paralyzed as a consequence. The motion and strength of the joint is very much abridged." Examiner J. V. Harris reported, September 4, 1873, that the pensioner's condition was unchanged.—2. "Pt. C. Chapin, Co. E, 10th Illinois, aged 21; wounded at Kenesaw Mountain, June 20, 1834. Gunshot wound of the ulnar nerve, the ball striking the ulnar side of the right forearm. The three last fingers are flexed, the muscles contracted, impaired, aud having a pricking sensation. The wound is nearly healed." This soldier was discharged from Camp Butler July 15, 1855, and pensioned. Examiner J. Bobbins, of Quincy, reported, July 20, 1835, that: "A ball passed through the forearm at the junction of the middle and lower thirds, without fracturing it. The fore- arm and wrist are weakened from destruction of the muscles. One-half pension recommended." On January 27, 1836, the claimant stated that he had so far recovered from his disability that he declined to further prosecute his claim for pension.—The next two cases were reported by Surgeon R. A. Christian, U. S. V., from Turner's Lane Hospital, Philadelphia: 1. Pt. J. Bagley, Co. G, 3d Massachusetts Cavalry, aged 28; "wounded at Winchester, September 19, 1831. Partial paralysis of the left arm from a slight gunshot flesh wound, with injury to the ulnar nerve." This patient was discharged September 4, 1865, and pensioned.—2. "Sergeant M. V. Collins, Co. A, 103th New York, aged 24; wounded at Monocacy, July 9, 1834. Severe gunshot flesh wound of the left elbow joint, dividing the ulnar nerve." This soldier was discharged June 22, 183), and pen- sioned.—Acting Assistant Surgeon S. F. Few reported, from the hospital at Fort Leavenworth: "Pt. L. H. Cole, Co. D, 9th Kansas Cavalry, aged 18; wounded on the way from Foit Scott, November 28, 18 32. A ball entered the right forearm, passed between the shafts of the ulna and radius, and emerged at the olecranon process, wounding the ulnar nerve, and resulting in complete anchylosis of the elbow joint and wasting of the limb." The patient was discharged May 23, 1834, and pensioned. In June, 1873, the pensioner's claim was suspended, no response having been received for two years.—Surgeon D. P. Smith, U. S. V., reported, from Fairfax Seminary Hospital: " Sergeant, C. Bosworth, Co. G, 16th Maine, aged 47; wounded at Fred- ericksburg, December 13, 1862. Paralysis of the left forearm, the result of a shot wound." The patient was discharged March 16, 1863, and pensioned. Examiner G. A. Wilbur, of Skowhegan, reported, March 5, 1863: "Flesh wound through the left arm, with injury to the ulnar nerve. He cannot now completely flex the lingers. The little and ring fingers are numb." Dr. Wilbur forwarded a photograph of the pensioner to the Museum {Contributed Photographs, Vol. 1, p. 11).—Pt. D. Finn, Co. H, 34th Massachusetts, aged 23; wounded at New Market, May 15, 1834. Surgeon J. B. Lewis, U. S. V., reported, from Cumberland: "Gunshot flesh wound diagonally across the bend of the left elbow, with injury of the ulnar nerve; the ball was extracted before admission." The patient was discharged July 25, 1885, and pensioned. The Hartford Examining Board reported. September 11, 187:5: "A little stiffness of the joint, and some weakness."—Surgeon I. I. Hayes, U. S. V., reported, from Satterlee Hospital, Philadelphia: "Pt. H. Voight, Co. E, 13th Massachusetts; wounded at Antietam, September 17, 1832. Cicatrized gunshot wound of the right arm, with paralysis of the ulnar nerve. Necrosis involving different branches of the sympathetic nerve. Discharged April 18, 1833," and pensioned. Examiner G. S. Jones, of Boston, reported, December 21, 1837: "Partial paralysis of the left hand, which impairs its power and usefulness."—Surgeon T. Antisell, U S. V., reported: "Captain G. H. Wells, 1st New York Dragoons; wounded at Winchester, September 19, 1834. Gunshot wound, injuring ulnar nerve of the left arm. Discharged February 10, 1835." and pensioned. Examiner W. W. Potter, of Washington, reported, July 5, 1835: " Five abscesses have formed at different places as the result of the wound, and the operation of bisecting the ulnar nerve, for the relief of intense pain, had been made. This man is compelled to use subdermal injections of morphine for relief." * * In 1871, Captain Wells's condition was so much improved that his pension was reduced.—Acting Assistant Surgeon G. K. Smith reported: "Lieutenant S. Gait, 10th New York Cavalry; wounded at Todd's Tavern, May 5, 1834. Gunshot wound of the right arm, with injury to the ulnar nerve." Discharged August 1, 1834, and pensioned. The Ehnira Examining Board reported, September 4, 1873: "The ulnar nerve was injured and causes numbness of the little an 1 ring fingers; he is unable to pursue his avocation of blacksmith."—Surgeon H. Janes, U. S. V., reported, from Sloan Hospital, Montpelier: "Pt. C Lapage, Co. C, 17th Vermont, aged 17; wounded at Lynchburg, April 2, 1865. Shot contused flesh wound of the left arm four inches above the elbow, injuring the ulnar nerve. The right hand is cold and partially paralyzed. Discharged June 24, 183)." and pensioned. Examiner A. L. Lowell reported, March, 1871: "A fragment of shell, passing between the right arm and the body. 1 Case of Pt. S. D. Barnum, Co. B, MJst Pennsylvania, which furnished Specimen 1817. This soldier was discharged November 30, 18C5, and pensioned. Examiner C 51. TL'UXEK, of Towanda, reported, September 1. 18T3: " The fingers aud hand are numb an 1 destitute of voluntary motion. The arm and wrist are very weak, and atrophied in a degree." Slid'. 1.] SHOT FLESH WOUNDS. b»7 barelv grazed the inner margin of the biceps muscle, and there now remains a thin nonadherent cicatrix, which is healthy. ] find no injury of function following the lesion. The limb is well developed and strong." Disability censed.—In the next four cases, no application for pension was made: Surgeon J. J. Reese, IJ. S. V., reported the two following discs from Christian Street Hospital: 1. "Sergeant C. A. Paulson, Co. (I, 88th Pennsylvania; wounded at Gettysburg, July 2, 1833. Gunshot wound of the right ulnar nerve; paralysis and general debility." The patient was discharged December 10, 1863.—2. Pt. AV. Gordon, Co. C. 26th Pennsylvania, aged 20; wounded at Gettysburg, July 2, 1H33; "gunshot wound of left arm, injuring the ulnar nerve and obliterating the brachial artery." This patient was transferred to Turner's Lane Hospital, 31 arch 14th, and discharged June 18. 1834.—3. Surgeon S. N. Sherman, IJ. S. V., reported,.from the hospital at Grafton: "Private R. Mid- dleton. Co. E. 21st New York Cavalry, aged IS; accidentally wounded .June 1, ]8(>4. Shot wound of the lower third of the left arm, injuring the ulnar nerve." .Mustered out of service.—1. Surgeon .1. Moore, U. S. A., reported, from the Ladies' Home Hospital, Xew York: "Pt. AAT. MeXally, 15th New York Battery, aged '21 ; wounded.at Cold Harbor, June 2, 1864. Gunshot wound, ball passing through the lleshy part of the right upper arm, cutting the ulnar nerve. There is loss of sensibility in the little finger." This soldier was discharged from service October 2i>, 18G4. Injuries of the Jut dial Nerve.—But I wo examples of this lesion unattended by frac- ture of the bones of the forearm Avere specified in tbe reports:1 Cask 1407.—I'rivate John Donnovan, Co. G, 17th Maine, was wounded at the Wilderness, May 6, 1834, and was admitted to hospital at York, Pennsylvania, May vilst, and discharged the service March 7,1863, and pensioned. Surgeon A. N. McLaren, l\ S. A., examined Donnovan for the 4,M Veteran Regiment, May 24, 1867, and reported: "Gunshot wound of left arm at junction of upper and middle thirds, through the flexor muscles; slight exfoliation of bone from edge of radius, and probable injury of radial nerve; also a sabre wound of right arm. Slight loss of sensation, but not of power, of first and second fingers. Sabre wound received at Mine Run, November, 1833. Both wounds perfectly healed." This man was finally discharged the service April 2, 1839, and again pensioned. Examiner F. L. Sprague, of Boston, reported, Eebruary 23, 1869: " The scar on the ulnar side is puffed out, and is soft and easily depressed by the fingers. It is sensitive." In September, 1873, the Boston Examining Board reported: "The fingers cannot be fully extended, and the movements of the wrist are restricted through atrophy of the muscles aud adhesion of the tendons." Case 1408.—Corporal S. Berry, Co. B, 4th Vermont, aged 2(i years, was wounded at Fort Fisher, March 25. 1865, and admitted to Sloan Hospital, Montpelier, April 14th. Surgeon Henry Janes, U. S. V., noted : "Gunshot flesh wound, right fore- arm ; ball injuring radial nerve; discharged the service June 26, 1835, with partial paralysis of hand." Examiner J. F. Skinner, of Boston, reported, January 20, 1833: "The ball passed through the right arm at the junction of the middle with the upper third of the forearm, * * * greatly injuring the nerve and muscles. There is great loss of nervous influence; the lingers cannot be extended nor flexed, and have but little power." Dr. Skinner reported, September 5, 1873, that : " The arm is wanting in power, and painful when used. The circulation is low in the arm below, requiring care to keep it warm in cold weather." There were fourteen instances of shot flesh wounds of the upper extremities with lesions of the nerves, in which the injured nerve trunk was not designated. One of the patients was returned to duty, twelve were discharged, and, in one case, death resulted from tetanus." Case 1409.—Private J. Roby, Co. G, 7th New Hampshire, aged 51 years, was wounded at Olustee, February 20, 1864, and was sent, with other wounded, to the hospital at Hilton Head. Assistant Surgeon J. E. Semple, U. S. A., reported : "A simple flesh wound of the left upper extremity, from gunshot, the nature of the missile being unknown. Symptoms- of tetanus were observed soon after the patient's admission into hospital, and speedily became ofthe gravest character. On February 26th, opisthotonos supervened, and the symptoms becoming more violent, the case terminated fatally. February 28. 1834." Commonly shot lesions of the larger nerves of the extremities do not immediately jeopardize life; but, as Matthew has well observed, "from the vast amount of misery and annoyance entailed, extending often over an indefinite period, their importance to the joatient can hardly be exaggerated." - The pathological anatomy of these lesions has, in later Avars,3 been carefully studied, and, with the bibliography of the subject, will be adverted to hereafter. 1 51. Xicaise (Article Bras, in Diet Eneyclapid. des Sci. Med., T. X, p. 503) alleges that in wounds of the arm tbe radial is the nerve oftenes' implicated, "car a la partie inferieure il est situ6 a la face externe du bras." He appears to reason a priori, without discussing any considerable body of facts. Our returns indicate that lesions of the median nerve are the commonest, and those of theulnar are next in frequency. - Three instances of tetanus in cases of shot flesh wounds of the upper extremities, with lesions of the nerves, have already been cited: Cask o' II. L. Prince, 7th Maine (the last case of note 4, on page 462); Case l:)34, .1. S. Mills, 57th Mass., p. 464 ; and Case 1390, J. H. Matthews, p. 465. 3 Klebs (E.) (Beitrage zur Pathologischen Anatomic der Schusswunden, Leipzig, 187^, p. 21), after citing a case of neuroma after injury of the ulnar nerve in a shot flesh wound of the arm, remarks: ■' The neuritis which here supervened, in consequence of the bruising of the nerve trunk, has disappeared. the regeneration of the nerve fibres has begun in the manner described by E. Neumann,—from the nerve ends, severed by bruise or cut, fine bundles o' fibres were developed, and gradually united into a larger cylinder-axis, becoming enclosed in a common sheath. This regeneration can be best observed in cases of neuromata after amputation. The severe pains probably are closely connected with the proliferation of the connective tissue, for the nerve fibres as they grow are obstructed and pressed by (he thickening interstitial tissue. The less the latter is, the easier and more perfect will be the regen eration of the nerve fibres." 46S INJURIES OF THE UPPEtt EXTREMITIES. [ < ■ 11A P. IX. Amputations consequent on Flesh Wounds.—It has already appeared, in the review of the cases of shot wounds of the soft parts of the upper extremity implicating the blood-vessels and nerves, that the extreme resource of amputation was not infrequently adopted, either on account of primary haemorrhages, of diffuse consecutive aneurisms, or of extended sloughing or suppuration, or of bleeding regarded as uncontrollable. These cases will be enumerated, for the most part in tabular form, in the order of the propinquity of the operations to the trunk. Amputations at the Shoulder Point.—Fourteen such cases were reported. Three have already been noted,1 and one has been elsewhere published.2 One was a primary operation/' seven were intermediary, and the other six secondary.4 They may be summed up as follows : Table XIV. Numerical Statement of Fourteen Amputations at the Shoulder for Complicated Shot Injuries unattended by Fracture. Name, Ace, and Military Description. Date of Injury. Bowers, J.W., Pt., D, IstMary- June 1, land, age 36. 18C4. Cape, J., Sergeant, K, 18th Mississippi, age 22. Denton, F. M., Pt., II, 4th South Carolina, age 34. Draper, E., Pt., A, 3d Dela- ware, age 23. Eaton, X. J., Corporal, H, 8th New York Artillery, age 21. Harver, S., Pt., E, 19th Ohio. Irwin, S., Corporal, F, G7th Pennsylvania, age 23. Jasper, J., Pt., D, 5th Michi- gan. Lightfoot. J., l't,. E. 25th Mas- sachusetts, age ,'S. 10 | McKissock, P., Pt., 0,4th New Hampshire, age 21). Moore, H. C, Pt., A, 26th Georgia. Page, F. A., Pt., K, 4th Aver- ment, age 19. 13 Parker. J. P.., Pt., I, 3d Maine, age 40. Smith, D., Pt., C, 6th Penn- sylvania Cavalry, age 29. July 3, 1863. May 28, 1864. March 31,1865, 1864. May 22, 1862. Sept. 22, 1864. May 31, 1862. August 10,1864. *ept. 29, 1864. May 12, 1864. April 16, 1862. May 5, 1864. June 11 18.4. Nature of I.njuhy. Gangrene and secondary haemorrhage after shot wound of left forearm. Ca- rious bone could be felt with a probe. Sloughing consequent on shot wound of the rigid arm. Shot perforation of left axilla: exten- sive diffuse aneurism. Shot wound of right axilla, with division of vessels; arm swollen, and wound in a sloughing condition. Shot wound of right axillary artery. July 8th and 10th, haemorrhage from recurrent branches. Left arm lacerated by shell fragment; complete destruction of soft tissues. Necrosis of shaft of the humerus conse- quent on burrowing of pus after a shot flesh wound of the arm. Gangrene of left arm following shot penetration, with lodgement and dif- fuse phlegmonous inflammation. Shot perforation of left axilla.......... Opera- tion. Aneurism of right brachial, followed by mortification of the entire arm. Gangrene of left arm, with secondary haemorrhage. Shot perforation of axilla: haemorrhage; inelfectual attempts made to reach the vessel. Shell laceration of auterior aspeot of left arm near shoulder. May 28th. haemoiThage from brachial artery and superior branches: pressure applied to subclavian artery for several hours. Traumatic aneurism of left brachial artery. July 8, 1864. March 22,1865. August 26,1863. Sept, 1, 1864. April 9, 1865. July8, 1864. Mav22, 18*62. October :8,1864. January 13,1865 June 18, 1862. Sept.19, 1864. October 13,1864. May 23, 1864. April 25, 1862. May 28, 1864. August 5, 1864. Operation and Operator. Result. Flap amputation at the middle third; A. A. Surgeon A. McLetchie. Amputation ut shoulder joint; H. 11. P. Yeates. Amputation of right arm at shoulder; Surgeon II. Hinkley, C. S. A. Ligation of the left subclavian ; ampu- tation at shoulder joint; Assistant Surgeon J. C. McKee, U. S. A. Amputation at the shoulder by Larrey's method; Assistant Surgeon W. F. Norris, U. S. A. Flap amputation at right shoulder joint; Surgeon It. B. Bontecou, U. S. V . Amputation of left arm at shoulder, on field. Ligation of anterior circumflex........ Amputation at right shoulder joint by Larrey s method; A. A. Surgeon W. P. Moou. Amputation of left arm at shoulder by Larrey's method; A. A. Surgeon D. W. Cheever. Amputation of left arm at shoulder joint; A. A. Surgeon L. K. Baldwin. (See Case 1255 ante.) Flap amputation at the right shoulder joint; Ass't Surgeon D. It. Brovver. Left arm amputated at shoulder joint. (See Case 1253 ante.) Amputation at the right shoulder joint, and axillary artery secured; Surgeon It. B. Bontecou, il. S. V. Amputation at the left shoulder joint: Surgeon D. AV. Bliss, U. S. V. Amputation of left arm at shoulder joint; Assistant Surgeon II. S. Schell, U. S. A. (See Case 1259 ante.) Disch'd July 9, 1865. Died July 21, 1868. Becov'd No- vember,! 863, Died Sept. 0, 1864. Died April 16, 1865. Died Julv 10. 1864. Spec. 6312. A.M. M. Disch'd J uly 17, 1863. Disch'd Sept. 9,1865. Died June 21, 1862. Died Sept. 19, 1864. Spec. 3630, A.MM. Died October 14, 1864. Died May 23, 1864. Disch'd Sept. 1, 1862. Died May 30, 1864. Died August 8, 1864. Four of the operations were done on account of haemorrhage, four for so-called trau- matic aneurism, five for gangrene, and one for extensive consecutive necrosis of the humerus. There Avere nine deaths, or 64.2 per cent., a high mortality rate for this operation. 1 (asks 1253, 1255, p. 443, and 1259, p. 444. 2 HlXKLEY (IL), Treatment of Hospital Gangrene, in Confederate States Med. and Surg. Jour., 1864, Vol. I, p. 131. 3 Dr. B. BECK (Chir. der Schussverlttz., 1872, S. 572) sanctions the-ablation of the upper extremity for shot injury unattended by fracture, under certain circumstances: " Should, for instance, the entire package of vessels iu tbe axillary space be injured, the circumstances are far more unfavorable; since, from the anatomical relations, even if there is no uncontrollable bleeding, gangrene supervenes. In such cases, if the diagnosis is clearly estab- lished, it is preferable to amputate the limb, so as not to be compelled, after the appearance of gangrene or secondary haemorrhage, to operate under far more disadvantageous circumstances. Frequently, in cases of such lesions, the soft tissues are extensively lacerated, and the diagnosis is facilitated, and indications are afforded that more manifestly justify the removal of the limb." 4 The intervals between the reception cf the injury and the date cf operation were, respectively: IS. 54, 64, 9, 10, 0, 113, is, 40, 4,11, 9, 23, and 54 days; or, leaving out the primary operation, from four days to nearly four months. The mean was a little over 32 days. SECT. I.] SHOT FLESH WOUNDS. 4G9 Amputation of the Upper Arm.—The reported cases of amputation in the continuity of the upper arm, for complications of shot wounds unattended by fracture, numbered hftv-four. Most of the operations Avert1 practised either on account of haemorrhage or of gangrene, principally for the former cause: Table XV. Summary of Fifty-four Cases of Amputations in the Continuity of the Upper Arm, for Complicated Shot Tnjwies unattended by Fracture. Name, Ace, and Military Description. Amonett, J. P., Pt., II, 50th Illinois. Bell. (J. L., Sergeant, E, 10th Connecticut, age 34. Bony. II.. Government em- ploye, age 57. Best. J., Pt., F, 7th Indiana Cavalry, age 20. Bowers, J. V., Pt.. D, 1st Maryland, age 36. Bricknell, XV., Pt., H, 19th Wisconsin, age 20. Brown, T., Pt., C, 1st Massa- chusetts Artillery, age 50. Caplinger, D., Pt., A, 15th West Virginia, age 40. Carr, S., Pt., C, 90th Ohio, age 20. Chandler, W., Pt., D, 8th U. S. Colored Troops, age 34. Clark, T. B., Corporal, G, 17th Ohio, age 26. Cline, C. It.. Pt., D, 7th West Virginia, age 21. Conrad, A., Pt., C. 8th Illinois Cavalry, age 27. Dougherty, T. H., Pt., H, 13th Indiana, age 22. Darwood, H.. Pt., I, 15th In- fantry, age 17. Day, J.. Pt., F, 1st Massachu- setts Artillerv. age 30. Donnellv, E., Pt., C, 51st New- York, age 29. Duffy, H., Lieutenant, D, 155th New York, age 46. Emory, C. E., Lieutenant, F, 12th New Hampshire. Eva, J. H., Pt., K, 106th Penn- sylvania, age 42. Fish, C, Pt., A, 15th Maine, age 26. Fritzchey, W., Sergeant, M, 12th Pennsylvania Cavalry, age 24. Gill, M., Quartermaster's em- plov6, age 26. Giinther, G., Pt., B, 7th New York Artillerv, age 25. Heatherby, J.', Pt., E, 11th West Virginia, age 35. Hooker, W. II., Sergeant, II, 142d New York, age 39. Hooper, J. A., Pt., 10th Mas- sachusetts Battery, age 20. Howell, E., Pt., H, 9th Iowa Cavalry, age 20. Jarvis, A., Pt., G, 10th West Virginia, age 45. Knock. A., Sergeant, B, 84th Illinois, age 36. \pril !<>, 1862. Dee. 15, 1862. Nov. 5, 1861. Feb. 2}. ie,;:>. June 1, 1864. June 27, 1864. June 21, 1864. Mar. 31. 1865. June 20, 1864. Nature ok Injury. Feb. 20, 1864. May 27, 1864. June 1, 1864. June 21, 1863. lulv 20, 1864. A tig. 8, 1864. Oct. 1, 1864. Sept. 17. 1862. June 3, 1864. June 3, 1864. Julv 3. 186.3. April 8, 1864. Mar. 21, 1865. Oct. 29, 1864. May 18, 1834. Oct. 28, 1864. June 29, 1864. Oct. 14, 1863. Sept. 6, 1864. Oct. 13, 1864. .June 27, 1864. Shell laceration of tho right arm...... Haemorrhage after shot flesh wound of right forearm. Erysipelas and gangrene after shell wound if right forearm, with great destruction of soft parts. Wound of left interosseous artery; "the limb as far as the elbow apparently a lifeless mass." Gangrene and secondary haemorrhage after shot wound of the left forearm. Shot flesh wound "of the entire extent of the left arm; parts swollen from hand to shoulder, and muscles torn." Necrosis of humerus after flesh wound of the left arm. Gangrene after shot wound of the left hand. Gangrene and haemorrhage after flesh wound of the left arm. Gangrene following shot wound of the left arm. Gangrene after shell contusion of the left hand Shot injury of right brachial artery; haemorrhage ensuing after ligation. Recurrent haemorrhage after flesh wound of the left forearm. Laceration of left ulnar artery; entire forearm gangrenous. Haemorrhage from radial artery, follow- ed by gangrene. Flesh wound of right arm, followed by sloughing. Flesh wound of right arm; recurrent haemorrhage after ligation of brachial. Shot wound of left brachial artery; haemorrhage following ligation. Haemorrhage from ulnar artery after wound of the left forearm. Flesh wound ofthe left wrist, involving brachial and ulnar arteries; necrosis. Secondary haemorrhage after flesh wound of the right arm. Recurrent bleeding after ligation of brachial artery. Sloughing and mortification after flesh wound of the left forearm. Haemorrhage following wound of the left forearm. Gangrene and haemorrhage after wound of the left forearm. Shell contusion of the right elbow..... Shot injury to left brachial artery____ Median nerve and left brachial artery divided; haemorrhage. Shot laceration of right brachial artery and ulnar nerve; haemorrhage. Haemorrhage and gangrene ensuing af- ter ligation of the radial artery, in a wound of the left forearm. Opera- tion. April 18, 1862 Dec. 27, 1862. Jan. 9, Feb. 26, 18G5. Julv 8, 1864. June 28, 1864. Feb. 12. 1866. May 1, 1865. Julv 13, 1864. Mar. 14, 1864. lulv 10, 1864. June 21, 1864. July Si, 1863. Julv 27, 1864. Sept. 5, 1864. Oct. 18, 1864. Oct. 7, 1862. June 21, 1864. June 2C 1864. Julv 3, 1863. April 15, 1864. Mav 14, 1865. NTov. 20, 1864. Mav 28, 1864. Jan. 4, 1865. Aug. 15, 1864. Nov. 1, 1863. Nov. 15, 1864. Oct. 28, 1864. July 24, 1864. Operation and Operator. Amputation of right arm eight inches from shoulder, on field. Flap amputation of right arm at mid- dle third; Surgeon E. P. Morong, 2d Maryland. (See CASE 1275 ante.) Circular amputation of right arm at junction of upper and middle thirds; Surgeon J. Perkins, U. S. V. Flap amputation of left arm near the insertion of the deltoid muscle; Sur- geon J. M. Study, U. S. V. Flap amputation of left arm at middle third; A. A. Surgeon A. McLetchie. March 22, 1865, amputation at the shoulder joint. Circular amputation of left arm at up- per third. Circular amputation of left arm near shoulder; Dr. I. F. Galloupe, late Surgeon 17th Massachusetts. Amputation of left arm above elbow. Flap amputation of left arm, middle third; Surgeon A. C. Swartzwelder, (J. S. V. Flap amputation of left arm, middle third. Circular amputation of left arm at mid- dle third; Surg. S. E. Fuller, U. S. V. Flap amputation of right arm, upper third; A. A. Surgeon I-I. D. Vosburg. Flap amputation of left, arm at lower third: A. A. Surgeon G. McCov. (See Case UW post.) Flap amputation, left arm. middle third; Surgeon W. II. Thome, U. S. V. Circular amputation, right arm, middle third; Ass't Surgeon T. A. McGraw, U. S. V. Flap amputation of right arm. upper third; A. A. Surgeon G. A. Cliesley. Circular amputation of right arm; Ass't Surgeon W. M. Notson, U. S. A. Amputation of left arm. upper third; Surgeon D. W. Bliss. U. S. V. Amputation of left arm at middle third. Amputation just below elbow; Surgeon J. Aiken, 71st Penn. Oct. 28th, ampu- tation six inches below the shoulder; A. A. Surgeon T. G. Morton. Circular amputation, right arm, upper third: Surgeons B. B. Wilson. U. S.V., and M. D. Benedict, 75th New York. Amputation of left arm just above the point of ligation; Surgeon J. B. Lewis, U. S. V. Circular amputation at lower third of arm ; A. A. Surgeon G. L. Stockdell. Circular amputation of left arm at lower third; A. A. Surg. ('. B. McQueston. Circular amputation of left arm, middle third; Ass't Surgeou W. A. Banks, U. S. V. Flap amputation of right arm, middle third; Ass't Surgeon H. M. Sprague, U. S. A. Circular amputation, middle third, left arm; Surg. N. It. Moseley, U. S. V. Flap amputation, middle third, left arm; Ass't Surg. L. Lycan, 54th Illinois. Circular amputation, right arm, middle third ; Surg. J. B. Lewis, U. S. V. Circular amputation of the left arm; Surgeon R. L. Stanford, U. S. V. Disch'd Sept. 4, 1862. Died March 11, 1863. Duty, May 9. 1865. Disch'd Mav 7,1865. Disch'd July 9, 1865. Disch'd Feb. 7, 1865. Disch'd Aug. 7, 1865. Disch'd Sept. 23, 1864. Disch'd Dec. 26, 1864. Died Aug. 7, 1864. Died J une 25, 1864. Died July 11, 1863. Disch'd Nov. 25, 1864. Died Sept. 7, 1864. Disch'd Mar. 23. 1865. Died Nov. 7, 1862. Disch'd Oct. 13. 1864. Died Aug. 1, 1864. Disc. Sept. 26, 1864. Spec. 27o.'.A.M.M. Died Mav 18. 1864. Disch'd June 27, 186."i. Duty, Feb.27, 1865. Disch'd July 18, 1865. Died Jan. 24, 1865. Disch'd Oct. 5, 1864. Disch'd Feb. 17. 1864. Died Dec. 14, 1864. Disch'd June 23, 1865. Died October 1, 1864. 47<) INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. Name, Age, and Military Description. Date of INJURY. Nature of Injury. Date of Opera tion. Knox, B. E., Pt., A, 1st Dela- Feb. 15, ware, age 27. 1865. Leonard; II., Pt., II. 2d New jJune 10, Jersey Cavalry, age 24. 1864. Marks, J. C, Pt., D, 149th May 10, Pennsylvania, age 28. 1864. Milton, J., Sergeant, H, 25th July 1, Ohio, age 26 1863. MilleU. A. F., Pt., A, 17th Mar. 25, Michigan, age 37. i 1865. Marshall, II., Pt., E, 1st Mich- : May 28, igan Cavalry, age 20. 1864. Moon, J. M., Pt., C, 19th. Vir- ginia, age 26. O'Brien, M., Pt., 1,169th New York, age 24. Mav 12, 1864. June 30, 1864. Paine, W., Pt., K, 67th Ohio, I May 10, age 24. j 1864. Rea, J. K.. Pt., H. 102d Penn- May 5, sylvania, age 17. 1864. Rice, J., Pt., A, 20th Connec- Mar. 19, tiout, age 22. 1865. Ricker, B., Pt., G, 6th Ver- May 5, mont, age 45. 1864. Sinclair, F., Pt., B, 8th Maine, May 20, age 26. 18*64. Springer, R. B., Pt,, L, 2d Sept. 1, Iowa Cavalry, age 31. 1864. Stager, J., Corporal, E, 95th ; May 3, Pennsylvania. 1863. Staines, S., Corporal, C, 53d July 3, Pennsylvania, age 25. 1863. Vancellete, T., Pt,. D, 3d Ver- April 16, mont, age 21. 1862. Vincent, C, Pt., D, 122d Ohio, Nov. 27. age 19. 1863. "Waldo, A., Corporal, I, 35th May 19, Massachusetts, age 30. 1864. Wiener, N.. Pt., D, 10th New Aug. 23, York Cavalry, age 19. 1864. Williamson. J., Corporal, C, Dec. 13, 111th Illinois, age 26. 1864. Wright, W., Pt., C, 100th June 3, Pennsylvania, age 26. 1864. Teatman, R., Pt., D, 50th Aus. 27, Virginia, age 25. 1861. Zink, T.. Pt,, H. 45th New July 2, York, age 24. 1863. Shot wound of the biceps muscle and the median nerve. Shot injury of the principal nerves of the left forearm, followed by phage- dena and decomposition. Shot injury to the nerves of the right arm. Resection of three-fourths of an inch of both tbe median and musculo- cutaneous nerves, by A. A. Surgeon G. A. Mursick. Hsemorrhage from the brachial artery after a wound of the right arm. Sloughing and gangrene following a shell contusion of the left forearm. Haemorrhage consequent on injury to the ulnar and lwimeral arteries of the right arm. June 19th, ligation of the brachial artery. Shell laceration of inner surface of right elbow joint; bone laid bare. Haemorrhage recurring after ligation of the radial artery, in a shot flesh wound of the left forearm. Shot wound of left arm, severing the brachial artery and injuring the tissues of the elbow. Gangrene and haemorrhage after shot flesh wound of the upper third of the left arm. Brachial artery ligated May 14, 1864. Shot wound of the right arm, severing the brachial artery; acute inflamma- tion of the elbow joint. Gangrene following a shot flesh wound of the left wrist, April 10, 1865. June 13, 1864. Oct. 23, 1864. Aug. 8, 1863. May 5, 1865. June 24 1864. May 31, 1864. Aug. 2, 1864. May 18, 1864. May 17, 1864. May 7, 1865. May 16, 1864. Shot wound of the right brachial artery. June 1, 1864. Gangrene after a shot flesh wound of Sept. 21, the left hand. j 1864. Shot flesh wound of the left arm, with May 9, probable destruction of the brachial 1863. artery. i Recurrent haemorrhage after ligation of Aug. 2, the brachial artery in a shot flesh : 1863. wound of the right arm. Repeated haemorrhages consequent on April25, a shot, perforation of the right arm. 1862. Axillary artery ligated April 23d. Secondary hemorrhage from sloughing Dec. 27, of the brachial artery in a shot perfo- 1863. ration of the upper third of left arm. Shot wound of the left arm, injuring the May 25, brachial artery and dividing the ten- 1864. dons of the biceps muscle. i Shot wound of the left elbow, injuring Sept. 4, an arterial branch and producing an 1864. aneurism. i Recurrent haemorrhage after ligation of Jan. 7, the brachial artery in a shot wound, 1865. dividing the ulnar and brach'l arteries. I Dissection of all the muscles by bur- ' July 9, rowing of pus in a shot flesh wound ! 1864. of the left arm. Haemorrhage following a shot flesh Aug. 29, wound of right forearm, with division • 1864. of-the ulnar and radial arteries. Sloughing, with great loss of soft parts, July 15, followed by secondary haemorrhage j 1863. and gangrene, in a shot wound of the left elbow joint. Operation and Operator. Amputation of the right arm, upper third; Surgeon D. W. Bliss, U. S. V, Circular amputation of the right arm, middle third; A. A. Surgeon J. N. Sharp. Flap amputation of the right arm at junction of upper and middle thirds; Surgeon J. A. Lidell, U. S. V. Amputation of the right arm; A. A. Surgeon J. B. Smith. Circular amputation of the left arm at middle third; A. A. Surg. H. Craft. Amputation of the right arm at junc- tion of upper and middle thirds; A. A. Surgeon W. H. Ensign. Circular amputation of right arm at junction of middle and lower thirds. Amputation of the left arm at the mid- dle third; A. A. Surgeon 11. B. White. (See Case 1291 ante.) Circular amputation of the left arm at the lower third; A. A. Surgeon J. IL Hill. Flap amputation of the left arm at the upper third; Surg. C. Page, U. S. A. Circular amputation of the right arm, upper third ; A. A. Surg. H. Sanders. Flap amputation of the left arm at the upper third; Surgeon E. Bentley, U. S. V. Flap amputation of the right arm at the upper third; A. A. Surgeon M. Bald- win. Amputation of the left arm at the mid- dle third; Confederate surgeon. Re- amputation about a month after. Amputation of the left arm at the up- per third; Assistant Surgeon W. Thomson, U. S. A. Amputation ofthe right arm at the up- per third; A. A. Surgeon C. R. Mc- Lean. (See Case 1247 ante.) Amputation ofthe left arm, high up; Surgeon R. B. Bontecou, U. S. V. (See Case 1263 ante.) Flap amputation of the left arm just below the-shoulder joint; A. A. Sur- geon O P. Bigelow. Flap amputation of the left arm at the junction of the middle and upper thirds; Surg. D. W. Bliss, U. S. V. Flap amputation of the left arm at the lower third; Assistant Surgeon J. 0. McKee, U. S. A. Flap amputation of the right arm at the upper third: A. A. Surg H. Leaman. (See Case 74, Table XIII, p. 449.) Amputation of the left arm; A. A. Surgeon B. Leaman. Circular amputation at the middle third of the right arm; Assistant Surgeon W. F. Richardson, C. S. A. Circular amputation of the left arm at the lower third; Assistant Surgeon II. S. Schell, U. S. A. DiedApril28, 1865.* Died June 28, 1864. Disch'd May 57, 1865. Died August 19, 1863. Disch'd June 26, 1865.t Died July 12, 1864. Died July 23, 1864. Disch'd Feb. 11, 1865. Died July 5, 1864. Died Dec. 1, 1864. Disch'd Oct, 18, 1865. Died May 22, 1864. Died July 1, 1864. Disch'd Dee. 20, 1864. Disch'd Sept. 9, lfil~. Died Sept. 1, 1863. Disch'd Jan. 13, 1863. Died -Jan. 6, 1864. Died June 7, 1864. Died Sept 19, 1864. Died Feb. 1, 1865. Died Dec. 20, 1864. Died Sept. 27. 1864. Disch'd Nov. 21, 1863. There was an appalling mortality in this series. Half of the patients died. Three, amputated primarily for grave shot lacerations, recovered. Of thirty-five intermediary operations, twenty-one (60 per cent.) resulted fatally. Of the sixteen secondary amputa- tions, only ten had a successful issue. An analysis of the reports shows that amputation was resorted to on account of hsemorrhage in thirty-five of the cases. In eleven of them, ligation of a main arterial trunk had been already practised. The right limb was muti- lated in twenty-one, and the left in thirty-three instances. Thirteen amputations were in the lowvr. twenty-three in the middle, and eighteen in the upper third, and it will be noticed how the mortalitv increased as the trunk was approached. See Sp,r.i. 4038. 4056, and 4095, A. M M. jSpec 142, A. M. M. SECT. I.] SHOT FLESH WOUNDS. 471 Amputations of the Forearm.—Fourteen cases were reported of amputation in the forearm on account of the consequences of shot flesh wounds : Table XVI. Summary of Fourteen Amputations in the Continuity of the Forearm, for complicated, S/iof Injuries unatten-led by Fracture. Name, Age, and Military DKSCItiriTON. Bentz, V., l't., E. 100th New Vork, age 10. Cole, A., Pt., I, 4th Michigan, age 19. Hercules. C, Pt., G, 129th Illinois, age 37. Hurley, R., Pt., H, 159th New York, age 24. James, O., Pt., F, 1st Mich- igan, age 21. Karback, W., Pt., E, 1st Miss. Mounted Rifles, age 21. Kelley, \V. G., Pt., E, 4th Rhode Island, age 35. Palmer, A., Pt.. K. 73d Ohio, age 40. Perry, Ch., Pt., H. 13th New Hampshire, age 28. Pettigrew, M., Quartermaster's employe^ age 16. Ruber, C, Pt., F, 83d New York, age 20. Schleieker, N. N., Pt., K. 5th Michigan, age 39. Seipp, G. XV., Corporal. G, 1st Maryland, age 20. Sladden, R., Pt., F, 3d New Hampshire, age 29. May 7. 1664. May 6, 1864. Mav 26 1S64. Sept. 19, 1864. June 22 1864. Feb. 13, 1865. Sept. 17, lt-62. Julv 3, 1863. fune. 15, 1864. Sept. 24, 1864. Mav 8. 1864. Aug. 28, 1864. May 19, 1864. Mav 17, 1864. Nature of Injury, Dath | OF Or icu a HON. Shot wound of left hand, followed by gangrene Shot laceration of right hand, between thumb and index finger; erysipela- tous inflammation ; profuse and fetid discharge. Shot wound of left wrist and hand ; in- filtration of pus; abscess; ulna pro- truding : gangrene. Shot wound of right arm; brachial artery severed and ligated ; gangrene of forearm. Shot wound of back of left hand; ery- sipelatous inflammation. Shot laceration of superficial palmar arch ; erysipelas and gangrene. Shot wound of left forearm; haemor- rhage from interosseous; compres- sion ; recurrent bleeding. Shot wound above wrist; palmaris longus and flexor sublimis digitorum cut. Shot wound of left forearm, middle third : four inches of radius denuded; sloughing. Shot flesh wound of right forearm..... Shot wound of left forearm ; gangrene. Shi-,t wound of left hand and wrist; sloughing of muscles and tendons; gangrene. Shot wound of left middle finger; large abscesses of hand and under surface of forearm ; carpal bones denuded. Shot wound of left wrist; extensive sloughing; gangrene, and secondary haemorrhage. July 5, 1864. May 31 1864. July 11, 1864. ' Oct. 9, 1864. July 29, 1864. Peb. 26 1865. Sept. 26 1862. July 29 1863. July 15 1864. May 23, 1864. May 23, 18b5. June 3, 1864. June 9, 1864. Operation and operator. I'lap amputation of left forearm at junction of middle and lower thirds; Ass't Surg. W. Webster, U. S. A. l-'lap amputation of forearm at middle third; A. A. Surgeon G. II. Dare. Circular amputation of f.;rearm at up- per third; A. A. Surgeon George E. Walton. Flap amputation in middle third of foreann; A. A. Surg. P. P. Maury. Flap amputation of forearm at upper third; A. A. Surgeon A. Trail. Circular amputation at middle third of foreann; A. A. Surg. R. \V. Coale. Flap amputation of forearm at upper third; Surgeon C. W. Jones, U. S. V. Amputation of forearm by Ass't Surg. II. S. Schell. U. S. A.; haemorrhage occurred, and radial ligated by A. A. Surg. D. Kennedy on the same day. Circular amputation of forearm above middle third; A. A. Surgeon J. M. McGrath. Primary amputation of upper third of right foreann. Flap amputation of upper third of fore- arm: A. A. Surg. C. W. Koechling. Circular amputation of forearm at junc- tion of middle and upper thirds; A. A. Surg. D. O. Farrand. Flap amputation of forearm at middle third; A. A. Sargeon H. M. Dean. Circular amputation of forearm at mid- dle third; A. A. Surg. W. S. Ward. Disch'd Sept. ^7, 1864. Died July 1, 1864. Disch'd April 22, 1865. Disch'd Mar. 29, 1865. Disch'd Nov. 15, 1864. Disch'd May 14, 1865. Disch'd Nov. 29, 1862. Died July 31, 1863. Disch'd Mar. 2, 1865. Recovery. Died June 1, 1864. Disch'd Oct, 3, 1865. Disch'd Sept. 24, 1864. Disch'd Nov. 8, 1864. One primary and four secondary amputations resulted successfully. Of the nine intermediary cases, three were fatal. The mortality of more than 20 per cent, for fore- arm amputations was excessive, and, probably, must be explained by pyaemic or septi- cocmic complications. Nine of the operations were on the left and five on the right side. General Observations on Flesh Wounds of the Upper Extremities.—The facts set forth in the preceding Section sufficiently attest the frequency and importance of the injuries of the soft parts of the upper extremities observed in the War of the Rebellion. Punctured and incised wounds received in action were comparatively rare; those inflicted in affrays and brawls were more common ; but there was no great fatality from this class of injuries. Venesection was obsolescent during the War, and there were no recorded examples of arterio-venous aneurisms at the bend of the elbow. Shot wounds of the upper arm, forearm, and hand were, perhaps, the most common accidents of battle.1 They often resulted in diffuse inflammation and sloughing, and in disabilities due to muscular atrophy or loss of substance, to tendinous adhesions and contractions, and to other complications that will be briefly recapitulated. Notwithstanding the protected position of the principal arterial trunks on the inner sides of the bones, and the resiliency of these vessels, there 1 Billroth (Th.) (Chir. Briefe, u. s. w., 1872, S. 207) observes ; "The injuries of the upper extremity, especially of the finger and hand, are. as you may convince yourself by the examination of transports of wounded, enormously frequent; they form a large percentage of the slightly wounded, and are especially adopted to transportation." ■172 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. were many examples of division or laceration of tlie arteries unattended by fracture, both by large and small projectiles ; and yet more common were haemorrhages from arteries that had been bruised by the passage of a ball, or ulcerated from proximity to a ball track. I have not been able to find any instance of fatal primary bleeding1 from a shot lesion of the brachial or its branches. Of the cases of ligature of the brachial that furnished prepa- rations to the Museum, the following may be cited : Case 1410.—Private A. Conrad, Co. C. 8r.li Illinois, aged 27 years, was wounded at Upperville, June 21. 18G3. He was pent to Emory Hospital, at Washington. Acting Assistant Surgeon W. H. Ensign reported that: "A carbine ball, entering two inches above the bit wiist joint, passed upward behind the bone nearly to the elbow joint. On admission at Emory Hospital, the patient's arm was much swollen. On June '29th. the entrance wound was enlarged, and an unsuccessful search was made for the ball. Sinuses extended along the radius, which was denuded of periosteum in much of its extent. The forearm was bandaged and kept moistened with ice water. On June 30th, laudable pus was freely discharged. On July 2d, the situation ofthe ball was thought to be detected just below the elbow joint. The patient was gradually growing weaker. On July 3d, the position of the ball was plainly detected [compare Specimen 1387, Sect. I, A. M. M.], and it was proposed to cut down upon it, when haemorrhage com- menced from the point of entrance of the ball. A tourniquet was immediately applied to the brachial artery. The ball was then excised, and a bandage applied from the fingers to tbe elbow. The tourniquet was loosened, and (he haemorrhage did not return. On July 5th. the bleeding recurred. Compression was applied over the radial and ulnar arteries by means of bandages.'' On July 9th, Dr. Ensign being ordered away, Acting Assistant Surgeon G. McCoy took charge ofthe case, and '•' secondary haemorrhage being frequent, there was nothing left aradon^i^The but amputation, which was performed by antero-posterior flaps of the integument, with circular division of the left brachial two muscles, iust above the elbow. The patient was more cheerful, and his pulse came up ; but exhaustion finally days after ampu- J , ' tation.i$tpec.i38G. prevailed, and he died July 11, l8S.i. Venous haemorrhages of importance after shot wounds or other injuries of the upper extremities appear to have been infrequent; and no information was reported regarding the effects of shot lesions of the lymphatics of the arm. Many valuable observations were collected respecting shot lesions of the nerves, and some of the best recorded cases of causalgia, or "burning pain," and of "glossy skin," are derived from shot injuries of the soft parts of this region. Yet the proportion of such cases to the immense aggregate of shot wounds of the upper extremities was comparatively small, even less than observed, in another war, by Generalarzt LcefHer.2 It has seemed best to dwell on these flesh wounds of the upper extremity,3 since few writers regard them as worthy of separate consideration. The elder Langenbeck is one of the exceptions.4 MM. Desormeaux and Xicaise, in articles in the two new French dictionaries of medical sciences, treat systematically of wounds of the soft parts of the upper limb, and Dr. B. Beck has some sound observations on shot wounds of this category.5 'A most competent authority, Generalarzt L03FFLER, states (Generalbericht uber den Gesundheitsdienst, u. s. w., 1867, S. 157): "Important primary bleedings from injuries of the larger blood-vessels are rarely observed at the place of the first dressing for the reason that, if the bleeding does not cease spontaneously or from provisional compression, tbe time from the reception of the injury to the arrival at the place of first dressing is more than sufficient to cause death from hasmorrhage." This of shot wounds of the upper extremities. 2 The eminent writer just quoted observes (I. c. S. 149), in treating of shot wounds of the upper extremities: "When the soft parts only are injured, the arterial and nerve trunks, protected by their sheaths, fortunately escape, as a rule. Regarding the latter, especially, the small number of nine injuries of the larger nerve trunks only in a total of five hundred shot flesh wounds of the soft parts * * conclusively proves that the nerves frequently escape tbe inroads of tbe Spitzkugel and the Langblei. In certain regions of the upper extremities the nerves are so much exposed, that the rarity of their lesion is remarkable." In Herr Lceffleu'.s statistics the examples of important nerve lesions in shot flesh wounds of the upper extrem- ities were 9 in 500 cases. In our records the proportion is much less, 96 cases in 54,729. No doubt many cases are unreported in the America statistics. 'Matthew (T. P.) (op. cit, Vol. II. pp. 355, 35(i), in an aggregate of 7,660 cases, tabulates 2,189 cases of shot wounds ofthe upper extremities, as already stated in Table XII, page 434. Of these, 1,096 cases, or 59.2 per centum, were flesh wounds. Demme (Studien, 1860, B II, S. 201) remarks that of ""2,000 cases of shot injuries of the upper extremities, in the Italian War of 1859, 1,325, or 66.2 per centum, were uncomplicated flesh wounds." IISCHBR (H.) (Kriegschirurgische Erfahrungen, 1872, S. 13G). in a total of 249 cases of shot injuries of the upper extremities, reports 119 cases, or 47.7 per centum, as uncomplicated shot wounds ofthe soft parts. 4 Lanuesiieck (C. J. M.) (Nosologic und Therapie der Chirurgischen Krankheiten, Gottingen, 1830, 15. IV) devotes a chapter (III Capitel, S. 220) to flesh wounds ofthe upper extremities, treating specially of those complicated by wounds ofthe arteries and those treated by amputation. 6In treating of flesh wounds of the upper extremities, Dr. B. Beck (Chir. der Schusscerletz., 1872, S. 572) remarks: '"If the artery only is injured, and the bleeding may be controlled with almost entire certainty, the surgeon should strive for the conservation of the limb, even if the nerve i* al:-" wounded, and. in like manner, where the large veins are implicated." Dr. Wieliam MacCokmack, in his interesting Notes and Recollections (I. c, p. 'Xi), tabulates 63 shot wounds of the upper extremity unattended by fracture, treated at the Anglo-American Ambulance after Sedan, without a fatal case, and remarks: "' The patients recovered well, with scarcely an exception, from simple flesh wounds." But elsewhere the danger of deduc- tions from limited facts is recognized. SECT. II.] FRACTURES OF THE rLAVICLE AND SCAPULA. 473 Section 11. FKACTURES OF THE CLAVICLE AND SCAPULA. There appear in the reports twenty-three hundred and eighty-one cases of fractures of the clavicle1 or of the scapula2 unattended by primary lesions of ribs, head of humerus, or thoracic cavity. The vast majority are examples of shot fracture. A few instances of sabre and bayonet injuries of these bones will be noted. Ninety or more cases of simple or compound fractures of the collar bone or shoulder blade from blows, falls, railroad accidents, and the like, are reserved for the proposed chapter alluded to on page 209, on fractures not caused by weapons of war. The cases of shot fractures of the clavicle and scapula implicating the chest cavity have been adverted to in the Fifth Chapter of the First Surgical Volume, and abstracts of thirtv examples are there presented, thirteen of fractures of either bone separately, and four of simultaneous fracture of both bones. In this Section, the clavicle and scapula will be looked upon no longer as portions of the chest-parietes, but as portions of the upper limbs. The fractures on the left side had a slight numerical predominance.3 The returns indicate a comparatively moderate degree of danger to life from this class of injuries. Eliminating the risks of secondary implication of the viscera of the thorax, or of mischief to the great vessels and nerves therein, the mortality rate of injuries of the clavicle and scapula is small, amounting, in uncomplicated shot fractures of the clavicle to a little over 9 per cent., in analogous lesions of the scapula to 12.4 per cent., in simultaneous injuries of both bones to 23.3 per cent. The superficial situation of the clavicle accounts for the comparative innocuity of compound fractures of the bone unattended by lesions of the important organs in its vicinity. A large number of alleged partial excisions of the clavicle and scapula were reported; but, on examination, many of these operations are discovered to be merely extractions of detached bone splinters, or the removal of fragments of necrosed bone. Attention will be called to some important exceptional cases. Sabre and Bayonet Wounds.—One example was reported of bayonet fracture ot the clavicle, and four instances of sabre incisions4 and two of bayonet perforations of the 1 Clavicle, Lat., clavicula (small key) ("Quod instar clavi6 scapulam cum sterno claudant ac fitment."—DIEMERBUOECK, I. c, p. 550). Greek, itAeiStj; German, Schlusselbein; Italian, clavicola; French, clavicule. 2 Scapula, the Latin equivalent for shoulder blade,- VOSSIUS derives the name from o-Kanrco-dai, to be hollow. Diemeubroeck (I. c, p. 550) remarks: "barbaris spatula dicta." Greek, i>fion\aTri; Vr., omoplate,- Ger., Schulterblatt 3 In the proportion of a little over 4 per cent. There were 1,150 fractures on the right, 1,199 on the left, 11 of both sides, and in 21 instances this point was unspecified. Professor SOCIN (Verletzungen der Extremitdten, in Kriegschir. Erf.r 1872, S. 101) estimates that "both sides of the body are apparently equally exposed to hostile projectiles under the present manner of fighting; of 235 cases of shot wounds of the upper extremities, 116 were of the right and 119 of the left side." 4 The epaulet of the officer and shoulder-scale of the enlisted man, though now ornamental appendages, were originally part of the defensive armor, to shield the shoulders from sword-cuts. See Reeis (A.), The Cyclopsedia or Universal Dictionary of Arts, Sciences, and Literature, Philadel- phia, Vol. XIII. 60 474 INJURIES OF THE UPPER EXTREMITIES. [chap. ix. scapula; but, in several of these seven cases, the descriptions given were so indefinite as to leave doubt whether the osseous lesions were of a serious nature. However, the cases will be briefly recapitulated: Case 1411.—Private S. W. Bill'mgsby, Co. K, 46th Indiana, was wounded at Belmont, November 7,1831, and discharged for disability. He was subsequently, at Cincinnati, in January, 1837, examined for re-enlistment in the regular service l>v Acting Assistant Surgeon L. A. James, who noted, "bayonet fracture of the right clavicle." Case 1412.—Private J. Quinn, Co. G, 2d Missouri, was wounded at Chattanooga, September 19, 1833. Assistant Surgeon E. M. Powers, U. S. V., noted, at St. Louis, September 27, 1864: "A punctured wound of the trunk, caused by a bayonet entering immediately over the inferior angle of the right scapula, not penetrating the chest." Returned to duty October 1, 1834. Another example of bayonet injury of the scapula has been mentioned in the First Surgical Volume.1 Tliere were the following cases of sabre cuts of the scapula: Case 1413.—Sergeant J. Higgins, Co. G, 5th Cavalry, was Avounded at Gaines's Mill, June 27, 1862. He is reported to have had a sword wound of the superior angle of the right scapula, for which he was treated in regimental hospital. He had other wounds, and \v;is discharged. He was examined for re-enlistment in the regular service by Acting Assistant Surgeon J. Neill, at Philadelphia, in April, 1838, who reported that "no disability" then existed. Case 1414.—Private F. Boyer, Co. E, 18th Pennsylvania Cavalry, was wounded at Gettysburg, July 2, 1883, and sent to Cuyler Hospital July 5th. Surgeon Josiah Curtis, U. S. V., reported, "an incised wound of the scapula." This man is reported to have " deserted, July 23, 1863." Case 1415.—Private C. A. Woods, Co. A, 1st Pennsylvania Heavy Artillery, was wounded at Petersburg, July 3, 1864. He was discharged, but, on July 10, 1867, was examined as a recruit for the 42d Infantry by Surgeon A. N. McLaren, U. S. A., who reported: "A sabre wound about an inch in length over the left scapula, just below the centre of the spine. This man had also an inguinal hernia of the left side, the result of a fall received while climbing the enemy's breastworks at the same time and place." A fourth case,2 complicated by a sword wound of the cranium, is mentioned on page 20 of the First Surgical Volume. Shot Fractures of the Clavicle and Scapula.—Contrary to the general impression,3 shot fractures of the clavicle or of the scapula unattended by penetration of the chest are not infrequent in modern warfare. The cases reported from the War of the Rebellion are summed up in the following tabular statement: Table XVII Numerical Statement of Two Thousand Two Hundred and Eighty Cases of Shot Fractures of the Clavicle and Scapula unattended by Penetration of the Chest or Lesion of the Humerus. NATURE OF SHOT FRACTURE. Cases. Duty. V. R. C. Discharged or Paroled. Died. Undeter-mined. 527 1,444 105 204 242 598 18 83 46 94 3 4 188 554 58 48 44 177 24 69 7 21 2 Of clavicle or scapula near the shoulder, the fracture not precisely specified.. 2,280 941 147 848 314 30 Although the mortality in this group was less than 14 per cent., more than half of those injured were found incapacitated for further duty. Examples have been adduced of shot fractures of the clavicle and scapula associated with penetration of the pleural cavity; but the cases not thus complicated are too numerous to be passed over without further comment. 1 Case of Private R. Dorsey, Co. E, 17th West Virginia, First Surgical Volume, p. 469. ' Private P. Lucas, Co. G, 1st New York Cavalry, wounded at Winchester, June 13, 1863. -'FISCHER (II.) (Kriegschirurgische Erfahrungen, Vor Metz, 1872, S. 14:2), speaking of fractures of the scapula and clavicle, remarks: "How such wonnds are possible without inju^' to the lung, or without opening of the pleural cavity, is difficult to conceive." LCEFFLER (Generalbericht uber den Gesundheitsdienst. 1867, S. 1C2) tabulates 66 cases of fractures of clavicle or scapula without penetration of the pleural cavity, in a total of 2,355 cases, a still larger percentage of this class of cases than in the War of the Rebellion, where the percentage was only 0.9, or 2.280 cases in 253,142. sect, ii.] SHOT FRACTURES OF THE CLAVICLE. 475 Shot Fractures of the Clavicle.—The Museum possesses twenty-one illustrations of this form of injury, including examples of transverse fractures (Fig. 369], of oblique and comminuted fractures, of curios and necrosis following shot lesions, of fractures with attempts at repair more or loss successful, and of sequestra or fragments removed from the clavicle. Some of these specimens have been figured already;1 others will be shown in connection with the abstracts of eases now to be related. Of the few writers that have treated specially of shot fraetares of the clavicle, some have exaggerated their dangers,2 and others have underestimated <-> Fig. 309.—Transverse fracture of the middle ot the right clavicle hv a the frequency of grave complications.3 A conicalbalL *«• lsl°- century ago, Ravaton4 appreciated more justly than recent authors the gravity of these injuries. Several examples of complicated shot fractures of the clavicle were detailed in the third, fourth, and fifth Chapters.5 Some instances of uncomplicated fracture will be cited here : Case 1416.—Private G. D. Baxter, Co. O. 140th New York, aged 44 years, avus wounded at Gettysburg, July 2, 1S!>3. Surgeon H. Junes. V. S. V., noted : "a gunshot fracture of the right clavicle." On October 5th, the patient was sent to Phil- adelphia. Acting Assistant Surgeon C. B. King forwarded to the Museum, from Turner's Lane Hospital, the missile by which the patient was struck. It is a round iron ball, weighing 2~.~ grains, probably a spherical-case shot, and is numbered lo09 of the first section of the Museum. Dr. King described it as "entering at the inner third of the clavicle, fracturing this bone, and lodging under the pectoral muscle near the axilla. The ball was not extracted until May 3, 18;i4." On July ICtli, the patient was sent to Haddington Hospital, and discharged and pensioned September 2S, 1864. He re-enlisted June 4, lSGo, in the Mr.rine Corps, and was again discharged June 3, 1S60. His pension was restored from that date. Examiner J. F. Hall, of Portsmouth, reported, January 29, 1S73 : '" The applicant has a scar over the right clavicle. The bone was fractured, and, he says, severed, and pieces of bone came out. There are two or three scars below the clavicle; also one on tbe right arm, a little below the shoulder. * The scars are all healed and apparently sound. The adhesions in the healing ofthe fractured clavicle give some embarrassment iu the use of the arm." Dr. Hall reported, September 4, 1863: "There are troublesome adhesions, with considerable difficulty in raising the right arm." The pensioner "Was paid June 4, 1874. Cask 1417.—Private D. Crowther, Co. C, 13th Massachusetts, was wounded at Bull Run, August 30, 18IV2. and was admitted to Filbert Street Hospital, Philadelphia, on September 30th. Surgeon W. M. Breed, U. S. V., reported : "He was struck by a fragment of shell over the left pectoral muscle, fracturing the clavicle at its middle third, with an external wound an inch in length over but not communicating with the bone. There was considerable ecchymosis over the seat of injury. It wa3 dressed loosely, at first, with Fox's apparatus, and afterward, as the tenderness subsided, the apparatus was tightened np. The bone has consolidated with half an inch overlapping." The patient was discharged January 19, 1883, on certificate of disability, for "partial loss of use of the left arm from shell wound of the shoulder." Not a pensioner. In the five hundred and twenty cases of this group the mortality rate was small, but slightly exceeding 8 per centum. More than half of the patients were returned to duty, and about a third of the number were discharged; and, as their names do not appear on 'In the First Surgical Volume, viz: Spec. 2194, as FlG. 21 ft, p. 483; Spec. 137, as Fig. 242; Spec. 3760, as FlG. 243. Cases of partial excision are exemplified by Specimens 3844, 372. 4332, in FIGS. 256, 257, 258, of that volume. 2Xel'I)Oi;feu (J.) (Handbuch der Kriegscltirurgie, 1872, S. 1116) states: " While the simple fracture of the clavicle is comparatively the least important of that of any of the long bones, uniting readily with complete preservation of the functions of the arm, we must class the shot fractures of the clavicle with the, relatively, most severe and dangerous injuries; they are even more dangerous than the fractures ofthe upper arm." Gokdon (C A.) (Lessons on Ilyg. and Surg., 1873, p. 144), generalizing from a case of simjile fracture, a shot wound in the clavicular region at Sedan, and another at Floin'g, infers that: "These few cases furnish no just estimate of the rate of occurrence of this injury, but rather point out their extreme fatality." 3Beck (B.) (Chir. der Schussverletz., 1872, S. 641), treating of shot fractures of the claviole, says: "'If there are no special indications, no serious injuries of the vessels or nerves by deep-seated splinters, the healing should be left to nature without operative interference. Resections, as a rule, aggravate the condition by causing a large deficiency of bone. The less the wound and bones are manipulated, the better the result. I have, indeed, in my earlier campaigns, successfully practised resections in cases of comminuted fractures; but, judging from my later experience, the cases would have terminated successfully, without operation, at an earlier period." Generalarzt Beck believes that: "Fractures ofthe clavicle are rarely accom- panied by serious injuries of the neighboring blood-vessels ; but more frequently by lesions of the nerves." 4 Ravaton (Chirurgie d'Armie, Paris. 1768, p. 200) entitles his twentieth chapter: "De la cure de coups de feu qui fracturent la clavicule," and details three interesting cases of shot fractures of the davicle, from the battle of Dettingen, June 16, 1743. and adds some judicious reflections ou the frequency, danger, and treatment of this form of injury. sCompare, in the First Surgical Volume, the cases of: Corporal L. Shaw, G, 35th Ohio, p. 407; Sergeant O. E---, A, 2d Texas Cavalry, p. 432; Pt. C. Berry, I, 28th New Jersey, p. 474; Sergeant Samuel A----, 125th Pennsylvania, p. 482; Pt. Andrew G---, I, 5th Michigan, Sergeant Lemuel A. J. B---, I, 27th Mississippi, and Pt. Edward Osborn, H, ilth Pennsylvania Reserves, p. 483; Major G. N. Lewis, 12th Connecticut, p. 494; Pt. Monroe P. Sanders, F, 93d Pennsylvania, p. 499; Unknown soldier, p. 522; Pt. John B--- D, 51st Illinois, p 523; William S---, a scout, p. 546; Pt. Adam Grimm, D, 7th Connecticut, p. 547; Pt. E. ('. Melley, K. 2d West Virginia Mounted Infantry, p. 555: Pt. W. S. Jenne, B, 6th Vermont, p. 585; Pt. Allman M. P---, C, 34th Virginia, p. 588. 47, 1864." The sternal half of the necrosed collar bone (Fig. 370) was transmitted to the Museum with the foregoing report. The concomitant caries of the pubic bone lends color to the fig. :>70.—Sternal half of the left clavicle suspicion that the disease of the clavicle may, if not due to syphilis, have been agcra- necrosed after shot contusion. Spec. 2193. . ... . vated by a syphilitic taint. It has been surmised that the nerves suffer oftener than the blood-vessels in shot fractures of the clavicle:1 Case 1419.—Sergeant J. V. Flansburg, Co. E, 97th New York, aged '23 years, was wounded at Bull Run, August 30, 1862. On September 7th, he was admitted into Columbian College Hospital, Washington. Surgeon T. R. Crosby, U. S. V., reported: "A mini6 ball passed in about two inches behind and below the posterior fold of the axilla, and was taken out in front, about the middle of the clavicle. The clavicle was fractured and the brachial plexus injured. Discharged January 30, 1863, with imperfectness of the shoulder joint," and pensioned. Examiner C. B. Coventry, of Utica, reported, September 15, 1873: "There is weakness and tenderness and spasm of the muscles." Surgeon C. Pago, U. S. A., forwarded the missile to the Museum. It is "a conoidal ball, exceedingly misshapen by being compressed and bent upon itself, with jagged extremities and longitudinal grooves on one Fig. 371.-Mis-» side and a comparatively smooth surface on the other. Removed from among the fragments of the clavicle, sileflattened.on having entered above the angle of the left scapula '' {Cat. Surg. Sect., p. 667), and weighs 404 grains. It is Spec. 4505. represented of half size in the annexed wood-cut (Fig. 371). Excisions of the Clavicle.—Some observations on this subject have been presented in the Fifth Chapter, in connection with shot wounds of the chest. Ten examples were adduced, including two instances of extirpation of the clavicle,2 and five of partial excisions 'M. Chenu (Op. cit. Camp, d'Orient, p. 209) tabulates 103 cases of shot fracture of the clavicle, with 41 deaths; but undoubtedly these must include many instances of chest wounds. Steinberg (Die Kriegslazarethen und Baracken von Berlin, 1872, S. 149) notes 44 cases of fracture of the clavicle, with two deaths, in an aggregate of 8,531 wounded. Gillette (Blessures par armes a feu observies pendant le siige de Metz) details one case of shot fracture of the right clavicle, in an armorer aged 46 years, which resulted fatally from the burrowing of pus. 2 In thirty published cases of extirpation of the clavicle, of which I will presently give references, there were fifteen operations practised on account of caries or necrosis, ten for morbid growths usually designated osteosarcomata, and four on account of the immediate results of injuries. Of the latter category, only two were performed on account of shot injury. These were the two cases referred to in Chapter V, both complicated by injuries of the pleural cavity. It would be interesting, if further details could be had of the case reported by Professor J. L. Cabell, of which a memorandum is printed in the First Surgical Volume, p. 557. An account of the second extirpation of the clavicle for shot injur}-, by Surgeon General J. C. Palmkh, of the Navy, is printed in the Am. Jour. Med. Sci., 1865, Vol. XLIX, p. 357. In 1674, Dr. Palmer contributed to the Museum a prepa- ration (Xo. 6213, Sect. 1) from this case. It consists of the right scapula, upper third of humerus, and first and secon'd ribs. The fragments ofthe com- minuted clavicle were not preserved. The ribs are fissured; the humerus is uninjured; the superior angle of the scapula, the part where the supra- spinatus is attached, and that smooth portion of the spine over which the trapezius glides, have been carried away by the projectile. The note on page 557 of the First Surgical Volume, on extirpations of the clavicle, is incomplete, and contains some errors. Professor GROSS is-right in referring to Kemmer the operation in 1732, reported by KULMUS (J. A.), De exostosi steatomatode claviculse, ejusque felici sectione (printed in Halleus JDisp. chir., ' 1756, T. V, p. 655); but this operation was not an extirpation, but a partial excision for exostosis. Dr. Fuqua's operation likewise was not a removal of the entire bone, for the operator states: '"The inner extremity was exposed; not all of it, however, was found diseased, and it was determined to remove only the carious part" (Maryland and Virginia Med. Jour.. 1860, Vol. XV, p. 359). These corrections made, the recorded complete excisions may be enumerated in chronological order: 1. (1811-1813 [?]) McCkkary (C), removal of the entire clavicle for scrofulous necrosis in a lad, who survived the operation thirty-five years. JOHNSON (J. H.) (New Orleans Mad. and Surg. Jour., 1850, Vol. VI, p. 474) states that this operation was done at Hartford, Kentucky, on May 4, 1811. Professor H. H. Smith (Princ. and Pract. of Surg., 1863, Vol. II, p. 335) gives the date as 1813, adducing as authority Professor Gross's History of Kentucky Surgery, p. 180. 2. (1823) Meyer, of Ziirich (Encyclop. Worterbuch der med. Wissenschaftcn, 11. 29, S. 96, und v. GRJEFK und v. Walther's Journal, 1833, 15. XIX, S. 71), successfully removed the entire clavicle, for caries, in the case of a man aged 34. 3. 11828) MOTT (V.) (An Account of a Case of Osteosarcoma of the Left Clavicle, in which Exsection of that Bone was successfully performed, in Am. Jour. Med. Set, 1828, Vol. Ill, p. 100). 4 and 5. (1825-1832) Wutzer (Orsbacii, De resectione claviculse, Bonn, 1833, p. 6) in 1825, and again in 1822, performed the operation for caries. 6. (1832) Warren (J. C.) (Removal of Clavicle in a state of Osteosarcoma, in Am. Jour. Med. Sci., 1833, Vol. XIII, p. 17), a fatal case. 7. (1834) Roux (MlQUKL, Bull, gin de Therap., 1834, T. VI, p. 246) is said to have extirpated a carious clavicle, the case terminating fatally on the third day. 8. (1835) Mazzoni, of Pisa (Gaz. mid. de Paris, 1838, p. 460), successfully excised the clavicle in a child four years of age. 9. (1836) Tkaveus (B.) (Removal of the Clavicle, in Med. Chir. Transactions, 1838, Vol. XXI, p. 135), a successful operation in a bey . f 10, for a tumor referred to an injury in a fall from a wheelbarrow. 10. (1838) Biangini, of Pistoja (Gaz. mid. de Paris, 1828, p. 460), a case of successful extirpation for necrosis in a youth of 15; MlQUEL alleges that the bone was regenerated. 11. (1838) KrxsT (liber den totalen Verlust des Schliissel- brines, in Deutsche Klinik, 1850, B. II, S. 263), another of the few traumatic cases: "C. Angles, aged 36, a day laborer, able to follow his avocations after complete removal ofthe clavicle, injured by a blow from a stick." 12. (1852) WEDDERlilHN (A. J.) (Total Removal ofthe Collar Bone for Curies, in Ncio Orleans Month. Med. Reg., 1852. Vol. II, p. 1), a successful operation. 13. (1853) Bautlett (i:. M.) Report of Case of Exostosis of the SECT. II. | EXCISIONS OF THE OLAVIOLE. 477 in cases in which projectiles had penetrated the thorax ; and three instances of partial excisions were cited also,1 in cases unattended by lesions of the pleural cavity,2 that might more properly have found place in this Section. These three, with the cases described in the six following abstracts, and twenty-two enumerated in Table XVIII, form a group of thirty-one partial excisions of the clavicle for shot injury.3 The following is a fortunate instance of an early excision ofthe acromial extremity: CASE 1420.—Private J. Baird. Co. C, 8Gth New Vork, aged 26 years, was wounded at Gettysburg, July 2, 1863, and was treated in a field hospital until the 28th, when be was transferred to Camp Letterman. Acting Assistant Surgeon W. H". Hayes noted : "Ball entered middle third ot* tlie left clavicle, fracturing the bone, and passed out at the summit of the scapula posterior to the acromion process. A few days after receiving tbe injury the fractured pieces of bone were removed by the saw. When admitted into this hospital the two ends of the fractured bone were very much depressed, and the wound suppurating freely ; his general health was not good. The wound was treated by cold-water dressings and acetate of lead and opium, and Fox's apparatus for fracture of the clavicle was applied. September 10th, general health very much improved; depression of shoulder much less than when admitted." On September 28th, the patient was transferred to Philadelphia, and was discharged September 13, 18U4, and pensioned. Examiner A. Edelin, April 11). 18G7, reported: "There is a loss of full half of the left clavicle from the centre outward, the parts having been resected, the result of gunshot wound, * * rendering the arm weak and ineffective." The reports of subsequent examinations, the last made in 1874, do not differ markedly from the foregoing. This pensioner was paid June 4. 1874. In four of the operations, the portion excised is not specified; in eleven, the body of the bone, in thirteen, the acromial, and in three, the sternal portions were removed. Nine operations, with one death, were primary; eight, with one death, were intermediary; seven, with two deaths, were secondary; in seven cases, with two deaths, the dates of operation were not recorded. The excisions were on the left side in seventeen, and on the right in thirteen cases ; in one instance, this point was not specified. Eight of the patients recov- ered and were returned to modified duty; fifteen were discharged; six died; and in two Clavicle, and its Extirpation, in St. Louis Med. and Surg. Jour., 1854, Vol. XII, p. G4); good results. 14. (1854) OWENS (J. A.) (Osteosarcoma of the Claeicle, operation, in New Orleans Med. and Surg. Jour., 1854-55, Vol. XI, p. 164), a successful operation. 15. (185C) BLACKMAN, (G. C) (Removal of the entire Clavicle, in The Western Lancet, 1856, Vol. XVII, p. 336), a successful operation for caries, in the case of .1. I!----, aged 42. 16. (1857) CuiiTIS (C. R. S.) (Extirpation of the Entire Clavicle, in Am. Jour. Med. Sci., 1857, Vol. XXXIV, p. 350), an operation for malignant disease, in the case of Elizabeth P---, aged 20 ; recovery from the operation, but reproduction of the cancer. 17. (1857) NELATON and RICHARD (See OLLIEK. Traiti expirim. ct din. de la rcginir. des os, Paris, 1857, T. II, p. 174). The first-named excised the outer half of the clavicle of a woman for caries, and, a few months later, RICHARD removed the remaining sternal portion; the patient died a year subsequently. 18. (1859) ESMARCH (F.) (XlSSEX, Diss.de resect.ione. Kiliae, 18"9, p. 7), a successful operation for osteosarcoma. 19. (1860) HEYFELDER (,T. F.) (Totale Resec. des linken Schlusselbeiiies, in Deutsche Klinik, 1860, B. XII, S. 291), a fatal complete excision for caries in a girl, Aphymia Segorowa, aged thirteen. 20. (1860) Gunn (M.) (Case of * -■■ Extirpation of Clavicle, in Chicago Med. Jour., 18G8, Vol. XXV, p. 301). 21. (1864) A FIELD SURGEON (Med. and Surg. History of the War of the Rebellion, 1870, Part I, Vol. II, p. 557), a primary excision of the clavicle for shot comminution, recorded by Professor J. L. CABELL; the patient survived eleven days. 22. (1864) Palmer (J. C) (See Trvon, Exsection of the Right Clavicle, in Am. Jour. Med. Sci., 1865, Vol. XLIX, p. 357), a second case of total excision for shot injury, in the case of a sailor, aged 19 (Specimen 6213, A. M. M.). 23. (1866) BOWE (II.) (Case of Removal of the Entire Clavicle, in Med. Times and Gaz., 1866, Vol. II, p. 194), a successful operation, in the case of K. Kloetc, a colored child, aged 7, for caries consequent on injury by a blow. 24. (18(17) IRVINE (J. XV.) (On a Case of Excision and Regeneration of the Entire Clavicle, in The Lancet, 1867, Vol. I, p. 206): This was a successful operation, in the ease of George XV----, aged 16, with necrosis of the right clavicle following an attack of rheumatic fever. 25. (1868) JlOWX (D.) (Resection de la clavicule pour un carcinome, in Gaz. mid. de Lyon, 1868, No. 8, p. 93), a successful operation in the case of a young child. 26. (1868) DAWSON (W. W.) (Excision of the Entire Clavicle, in Cincinnati Lancet and Observer, 1868, Vol. XI, p. 1), a successful operation for necrosis, in the case of J. Black, aged twenty. 27. (1869) COOLEY (P.) (Removal of the Entire Clavicle for Osteosarcoma, in Leavenworth Med. Herald, 1869, Vol. Ill, p. 3021, a successful operation, in the case of John Scott, aged 30. 28. (1870) Varick (T. R.) (,t Case of Subperiosteal lie section of the Clavicle, in New York Med. Record, 1870, Vol. IV, p. 510), a case in which the bone was regenerated as was believed. 29. (1870) Eve (P. F.) (Exsection of the Clavicle—Death on the Sixth Day, in Nashville Jour, of Med. and Surg., 1871, Vol. I, p. 68): Case of J. Smith, aged 12, with an "enchondroma of a semi-malignant nature." 30. (1870) BltlTTON (D.) (Extirpation of Clavicle, in Med. Times and Gaz., 1870, Vol. I, p. 551), a successful removal of a ;'cancerous tumor" of the left clavicle, in the case of Samuel Smith, aged thirty-live. The recorded cases cf extraction of necrosed sequestra are numerous. Champion (Comers, a VHoiel-Dieu, 1800) relates that the elder Pelletan extracted the "entire" clavicle in the case of a child with abscess of the shoulder following small-pox, and that the bone was reproduced. Analogous cases in the practice of HOKEAU and of COSME d'Angeuville arc related in Bordkxave's memoir on exostosis, in the fifth.volume of tho Mem. de VAcadimie de Chirurgie, 1774, p. 361. ' Cases of Sergeant J. II----and Private J. H. N----, on page 559, First Surgical Volume, and of Corporal XV. H. Husky, on page 560. These, with the six cases detailed here, and twenty-two enumerated in Table XVIII, constitute the thirty-one. illustrations, found in*the reports, of partial excisions ofthe clavicle after shot injury unattended by penetration of the thorax. 2 Schwartz (H.) (Beitrage zur Lehre von den Schusswunden, 1854, S. 199) cites three cases of shot fractures of the clavicle, and remarks : " If there is a comminuted fracture of the clavicle, all loose fragments should be immediately removed and all sharp points should be cut from the bone. * But never be beguiled to remove more than the extreme points of the bone. * * Allow nature to manage, and you will soon see exuberant granu lations cover all parts of the bone. * * Resection of the clavicle should be rejected, therefore, unless the splintering is so extensive as to involve either the acromial or sternal joint." 3On excision of the clavicle, compare, in addition to the authorities already cited: Jjeo.er (in Rust's Handbuch der Chirurgie, B. VI, S. 480), who j roposes partial excision of the bone as a preliminary measure to ligation of the first part of the subclavian ; MALGAIGNE (J. F.) (Manuel de Mid- Oper., 7-° ed., 1861, p. 240; CHASSAIGNAC (E.) (Traiti din. et prat, des opir. chir., 1861, T. I, p. 664); Richet (Article Clavicule, in Nouveau Diet. de Med. et de Chir. Prat, 1868, T. VIII, p. 42); FEHGU8SON (W.) (^1 System of Pract Surg., 4th ed., 1870, p. 281); Wagner (A.) (Uber den Heilungs- prozess nach Resection und Extirpation der Knochen, Berlin, 1853, S. 26. New Sydenham Society's translation, Vol. V, p. 136). ■17* IN.IURIKS OF THE UPPK1! EXTREMITIES. |c HAF. IX. instances tho result was undetermined. Examples of several varieties of partial excision of the t-lavicle1 are appended : Cask 14J1.—Corporal J. Schrawger. Co. F, 2d Iowa, aged :>4 years, was wounded at Fort Donelson, February 1">, is ;>. He was sent to the Third Street Hospital, at Cincinnati, and discharged and pensioned July 10, 18oi. Examiner J. C. Hupp, of Wheeling, West Virginia, reported, September 5, 1S63 : '' Gunshot wounds in left side, neck, and shoulder. One ball entered the stirno-cleido-inasloideus an inch above its sternal insertion, and escaped through the scapula above its spine. Another ball frac- tured the clavicle in its upper third, where it lodged, and whence it was extracted in July, lHii.2. The first wound is cicatrized. Several marks of abscesses are to be seen about the shoulder and region of scapula. The clavicle is ulcerated, and an open ulcer exists below the clavicle." Corporal Schrawger subsequently entered the Veteran Reserve Corps, and was appointed a Serjeant ill the 2d battalion. On September 30, 1864, he was sent to Seminary Hospital, Columbus, Ohio. Assistant Surgeon (i. Saal, U. S. V., noted: "Gunshot fracture of clavicle, with injury to spine of scapula. Fragments of lead remained in the shoulder, perceptible by means of a probe, one piece being embedded on the under side of the acromial end of the clavicle. Fistulous openings exist through and below the clavicle. On February 20, 1835, Acting Assistant Surgeon CE. 15 >yle trephined tbe clavicle and removed the lead fragment, weighing about three drachms, also several small pieces from the supra-scapular fo-sa, together with necrosed bone. The wound closed rapidly after the operation, and the fistulas diminished greatly in size and depth. The patient was returned to duty to Camp Chase on March 20, 1865, his wound being nearly well, with prospect of complete cure." On June 19, 18J5, he is reported by Surgeon I. D. Knight, U. S. V., as having "died of erysipelas" at Tripler Hospital, Columbus, Ohio. Case 1422.—Sergeant W. V. Taylor, Co. G, 66th Ohio, aged 25 years, was wounded at Peach Tree Creek, July 20, 1864. •About November 10th, he was transferred to Nashville. Surgeon B. B. Breed, U. S. V., noted: "Gunshot fracture of the acromial end of the left clavicle by a minie ball. On August 4th, excision of two and a half inches of the acromial end of the bone wns performed through an incision three inches long over the superior border of the clavicle. The wound healed without any untoward symptoms." The patient was sent to Columbus, and mustered out of service December 15, 1864, and pensioned. F.xaminer J. S. Carter, of Urbana, Ohio, reported, November 14, 1865: "A ball entered at the middle of right clavicle, passed through the shoulder and out at the upper portion of the scapula. The wound is still discharging. He has very little motion of the joint, lie also received at Gettysburg a wound in the head, at the upper portion of the frontal bone. About one inch of both tables of the skull has been removed. Dr. B. B. Leonard, of West Liberty, Ohio, states, "that this pensioner came under his care several months after being mustered out of service, and that on passing a probe through the wound of the shoulder he detected a foreign body which he supposed to be bone, but on removal proved to be half of a conoidal ball, weighing a half ounce, also that the wound healed readily." This pensioner was paid July 4, 187o. 1 Of partial excisions of the clavicle, I find thirty-eight instances recorded, with some details, in surgical annals. There are others briefly alluded to, and others, again, complicated by excisions of portions ofthe scapula or humerus. Of the thirty-eight cases that will be enumerated here, eleven or twelve were operations consequent on shot injuries. These operations were by VELPEAU, STROMEYER (2), SCHWARTZ, D. AYRES, Paravicim, P>eck, Lu.-ke. GUILLERY, BOCKENIIEIMER, and DESPt ES. An operation, in 1719, by CASSEBOHM, was on a soldier aged 28; but it is not stated whether or not it was practised on account of shot injury. It was successful, and, if included in this category, there would be twelve paitial exisions of the clavicle for shot injury, with two deaths. Dr. O. Heyfelder (Lehrbuch der Resectionen, 1863, S. 300) tabulates eighteen cases of partial excision ofthe clavicle six ofthe diaphysis, five of the sternal and seven of the acromial p< rtion. I am unable to verify the case referred to M. CHASSAIGNAC; several ante- cedent cases are omitted, and the succeeding decennium has supplied many other'instances. It is an incomplete chronological enumeration of operations of this group. 1. (1715) PETZOI.li (C.) (Obs. med.-chir. select.. Breslau, Obs. EX II, p. 126), an excision for necrosis, in a child of nine. 2. (1719) Casse- BOH.m (Acta med. Berolin, Vol. I, Dec II, p. 98), according to Hied (F.) (Die Resectionen, 1860), removed three inches of the body of the clavicle, in the ease of a soldier, aged 28, who recovered with good use ofthe arm. 3. Davie, according to Sir Astlky Cooper (A Treatise on Disloc. and Fract. etc., 2d ed., 1823), excised an inch and a half of the sternal extremitj-of the clavicle for a compound luxation, and the patient recovered with perfect use «.f the arm. 4. (1830) Velpeau (Nouv. Elim. de Mid. Opir., 1839. T. II, p. 571) successfully excised the acromial end ofthe clavicle in a case of shot fracture, in the French revolution of that year. 5. (1831) Roux (as reported by Hurtkaux, Resection des ext. artic. des os, etc., These, 1834, p. 18) successfully excised two inches of the acromial end of the clavicle for caries, in the case of a man of forty-one. GEliDY (De la resect des ext. artic. des os, 1839, p. 19) also mentions this case. 6. (1837[?]) Carus (according to Noodt, Das Osteotom, 1838, S. 63) excised successfully the middle portion of the shaft of the clavicle, in a man aged forty-one. 7 and 8. Noodt also relates that two successful excisions of the diaphysis of the clavicle were performed by Sadler and Welz, and Dr. Heyfelder accepts these cases: but no references are given. I cannot discover the writings of Sadler; but have examined those of four Doctors Welz: Edward. Adolphus, Joseph, and Robert (compare BERNSTEIN, Bibliothek, S. 217; Cat. Library, S. G O., Vol. II, p. 884), without finding this case. Is it not possible that the Bavarian physician was misled by the report of an operation on one cf the victims of the disaster at the Sadler's Wells Theatre, in North London? 9. (1838) R.EGXOLI (G.) iAnnali medico chirurgici di Roma, Vol. I, p. 30), in a case of necrosis of the sternal end of the clavicle, in a man of forty, practised a successful excision. 10. (1840) MALOGO (Giornale per servire di progressi delta patologia e delta materia medica, Feb., 1840) successfully removed the outer two-thirds of the clavicle, in the case of a boy of seven years. 11. (1843) Asso.v (M. A.) relates (in the Giornale dei progressi delta patot, etc., 1843, as quoted in the Arch. gin. de mid., 1844, 4n,• s§rie, T. V, p. 374) a successful excision of (he sternal extremity of the left clavicle, in a man of forty-four, for syphilitic caries. 12. (1844) Blandin (P. P.) Bull, de la Soc. Anat de Paris. 1S41, T. XIX, p. 33-!) excised nearly the whole of a necrosed clavicle, in the case of a medical student, who recovered with good use of the corresponding arm. 13. (1845) Cuaumet (Resection de la clavicule pour un sarcome vasculaire, in £az. mid. de Paris, 1846, p. 209) records a suc- cessful case, frequently quoted as an extirpation of the clavicle. The outer two-thirds appear to have been removed. 14. (1848) EVE (P. V.) (Removal of four and a half inches of the Clavicle—patient fully recovered, in Southern Med. and Surg. Jour., N. S., 1848, Vol. IV, p. 158) relates an instance of partial excision of the left clavicle, for necrosis following a blow from a stick, the case of " Ned, a very powerful young man, belonging to Mr. II---"! 15. (18481 Pnl r;:;t (II. G.) i Excision of the Clavicle, in The Lancet, 1849. Vol. 1, p. 392), in the case of Agnes T---, aged 42, with disease of the left clavicle, following rheumatism, removed the greater portion of the bone; "about half an inch of the sternal end was left attached to the sternum.'' The clitor of The Lancet (op. cit. February 5, 1857. p. 132) very carelessly states that "the whole of the clavicle was excised by Mr. Potter,'' evidently not taking pains to verify his references to his own journal. 16. (1848) Sedillot (Ch.) (Traiti de mid. operat. etc.. 1865, T. I, p. 409) excised a portion if the clavicle for osteitis, with excellent result. 17. (184!) GROSS (S. D.) (System of Surgery, 5th cd.. 1872, Vol. II, p. 1078) successfully excised ""nearly the whole of the left clavicle"' from a lad of thirteen. 18-19. (1849-1851) f.TROMEVER (!. ) (Maximen der Kriegsheilkunrt, 1855, S. (87) observed two cases of shot fracture "in which resection in the continuity of the clavicle became necessary. In one case, not seen until the eighth day. * * tlie outer fragment had beeu driven int.) the brachial plexus and caused the most excruciating pains, which extended even to the other arm SECT. 11.] KXU1SIONS OF THE CLAVICLE. 479 Figukes '2o6 and -f>7, on jnii!;c of)',) of the First Surgical Volume, illustrate jiatlio- Wical preparations of excised portions of the collar bone, and on page b'1'2 of that volume a o-ood example of longitudinal splintering of the right clavicle by a musket ball is delin- eated. The annexed wood-cut represents the partial repair of an oblique shot fracture: Case 14:23.—In a tabular statement of operations practised at the City Hospital, St. Louis, from September, lSol, to October, IS.)-, Surgeon J. T. Hodgen. U. S. V., reported a ease of resection of tlie clavicle resulting fatally. No particulars are given. About the same date, Dr. Hodgen contributed to the Museum Specimen 30:) of Section I (Cat. Surg. Szct, p. T.f), which lacks any recorded memorandum. It is possible that tins specimen (Fit;. 37°.) is from the case of excision referred to. It is described by Dr. Woodhull as: "The inner two-thirds of the right clavicle after an oblique comminuted fracture at the junction of the outer third. A bony fragment, with the inner portion eusheathed with callus and the outer extremity necrosed, projects upward and outward from the outer border of the bone. On the outer portion of the fig. 372.—Inner two-thirds of the right clavielesplin- sternal concavity there is a thin deposit of callus." tercd by shot, and probably excised.(.) Spec. 301), Cash 14:24.—Corporal L. Hartel, Co. K, 4th .Massachusetts Cavalry, aged 23 years, was wounded at Beaufort, July 1G, ISO;}. On November 4th, he \v;is sent to Portsmouth Grove, Rhode Island. Assistant Surgeon XV. V. Cornick, U. S. A., reported, from Lovell Hospital : " Gunshot fracture of left clavicle ; the ball perforated the left scapula and emerged anteriorly, fracturing the clavicle at its middle third. The wound is sloughing, and small abscesses have formed near the edge of the wound, yielding apparently healthy pus. The edges of the wound are everted and callous, -and caries of the clavicle was discovered by probing. The patient was restless and suffering much pain. On January 20, 1834, Acting Assistant Surgeon E. Seyffarth placed the patient under ether and exsected a portion of the clavicle, cutting along its middle portion to the extent of two inches, avoiding as much as possible all the attachments of muscles, dissecting off and gouging out the diseased bone to the amount of one inch and a half in length and to the depth of half the diameter of the clavicle. The gouge and cutting forceps were used for the operation. The patient rested well after the operation. On the third day he had regained appetite, and healthy granulations were springing up. Ou the ninth day, the bone, as far as denuded from periosteum, was covered to the margin of excavation. Steady and rapid improvement continued. On March 1st, the wound had healed, and though callus was still prominent, the patient had perfect use of the arm. He had perfectly recovered on Marcli "ioth, and was returned to duty on May G, lSiJ4.'' On December 3, 1SJ4, he was mustered out and pensioned. Examiner J. H. Mackie, of New Bedford, reports, November 13, 1S?1 : "Ball entered over left clavicle and came out at left scapula, fracturing both bones. Resection of part of the clavicle was performed in consequence of the wound. The left arm is now atrophied and weak, and almost useless. He cannot hold a fork, or dress himself without assistance." causing immobility of both. * * The operation brought amelioration, but did not prevent death from pyaemia. In the second case, secondary haemor- rhage led to the resection. The bleeding ceased after the removal of splinters and the resection of fragments, without the discovery of injury to the large bloodvessels. Here, also, death from pyaemia ensued, probably caused by bleeding." Dr. STROMEYER continues: "I only cite this case to add the remark, that in case of secondary bleeding from the injured or contused subclavian artery, if not rapidly fatal, the resection of the clavicle solely paves the way for the ligation." PlKOJOFE (X.) (Grundzuge der Allgemeinen Kriegschirurgie, 18C4, p. 774) says: "Several times I have observed severe haemorrhages in cases of shot fractures of the clavicle; but they were arrested by rest and cold compress, if they did not occur from the lung. Other surgeons advise to resect the fractured ends for the purpose of finding the source of the bleeding, and to ligate the subclavian." 20. (1850) SCHWARTZ (H.) (Beitrage zur Lehre von den Schusswunden, 1854, S. 199) relates the case of W. E---, a Saxe-Weimar soldier, shot through the left clavicle. The greater part of the diaphysis was successfully excised. 21-22. (1852-1853) LANGENBECK (B.) is reported (LtiCKE, Beitrage zur Lehre von den Resectionen, in LANGENBECK's Arcli., 1862, B. Ill, S. 30C) to have practised two successful partial excisions of the clavicle for necrosis in these years. 23. (1856) TOI.AND (H. H.) (On the Reproduction of Bones, in Pacific Med. and Surg. Jour., 1858, Vol. I. p. 8) reports a successful excision of the sternal extremity of the clavicle, in a sailor with syphilitic caries. 24. (1857) AYUES (D.) (Gunshot Wound of the Shoulder—Two and a half inches of the Clavicle removed—Reproduction and Complete Recovery, in JVew York Jour, of Med., 1857, Vol. II, p. 10) records a successful excision, with partial reproduction, in the case of a man of (3 years, wounded by bird-shot. 25. (1857) COOI'EK (E. S.) (Case of Osteosarcomatous Affection, in the Pacific Med. and Surg. Jour., 1858, Vol. I, p. 49) describes a successful excision of the clavicle. In a note on page 557, First Surgical Volume, this case is wroDgly referred to 1837. 26. (Iv'u) KOciILEli (H.) (Resection von vier Fiinflcl des Schliisselbeiues, in Deutsche Klinik, 1859, B. XI, S. 412) performed a partial excision of the clavicle, on a man of 22 years, on account of a carcinomatous tumor; the ease terminated fatally. 27. (1851) HEY- FELDEU (J. F.) (Resection des Schulterendes des linken Scldiisselbeiues, in Deutsche Klinik, 1857, 15. IX, .S. 199) records a fatal excision, in the case of a soldier, aged 28, of the acromial extremity of the left clavicle. 28. (1858 [0) KOTUMu.ni> (A.) is reported (KEID, Die Rcsectinuen, u. s. w., 18G0, S. 269) to have performed a successful partial excision of the clavicle, in a case of caries following simple fracture. 29. (1858) (Iay (J.) (Disease folloxved by Fracture of the Clavicle—Operation—Recovery, iu Med. Times and Gaz., 1858, Vol. I, p. Gl) records the case of XV. B----, a man of 35, with abscess over the acromial part of the clavicle. 30. (1859) PaKaVICINI (Demme, Studien, 1800, B. II, S. 217) resected the acromial end of the clavicle, in a case of shot fracture, in the Italian campaign of that year. " Seven weeks after the operation the wound had entirely healed. The resected ends were connected by a firm, hard, fibrous cord." 31. (185:) Bowman (W.) (Medullary Tumor of the Clavicle,- successful Removal, with the outer Half of the Bone, in The Lancet, 1859, Vol. I, p. 132). 32. (1860) FlIQUA (\Y. X.) (Excision ofthe Clavicle, in The Maryland and Virginia Med. Jour., 1860, Vol. XV, p. 358) records a successful excision of the outer part of the clavicle, for caries, in an Irish laborer, forty years old. 33. (18C4) Beck (B.) (I.angen- beck's Archiv, 1864, B. V, S. 232) cites a case of shot wound, a cannon ball laceration of muscles and brachial plexu* ; a large portion of bone removed to prevent injury to blood-vessels and pleura. 34. (1870) LUCKE (A.) (Kriegschirurgische Erf, u. s. w., Bern, 1871) tabulates, among the operations performed at the hospital at Darmstadt, a successful case of excision of the body of the clavicle for shot injury. 35. (1870) (U'ILLE'.iy (Prisentation des blessis, in Bullelinde I'Acad. de Me I. de Belgique. 1871, T. V, p. 91) cites a case of partial excision of the clavicle for shot injury, with subsequent exfoliation of the larger part of the remaining portion. 36. (1670) Bockf.xiiei.meu is stated to have done a successful operation of this sort (C'ASrARI, Mittheilungen aus dem Reservelazareth II. zu Frankfurt a. M., in Deutsche Klinik, 1870, B. XXII, p. 452): M----, aged 26, shot at Dillingen, September 22, 1870; the clavicle was fractured and the greater part of the bone excised; good recovery. 37. (1871) Sesn (N.) (Excision of Clavicle for Osteosarcoma, in North Western Med. and Surg. Jour., 1871-72, Vol. II, p. 259) records a successful removal of a tumor of the outer part of the left clavicle, in the case of J. A----, a Bohemian, 13 years of age. 38. (1871) DESPUES (A.) (Rapport sur les Travaux de la 7e ambulance, Campagne de Sedan, Paris, 1871, p. 46) tabulates a successful case of partial excision of the clavicle for shot injury. It would probably not be difficult to find other examples of partial excisions of the clavicle for disease. 1 have enumerated only those encountered in searching for excisions for shot comminutions. so IXJURTKS OF THE UPPER EXTREMITTFS. [chap. ix. It appears that in traumatic osteomyelitis of the clavicle, as in other long hones, morbid action is liable to extend to the sound parts, after the portions that have under- gone structural alteration have been removed: Cask 14'-2">.—Private A. D. Kelley, Co. H, 45th Ohio, aged 22 years, was wounded at Kenesaw Mountain, June "J7, 18.il. lie was sent to Nashville on July '20th; Surgeon B. B. Breed. U. S. V., reported: "A shot fracture of the left clavicle, with resection of the acromial end. Gangrene made its appearance on September l'2th, but was arrested by two .applications of bromine." The patient was transferred to Jeffersonville, and discharged May 21, 18d3, and pensioned. Examiner W. II. Philips stated, in 13117 : "A ball fractured the left clavicle and passed obliquely backward, emerging at the posterior and superior angle ofthe left scapula. The wound was followed by gangrene, and a portion ofthe clavicle, amounting to one-half its length, was removed. The wound is still open, and discharging from beneath the pectoral muscles and in the axilla. The shoulder joint is drawn out and atrophied, and useless from want of support by the clavicle." This pensioner died July 19, lHiiS. Table XVIII. Sum uiary of Twenty-two Cases of alleged Excisions of Portions of the Clavicle after Shot Injury. Name. Age, and Military Description. Breyles, B. F., Pt., F, 9th Alabama, age 19. Bull, J., Corporal, C, 53d Georgia, age 24. Cheney, D. J., Pt., F, 31st Ohio, age 24. Clark, H. C, Pt., B, 37th Massachusetts. Cox, ./., l't.. I), 14th North Carolina. Curley, M., Sergeant, V, 2d Delaware. Decker, M., Pt., D, 6th Wis- consin. Click, XV. II., Corporal, B, 9th Iowa. Goodfellow, M. A.. Lieut., 10, 53d Illinois, age 21. Hoard, W. F., Pt., B, 33d North Carolina. Jackson, L. C, Pt., H, 14th Tennessee, age 22. Myers, J. D., Pt., F, 28th North Carolina, age 34. Phillips. H., Pt., K, 148th Pennsylvania, age 18. Pursley, I,., Pt., C, 19th Indiana. Sanders. J. (1., Corporal, B, J 8th Ohio, age 19. Schneider. G., Pt., G, 5th Cavalry. Scott, Z. S., Sergeant, G, 89th Indiana, age 25. Shirley. W.. Pt., E, 13th Indiana. • Spaulding, G. >V., Pt., D, 52d Indiana. Thayer, M., Pt., A. 10th Connecticut. Wicker. N. S.. Pt.. ('. 90th Illinois. Willing, W. D. Sergeant, F, 15th South Carolina. Date of Injlry May 3, 1803. May 5, 1804. Nov. 25, 1803. April 0, 1805. June 2, 1804. July 2, 1803. May 12, 1804. Xov. 25. 18G3. July 21, 1864. July 1, 1803. Dec. 13, 1862. Sept. 1, 1803. Aug. 15, 1804. Mav 5, 1804. Dec 15, 1804. July 28, 1804. April 9. 1804. Dec. 13, 1801. April 6, 1862. Sept. 17, 1802. Nov. 25. i8G3. Julv 3, 1853. Natuke of Injury. .Minie ball fractured the clav- icle and lodged in the axilla; missile extracted. Compound comminuted shot fracture of the scapular end of the left clavicle. Shot fracture of the left clavicle. Fracture of the left clavicle by a mini6 ball. Fracture of the right clavicle by a mini(3 ball. Shot perforation of left shoul- der, fracturing the clavicle. Shot fracture of the outer third of the right clavicle; minie. ball. Musket ball fractured the left clavicle. Musket ball perforated right shoulder, fracturing the mid- dle third of the clavicle. Musket ball struck the right clavicle near its middle, frac- turing it in both directions. Comp'd fracture cf the sternal half of right clavicle; missile lodged at sterno-clavicular articulation; necrosis. Gunshot wound of the right shoulder and back. Shot perforation of the right shoulder, with fracture of the clavicle and scapula. Fracture of the left clavicle by a minie ball. Compound comminuted shot fracture of the middle portion of the right clavicle. Gunshot wound through left shoulder, fracturing the clav- icle and scapula. Mini6 ball passed through the right shoulder, fracturing the clavicle. Shot fracture of the left clav- icle and first rib. Gunshot fracture ofthe middle third of the left clavicle. Musket ball perforated the left shoulder, fracturing clavicle. Severe shot wounds of right shoulder and thigh. Gunshot fracture of the right clavicle. Date of Opera- tion. Mav 9, 1803. Mav 5, 1804. Mav 10, 18*04. April 6, 1865. Mav 12, 1804. Nov. 25, 1803. July 21 1804. July 9, 1803. Feb. 8, 1803. Oct. 7, 1803. Aug. 19, 1864. May 5, 1804. Dec. 16, 1864. Aug. 29, 1804. April 20, 1804. Nov. 25 18G3. Operation and Operator. The wound over the clavicle was enlarged, and the frac- tured ends removed by means of a Iley's saw. Excision of two-thirds of the acromial end of the clavicle; Surg. J. J. Knott, P. A. C. S. " Excision'".................. "Excision : Excision of the middle third of the clavicle. Excision of two-thirds of the clavicle. Extraction of missile and re- moval of the outer third of the clavicle. Excision of the distal third of the clavicle; Surgeon E. J. McGoorisk, 9th Iowa. Excision of two inches of the middle third of the clavicle. Excision of the whole of right clavicle with the exception of one inch of its humeral end. Resection of one inch, of the clavicle and removal of the missile. Fragments removed, and the acromial end of the clavicle excised Excision of one-fourth of an inch of the clavicle and re- moval of several fragments; Surg. N. It. Moseley, U. S. V. Excision .................... Excision of two and a half inches of the clavicle; A. A. Surgeon M. N. Benjamin. Removal of the middle third ofthe clavicle; A. A. Surg. H. Sanders. Excision of three inches of the middle third of the clavicle. Clavicle divided, with Iley's saw, oneinchfromits acromial extremity, and disarticulated at the sternum. Excision of two-thirds of the whole clavicle at its middle portion: Surg. E. C. Frank- lin, u. S. V. Excision ................... Excision of clavicle Excision. Sent home June 9, 1863, Discharged September 24, 1834. Not a pensioner. Discharged October 6, 1865. Not a pensioner. Recovered rapidly. Furloughed Julv 15, 1804. Disch'd June 28, 1864. Arm al- most entirely useless, and shoul- der joint partially anchylosed. Duty, December 17, 1864. Arm permanently weakened. Veteran Reserves, Feb. 7, 1804. Motion and strength of arm much impaired ; neuralgic pain in shoulder joint. Disch'd March 30, 1865. Shoul- der partially anchylosed, arm wasted, nearly useless. Death from pleuro-pneumonia Decem- ber 14, 1870. September 10th. Use of the arm regained. Paroled. Wound healed rapidly. Fur- loughed Marcli 9, 1863. Discharged June 18, 180; a pensioner. Disch'd October 19, 1864. Use of the shoulder joint impaired. Discharged June 14, 1805. An applicant for pension. Disch'd October 18, 1804. Shoul- der joint weak and painful. Died June 12, 18C4. Died February 19, 1862 Died May 7, 1802. from the effects of sloughing produced by ery- sipelas. Discharged Jan. 12, 1803. Par- tial disability of arm. Died November 28, 1863. SECT. II.] SHOT FRACTURES OF THE SCAPULA. 481 The reader must collate, with the instances presented in the foregoing tabular state- ment and the six abstracts that precede it, two cases of extirpation of the clavicle, and five of partial excision of the bone where shot fracture accompanied penetration of the thorax, and of three unattended by primary lesion of the chest cavity, that have been detailed1 in the First Surgical Volume. The conclusions to which he would probably be led by an analysis of the reports of these thirty-one cases, were all the details at his disposition, would probably be, that extirpation of the clavicle for shot injury is seldom if ever called for; that, as in shot fractures of other long bones, detached splinters should always be immediately extracted, and that, as elsewhere, necrosed osseous fragments should invariably be removed at the earliest practicable moment. It is probable that instances may occur, in which it may become necessary to excise portions of the clavicle in order to reach wounded blood-vessels beneath it. Shot Fractures of the Scapula.—Of fourteen hundred and twenty-three determined cases, one hundred and seventy-seven terminated fatally. Hennen long since observed2 that shot lesions of this bone, if they did not implicate the thoracic cavity or shoulder joint, were not, comparatively, perilous; facts accumulated by later observers3 have con- firmed his judgment, and the data consolidated in Table XVII conclusively establish . this point. The fatal results, which were not in large proportion, could usually be traced to secondary affections of the chest or shoulder, probably due to some undiscovered fissures extending to the glenoid cavity, or unsuspected injury to the thoracic walls; or else might be referred to those complications that attend all, even the slightest, traumatic affections. The commoner forms of shot fracture of the scapula associated with shot pene- trations of the chest have been exemplified in the Fifth Chapter of the preceding surgical volume.4 Further illustrations, derived from cases not thus complicated, will be offered 1 First Surgical Volume, pp. 557, 558, 559, and 560. * Hexxex (J.) (Principles of Military Surgery, 3d cd., 1829, p. 394): " The injuries of the scapula itself are not of a very serious nature. Balls make a clean passage through its broad plate, and the splinters occasioned by them are easily removed." Seuuieu (Traiti de la Nature, des Compli- cations et du Traitement des Plaies d'Armes d, feu, Paris, 1844, p. 222 ct seq.) treats quite fully of shot fractures of the shoulder blade, holding that they are not very dangerous in themselves, and insisting on the importance of extracting detached splinters of bone. In the valuable publication containing the communications made to the Paris Academy of Medicine, in 1848, by Professors ROUX, Velpeau, Malgaigne, Begin, and others, on shot wounds, Baudens (Des Plaies d'Armes a feu, Paris, 1849, p. 222) cites instances of shot fractures of the scapula observed in the military hospitals during the French revolution of that year. John Thomson (Report of Observations * * after the Battle of Waterloo, Edinburgh, 1816, p. 149) gives similar testimony. He mentions three cases of shot fractures of the scapula; all the patients recovered. The scattered observations recorded by the older military surgeons are of the same tenor. Thus, Bordexave (Precis de plus. obs. sur les playes d'armes d, feu en diffirentes parties, in Mim. de I'Acad. de Chir., 1753, T. II, p. 533) relates an interesting case of comminution of the scapula by a cannon ball, successfully treated by M. DESl'ELETTE; and Ravaton (Chirurgie d'Armie, 17C8, p 240 et seq.) gives three examples of shot fractures of the scapula (06s. LIII, LIV, and LV) resulting favorably. 3 Schwartz (H.) (Beitrage zur Lehre von den Schusswunden, 1854, S. 139, u. s. w.) details five severe cases of shot fractures of the scapula that came under his notice, of which four terminated fatally. He remarks that: " Tho most careful treatment is required when there is consecutive burrow- ing pus. No attempt should be made to press out the pus; but to allow free escape, the shot opening must be dilated. Should the burrowing continue, its extent, should be ascertained by the sound, and limited by deep and large incisions. * * If one incision is insufficient, one should not hesitate to make several, and should not he frightened at the extent and the depth ofthe wound, but should cut down to the ribs even." From the civil commotions in Paris, in 1830, JoiiEitr (de Lamballe) (Plaies d'armes & feu, 1833, pp. 319, 320) cites eight cases of shot fractures of the scapula, and remarks: "Par son etat spongieux l'omoplate peut etre perforeo dans tons ses points avec une facilite 6tonnante. La saillie de ses apophyses spongleuses les expose a etre enlevees en partie, sans fracture du reste de l'os, ou il etre perforees, comme on la observe, plusieurs fois sur repine de l'omoplate et l'acromion. En portant le doigt a la surface de ces apophyses, on sent un vide, uno glace ronde, qui indique le passage de la balle et la perte de substance. La largeur et le defaut d'epaisseur du scapulum l'exposent a des perf irations analogues a celles quo Ton pourrait faire sur un papier fortement tendu." M. Chenu (op. cit Camp, d'Orient, p. 209) tabulates 106 instances of shot fractures of the scapula, with 33 deaths, a fatality of 31.1 per cent.; but the cases compli- cated by chest penetration are not discriminated. Dr. G. Williamson (Mil. Surg., 1803, p. 127) infers, from his experience in India, that: "Fractures of the scapula are not dangerous, unless they shatter the neck of the bone or cause a fissure into the joint. Abscesses are apt to form under the fascia of the back, and require to be laid freely open by incision." Inspector-General MOUAT (op. cit. Special Rep. from the New Zealand War of 1863, etc., in Statist, Sanit, and Med. Reports, London, 1807, Vol. VII, p. 494) records five cases of recovery after shot fractures of the scapula, and observes that: 'None of the cases have had extensive injuries; but here again, as in the cases of fractured clavicle, after exfoliation and cicatrization, the mobility of the shoulder joint is interfered with, and a man's usefulness as a soldier is injured." Dr. C. A. Gordon (Experiences of an Army Surgeon in India, London, 1872, p. 28) cites an example of a shot fracture of the right scapula, with a favorable result. 4 Museum specimens of shot fractures of the scapula are illustrated by wood-cuts in the First Surgical Volume, in the cases of Pt. J. P----, Fig. 211, p. 475; of Pt. F. T----, Fir;. 212, p. 475; of Pt. XV. F----, Fid. 213, p. 476; of a soldier wounded at the First Bull Run, FIG. 221, p. 484; of a prisoner at Fort Donelson, Fig. 222, p. 485; of Pt. G. W----, Fig. 223, p. 485; of Pt. Thomas L-^—, Fig. 224, p. 485; of Pt. Edward L----, FIG. 225, p. 486; of Pt. Patrick F. W----, Fig. 252, p. 551; of Pt. F. E. Bickett, FlG. 259, p. 562; of Pt. J. B----, Fig. 260, p. 563; of Pt. George R. M----, FlG. 201. p. 563; of Pt. Morris O----, Fig. 203, p. 564, removal of necrosed portions of the right scapula; of Pt. ,T. P----, Fig. 2C4, p. 564 (an adden- dum to the case detailed on p. 475); of Pt. W. A. Forbush, FlG. 265, p. 564, also noticed on p. 475; and, las'.lv, of Corp'l Sam'l A. C----, Fig. 274, p. 576. Gl ■1S:> INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX.. FIG. 373.—Shot perforation,with fracture of the spine of the scapula. [ From a photograph-1 here; bat first some instances of recovery1 will be presented, with reference to the position of the external wounds in this group of cases: Cask 1 426.—Assistant Surgeon W. II. Forwood, U. S. A., was wounded in the cavalry engagement at Brandy Station, October 8, 1883. He was sent to Washington on October loth, and placed in Douglas Hospital. Assistant Sargeon W. Thom- son recorded a "gunshot fracture of the right scapula," and the extraction of the missile on the date of the patient's arrival. On October 27th, Dr. Forwood was so far convalescent as to be able to travel to his home in Pennsylvania, and soon afterward he resumed active duty in the field. He now (1874) suffers comparatively little inconvenience from this serious shot fracture. Case 1427.—Private F. Eeager, Co. F, 93d Pennsylvania, aged 18 years, was wounded at Petersburg, Marcli 25, 1885, was treated in a Sixth Corps hospital, and thence sent to Wash- ington. Surgeon R. B. Bontecou, U. S. V., noted: "Admitted to Harewood Hospital, April 2, 18.)."), suffering from a gunshot wound through the upper portion of the back and the right shoulder, fracturing the spine of the scapula, and making its exit over the inner angle of the right scapula. On admission, the constitutional state of the patient and the condition of the injured parts were good. The patient progressed favorably under simple dressings and a nourishing supporting diet throughout, and the parts had entirely healed when he was discharged, May 30, 1805." The photograph, from which the wood-cut (FlG. 373) is taken, was contributed from Harewood by Surgeon Bontecou. In his application for pension, Eeager makes oath that he ''was wounded through the right shoulder hy a minie ball; that it seriously injured him, and materially interferes with him in the performance of his daily labor, at times altogether incapaci- tating him therefor." His claim for pension was suspended June 30, 1873, in consequence of no response having been received for two years. Case 1428.—Private J. Whitlatch, Co. B, 7th West Virginia, aged 19 years, was wounded at Petersburg, April 1, 1855, and sent to Washington, to Carver Hospital. Surgeon 0. A. Judson, U. S. V.; noted: " Gunshot wound of right shoulder. Ball entered superiorly, near the acromion process, passed downward and backward, and lodged near the inferior angle of the scapula, producing compound comminuted fracture of the spine of the scapula. The wound became greatly swollen and very painful. On April 9th, the patient was placed under the influence of sulphuric ether, and sequestra of the fractured spine of the scapula were removed hy Acting Assistant Surgeon J. Z. Wentz, who also extracted the missile by enlarging the original wound. Favorable progress followed the operation. The wound continued to improve rapidly. No unfavorable complications occurred except exfoliation. Discharged from service on June 12, 1885, necrosis of the scapula following the injury." Examiner J. C. Hupp, of Wheeling, reports, on April 30, 1868: '"Ball entered the top of right shoulder, passed through the right scapula parallel with its spine, extensively fracturing that bone in the region of the fossa infra-spinata, portions of which have been removed. A deep cicatrix, four inches in length, exists below and parallel with the spine of the scapula. Right shoulder painful aud enfeebled." The Examining Board of Wheeling reports, on September 12, 1873: "The ball was subse- quently extracted from the scapula near its posterior edge, etc. Disability rated one-half." Case 1429.—Private J. Anderson, Co. E, 207th Pennsylvania, aged 22 years, was wounded • at Petersburg, April 2, 1835, and was treated in a Ninth Corps hospital, and thence transferred to Washington. Surgeon E. B. Bontecou, U. S. V., noted: "Admitted to Harewood Hospital April 6th, suffering from gunshot wound of ihe right shoulder, the ball entering one inch above the clavicle, making its exit near the spine of the scapula, fracturing the same. On admission, the condition of the injured parts and constitutional state ofthe patient were good. Result favorable. Patient was doing well when transferred." The photograph copied in the wood-cut (Fig. 374) was taken at Harewood and contributed by Surgeon Bontecou. The patient was subsequently treated in Whitehall and Mower Hospitals, and was discharged from the latter September 9, 1885, and pensioned. Examiner W. M. Cornell, Philadelphia, September 11, 1835, reported : * * "The use of the arm is totally destroyed. The wound has not yet healed, and it is not possible to say how the case may be a year hence; but at present he is unable to labor." March 18, 1874, Examiner W. B. Rich reported: "Ball entered right side of neck, passed through shoulder, and came out near the top of the right scapula, fracturing the scapula, lacerating the muscles, tendons, blood-vessels, and nerves. The wound in the neck became gangrenous; extensive sloughing; exfoliation of bone from the scapula. The disability in this case was partial loss of use of the right 374.—Entrance and exit arm; the shoulder dropped nearly three inches; there was partial paralysis of the arm and of the wounds in a shot perforation of s\^e 0f the neck; there was a large cicatrix on the side of the neck, and frequent .eruptions on the the right scapula. [From a pho- ,.,„,,.. . , tograph.] skin. This pensioner was paid June 4, 1874. Many illustrations of recent shot perforations of the scapula might be selected from 1 Surgeon H. St. JOHX Xeale (Chirurgical Institutes of Gunshot Wounds, 2d ed., London, 1805, p. 164 et seq.), who served "formerly in H. M. 5th Infantry and ICth Light Dragoons, in the late war in North America," publishing 'for the Service and Benefit of the brave Warriors in Arms in Defence of our Country," devoted several pages to 'Remarks on wounds of the scapula, or shoulder blade," and made some judicious observations on the subject. He held that if an oblique shot broke only the scapular spine, there was no reason to be apprehensive of bad symptoms, provided the surgeon followed the ordinary rule of treatment. If the bone was perforated, bits of clothing and of bone were likely to be driven in, and then '" we should make bold incisions. * * * If any large splinters are separated (which, however, but seldom happens) it is proper to extract them. Mr. Pauscii, Surgeon-major of the regiment De Knyphausen, of the allied army in America, desired me to see Captain Van Bassewitz, a gallant officer of the above corps, who was wounded in the right scapula by a grape-shot, fired from a cannon during the reduction of Fort Washington, on the 20th of sect. n.J SI-TOT FRACTURES OF THE SCAPULA. 483 photographs in the Museum; but the two wood-cuts opposite, the following sketch, and another figured on the next page, show the more common varieties of such shot tracks:1 Case 14:10.—Private II. Yore, Co. B, 208th Pennsylvania, aged 40 years, was wounded at Petersburg, April 2. 1865. He was admitted to a Ninth Corps hospital, and the hall was extracted. On the 5th, he was transferred to Harewood Hospital. Surgeon R. B. Bontecou U. S. V., reported: "The missile entered the left shoulder, fractured the acromion process, and lodged in the supraspinous space of the scapula. Small fragments of bone have been extracted from time to time. The wound did well." On May ISth, the patient was transferred to Satter- lee Hospital, Philadelphia, and, on June 21, 1S65, was discharged the service and pensioned. Examiner (!. W. Smith, of* Hollidaysburg, Pennsylvania, July 19, 18;>(>, reported: "Ball entered the belly of the deltoid muscle, carrying away a process of the left scapula and the superior border of that bone, causing lameness and some disuse of the arm and shoulder." Examiner W. M. Findley, of Altoona, September 4, 1ST;!, reported: "His disability entitles him to an increase of pension. * * Motion upward is much impaired; lifting weights is painful; disability three-fourths." This pensioner was paid to June 4, 1^74. The photograph copied in the wood- cut (Fig. 375) was taken at Harewood, and contributed to the Museum by Dr. Bontecou. Case 14:>1.— J. Bottinger, aged 42 years, a soldier from Co. C, 4th New Jersey, discharged on account of hernia, arrived at Baltimore on his way home, on February (i, 18J2, and was shot on the evening of the same day by a sentinel, who mistook him for a deserter. Two days after- .hot'wou^Tn^^rof^cfure ward he was admitted to Camden Street Hospital. Acting Assistant Surgeon E. G. Waters of the left acromion. reported: "The ball entered the back of right shoulder about four inches from the joint, struck the spine ofthe scapula, glanced off. fractured the coracoid process, detached the glenoid cavity, and made its exit in front, below the clavicle, without having injured the vessels or the humerus. On February 11th, pieces of clothing were removed, also pieces of bone embracing the entire coracoid process. On the 17th, typhoid symptoms appeared; pulse irritable; respiration labored; tongue dry and cracked; abdomen much distended and tender; discharge offensive and unhealthy. Cold-water dressings slightly impregnated with a solution of chlorinated soda were applied. Alcoholic stimulants,^quinine, and beef-tea were given, and stupes of turpentine were applied to the abdomen. On February 20th, the tenderness of the abdomen had diminished; the tongue was coated but moist, the pulse was at 93. A small piece of the acromion made its way to the orifice of the wound and was removed. The patient was excessively wakeful, and opium was ordered. On June 18th, the anterior and posterior orifices of the wound were still open and discharging freely; there were also extensive sinuses. One of these could be traced laterally, having its orifice near the insertion of the deltoid; another communicated with the axilla, forming a large abscess. These were laid open. No necrosed bone could be detected. The treatment adopted was moderately stimulant and tonic, with nourishing diet. Simple dressings were applied, and the arm bandaged from hand to shoulder. On July 4th, there was an attack of erysipelas in the arm and shoulder, which readily yielded to treatment. On August 14th, the shoulder was observed to be flattened, and the head of the bone could be felt in the axilla, as usual after unreduced dislocations of the shoulder joint. The posterior orifice had ceased to discharge for several weeks; the anterior one was still suppurating slightly, but was nearly healed, and no sinuses were observable. The patient had considerable use of the limb, which will doubtless prove serviceable. He experienced no such pain as generally occurs when the head of the humerus presses on the brachial plexus. On September 17th, he was sent home quite cured, and enjoying extensive mobility of the arm." This man was a pensioner until January 19, 1871, when he died. Examiner D. L. Beaver, of Reading, reports, September 28, 1867: "He was injured in the pelvis by falling on a stump while aiding in building a fort at or near Camp Seminary, in 1861, which resulted in leaving something like an irritable condition of the bladder, from which he has to micturate frequently both night and day; suffers pain in consequence. Was also accident- ally wounded at Baltimore, while on his way home, by a musket ball, which passed through the right shoulder. Is unable to raise his arm to his head; otherwise can use it." November, 1776, near the banks of the Hudson's [sic] river, in the Province of New York. * * The ball had struck him in an oblique line, had shat- tered the spine of the blade bone, and also fractured its body. The muscles were much lacerated, and appeared all jagged and torn. Although the surgeon had made a considerable dilatation, it was soon found necessary to make still larger incisions. In the space of a month, several splinters of the bone came away with the dressings. An unfavorable suppuration continued to attend this wound for a long time, and seemed to threaten a gangrene; but by the free use of the Peruvian bark, and of opium, with a proper attention to the general treatment of the wound, this brave officer was again restored to his health. In the space of fourteen weeks he had taken upwards of four pounds of Peruvian bark. Many cases similar to the above might be stated which occurred during the campaigns in America, but a repetition of them is needless." 1 The following practical observations by HF.XXEN (I'rinciples of Military Surgery, 3d cd., 1829, p. 39(1) should be pondered: "There is a class of wounds in the neighborhood of the scapula, which, though not of a threatening nature at first, yet often and unexpectedly have a fatal termination. These are principally occasioned by gunshot, but sometimes by punctured wounds, which directly open the infra-scapular vessels, or cause them subse- quently to slough and pour forth their contents internally; giving to the eye the appearance of very trifling haemorrhage, but filling the whole sub- scapular space with blood, which makes its way down to the very loins hy infiltration, and there causes deep abscesses and even gangrene. The long and distant range of parts through which the blood passes prevents the detection cf the cause immediately ; and, indeed, could we even discover it, I am not aware of any effectual mode of securing the bleeding vessels. In the cases I have met, the blood has been effused in large quantities, and has descended nearly to the sacrum, dissecting the interstices of the muscles completely, and giving to the posterior part of the thorax and the loins that appearance said by Valentin" (Recherches critiques sur la Chir. moderne, Paris, 1772) to designate sanguineous effusions into the sac of the pleura." The deductions from the facts set forth in Taiile XVII are corroborated by observations in other wars. Thus, Professor II. FISCHER (Kriegschir. Erf., 1872, S. 141), refen'ing to shot fractures of the scapula, remarks: "As a rule these patients recovered without serious hindrance. Of eight cases, but one died, from purulent infiltration, a mortality of 12.5 per cent. Herr LOSFFLEK, in his exact statistical work (op. cit, 18C7, S. 162) chronicles forty-two shot fractures of the scapula, with seven fatal cases, or lo'.G per cent. M. Gillette (Remarques sur les blessures par armes & feu observies pendant le siege de Metz, 1870, etc., in Arch. gin. de Mid., 1873, IVe ser., T. XXI, p. 312), with a happy facility in generalizing from a few facts, states that: " Ces blessures ne sont pas extreinement graves, mais elles sont tres-longues a gnerir en raison des absces." and cites several cases of this group. 1S1 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. The pension records indicate that impairment of the functions of the shoulder joint was, as might be anticipated, a frequent consequence of shot fractures of the scapula, even in those cases in which the articulation was not primarily or directly involved: Case 1432.—Corporal W. T. Symons, Co. G, 16th Maine, aged 2?> years was wounded at Fredericksburg, December 13, 180:2, and was treated in a First Corps field hospital, and subsequently in Prince Street Hospital, Alexandria, where Surgeon T. Rush Spencer, U. S. V., noted: "Admitted, December 19th, with gunshot wound of the right clavicle." He was discharged February 20, 1863, Dr. Spencer certifying that there was "Necrosis of the right scapula and clavicle, and inability to raise the right arm; results of gunshot wound. He is totally disabled from obtaining his subsistence from manual labor." Examiner Robbing, of South Norridgewock, Maine, April 28, 1863, reported: "The ball entered just above the right clavicle, fracturing it slightly, passing out through the supra-spinous fossa of the right scapula. The wound is yet suppurating, and occasionally discharges pieces of bone. The arm is very much limited in its motions." On March 5, 1856, G. A. Wilbur, late Surgeon 11th Maine, contrib- uted a photograph of Symons, represented in the wood-cut (FlG. 376), and reported that " pieces of bone, one of which is supposed to be from the glenoid cavity, have come away," and the front wound was still discharging. Examiner C. W. Snow, September 4, 1873, reported: "Gunshot wound of apex of right lung, with fracture of the scapula. Impaired motion of shoulder joint; respira- tion slightly obstructed." This pensioner was paid to June 4, 1874. In rare instances, there was troublesome haemorrhage from shot wounds in this region,1 necessitating recourse to the ligature, or even sacrifice of the upper extremity. Flo. 376.—Entrance and exit shot wounds in a case of fracture of the right clavicle and scapula. [From a photograph.] Cask, 1433.—Private J. S land Heights, July 6, 1864 -, Co. G, 1st Potomac Home Brigade of Cavalry, aged 34 years, was wounded at Mary- He was sent to Frederick. Assistant Surgeon R. F. Weir, U. S. A., reported: "A shot wound of the left shoulder, with partial fracture of the spine of the scapula. Haemorrhage occurred on July 19th, and again on the 20th, from the dorsalis branch of the subscapular artery, to the amount of eight ounces. The bleeding was temporarity arrested by compression. On July 24th, the artery was ligated in its continuity. This patient was transferred, convalescent, to Mower Hospital, and thence, December 6, 18j4, sent to duty. He was mustered out and pensioned June 28, 1865. Examiner C. H. Ohr reported, December 1, 1869: "Wound by a minie ball, which entered the left shoulder on its posterior aspect two inches below the acromion. It carried away much of the spine, passed through the scapula, and made its exit opposite the spinous process ofthe fourth dorsal vertebra. The motions ofthe scapula are restricted by the laceration and cicatrization ofthe * * muscles, and the power of the arm is much weakened and impaired. There is, recently, throwing off of dead bone, as shown by a fistulous opening midway the spine of the scapula." In shot fractures of the scapula, the lodgement of balls was very frequently observed: Case 1434.—Private W. H. Holmes, Co. F, 17th Infantry, was wounded at Fredericksburg, December 14, 1862, and was sent to Washington, and admitted to Stanton Hospital on the 17th. Surgeon J. A. Lidell, U. S. V., noted: "A gunshot wound of the right shoulder, the hall entering midway between neck and shoulder joint, passing under the scapula, and remain- ing lodged." This soldier was discharged February 3, 1863, and pensioned. On April 7, 1863, Examiner G. S. Jones, of Boston, reported: "His wound was at the top of the right scapula, six inches from the acromion process, and the ball is lodged among the tissues. He is unable to extend his arm at a right angle, and its other motions are impaired." In November, 1864, Kxaminer J. B. Bell reported that the disability had increased, from the presence of the ball under the scapula. On January 6, 1-70. Mr. Holmes, in response to a communication from this Office, stated: "I was wounded while lying down on the ground, on the heights facing the enemy; the bullet entered just back of the right shoulder, near the outer third of the spine of the scapula. The bullet was probed for at Fredericksburg, as also at Stanton Hospital, without success. I was discharged from the service at Stanton Hospital and went to St. Luke's Hospital, New York. During my stay at St. Luke's, three large pieces of bone were taken out; the wound closed in nine months. * * Dr. G. E. Brickett, Acting Assistant Surgeon at Kennebec Arsenal, extracted the bullet on November 1, 1869. Abscesses had formed under the arm during the past summer, attended with a great deal of pain and inability to use the arm; it was a whole mini6 bullet, well flattened, and lying upon and attached to the third rib. It had not probably changed its position, having passed through the upper portion ofthe scapula, back ofthe clavicle, downward and forward against the rib." Examiners J. W. Toward, W. B. Lapham, and I. H. Stearns, December 6, 1871, reported : "Ball entered on top of shoulder, badly shattering bone and integument; passed down and came out below the right axilla. There is an immense cavity from loss of substance at the seat of wound. The arm and shoulder are very weak and lame, and the movement of the arm is greatly impaired. All labor is performed with pain; can do but little work of any kind with right hand." On September 4, 1873, the same Board reported: "The bone above the spine of the scapula is wanting, having come away after the wound. The action of the muscles arising from and attached to that portion of the bone is destroyed to a great extent. The arm may be used for ordinary purposes with care, but with any unusual strain the arm will be useless for a time from soreness and lameness." Pension paid June 4, 1874. 1 See also Case 1438, ou p. 490, and in the First Surgical Volume the cases of Pt. E. Pfluger, p. 539, and J. Moser and J. Mackey, on p. 554. SECT. 11.] SHOT FRACTURES OF THE SCAPULA. 485 The following case is interesting in several points of view, hut particularly as demon- strating that the lumbar ecchymosis, regarded by Valentin and Larrey as of diagnostic value, and even as pathognomonic of penetration of tlie thoracic cavity, may attend wounds external to it—a much disputed point, to some extent discussed in a note on page 575 of the First Surgical Volume: Cask 143").—Private 0. Ely, Co. K, ltth Pennsylvania Cavalry, aged 11) years, was wounded in a skirmish near Suffolk, • Virginia, March 17, 1S63. Surgeon G. C. Harlan, of this regiment, described the case as follows: " lie was shot with a minie ball in the right shoulder, while mounted, March 17ili, at Franklin. Wound of entrance in the anterior fold of axilla. Ball extracted below the spine of the seapila, having passed between the bone and its vessels, ploughing a deep groove in the nock ofthe former, and passing through the body of the scapula. There was not much external haemorrhage, but enormous effusion between the muscular planes, extending to the spine behind, aud dissecting up, and distending, the pectoral muscles in front, inducing a great tumefaction about the shoulder joint. The head of the humerus was apparently uninjured. Cold-water dressings were applied. Marcli 19th. swelling about the same; warm-water dressings substituted for. the cold. April 9th, patient up and walking about with his arm in a sling. Wound has discharged very little The extravasated blood is for the most part absorbed. As the swelling subsided, a displaced piece of bone could be felt under the skin on the outside of the arm, just below the head of the humerus. April loth, the patient was sent to hospital at I'm t Monroe. He had slight motion ofthe arm, but free motion of the forearm and hand." This soldier was discharged June 15, 1S3'3, and pensioned. Examiner H. Roberts, of Providence, reported. July 3, 187 I : " The ball entered in front, fracturing the acromion process, which is now drawn downward. The ball came out, apparently, through the scapula just below the spine. At present Mr. Ely is unable to raise his arm up to a level with his shoulder, or put it behind him; neither can he put it up to his head except in front. Rotation of the ami not equal to half of the natural limits. The powers of the arm and shoulder are greatly reduced, and the muscles in the region of injury are tender, contracted, and shrunken." Ely was examined by the Seranton Board, Drs. A. Davis and R. A. Scjuires, September 5, 187;!. and September 2, 1874; no material change was reported. He was paid June 4. 1874. Several instances were reported of hospital gangrene1 attending shot fractures of the shoulder blade. The prominent scapular spines, like the ridges of the innominata and sacrum, subject the overlying soft parts to such pressure as peculiarly predisposes them to sloughing. A brief abstract, accompanied l>v a sketch from a photograph, may serve as an example: Case 14:if>.—Sergeant J. M. J------, Co. E, 12th Louisiana, aged 2'.i years, was wounded at Franklin, November 30, 1864, and was sent to hospital No. 1, Nashville, from the field hospital, on December "20th. Suigicu B. B. Breed, U. S. V., February 20,1865, contributed the photo- graph represented by FlG. 377, with the following history: "Gunshot fracture of the left scapula by a conoidal ball. Gangrene appeared on December 24th, and two applications of bromine were made. December 27th, cured." Further particulars of the progress of the case are not furnished, but the patient was transferred to the Provost Marshal, March 27, 1865, for parole. False anchylosis of the shoulder joint often occurred after shot fractures of the spine of the scapula, when the articulation was not injured primarily. Cask 14.57.—Corporal A- B. Clark, 2d Wisconsin, aged 24 years, was wounded at Bull Run, July 21. 1831. lie was treated at Benton Barracks, Missouri, until November 1, 1S'62, when he was discharged and pensioned. Surgeon James Irwin] 8th Iowa, certified on the discharge-paper as follows : "Gunshot wound; ball struck the left scapula, fracturing a portion of the spine, including the acromion process. Use of shoulder joint destroyed; portions of bone continue to discharge. The ball has not been extracted." This man re-enlisted iu the Veteran Reserves. On Marcli 29, 1S'">4. he entered St. Mary's Hospital, Detroit. Acting Assistant Surgeon D. O. Farrand reported: "Wound by conoidal ball, which entered from behind, passed forward and through the spine of the left scapula, and lodged just below the clavicle, immediately above the subclavian artery. On April 5, 18(54, the ball was removed by making about the same incision as for ligation of the subclavian artery ; chloroform was used. At the time of operation the patient was worn out by constant pain from presence of the ball, and he was much emaciated." He recovered, and was returned to duty June 1, V<)\, and was finally discharged April 3, 1 St>5, resuming his pension. In 18o7, Examiner Louis Davenport reported : "It is impossible to raise the arm more than six inches from the body, or place the left hand to the mouth." The Detroit Examining Board reported, February 7, 1S72: "The muscles ofthe arm are atrophied; this atrophy is increasing. * * The anchylosis is complete, so that he is unable to move the joint at all. The atrophy of the muscles is of such an extent as to produce extreme weakness of the hand and arm. The limb hangs useless at his side." This pensioner was paid Marcli 4, 1874. 1 Jobert (A. J.) (Plaies d'armes a feu, 1833. p. 321) relates an example of shot fracture of the scapula, in which gangrene repeatedly supervened, insisting on the utility of lemon juice in such cases: "Ce meme homme nous offrit aussi un exemplo de potirriture d'hopital, survenue a la suite d'un ecartde regime. Cet accident se renouvela chez lui plusieurs fois, quand il avait eu quelques rapports avec sa maitresse; on parvint toujours a dissiper les symptomes, aussitot qu'ils apparurenf, par l'application du citron." FIG. 377.—Gangrenous ulcer succeeding a shot fracture of the left scapula. [From a photograph.] 486 INJURIES OF THE UPPER EXTREMITIES. [ciiAr. ix. Of the consequences of shot fractures of the scapula,1 secondary implications of the pleural cavity were the most fatal; but consecutive disease of the shoulder joint the most frequent. A case in which each of these complications was believed to be present may be cited : Casio 14158.— Private G. 8. Livingston, Co. I, 1st Vermont Cavalry, aged 32, was wounded near Reams Station, June 23, 1884. He was made a prisoner, was exchanged and sent, August loth, to Camp Parole, Annapolis, from Richmond, and on October 3d he was furloughed. . He entered Sloan Hospital, Montpelier, on February 20, 1835. Surgeon H. Janes, U. S. V., contributed a photograph showing the entrance and exit wounds in this case (Card Photog., S. G. O., Vol. II, p. 5), with the following history : "This man was wounded by a minie" ball, which entered one inch to the right ofthe spine, passed horizontally to the right and emerged just behind the point of the shoulder, fracturing the scapula and opening the shoulder joint. The wound was nearly healed at the time of his admission to Sloan Hospital. He continued to improve during his sojourn in this hospital, and was discharged July 19, 18d5, in good health. Wounds healed; ligamentous anchylosis of the shoulder joint, with little use of the arm." Examiner A. L. Lowell, of Coventry, reported, August 28, 1870: "A musket ball struck the back between the spinous process of the fourth dorsal vertebra and the posterior margin of the right scapula, and, passing upward and outward through the subscapulars muscle, emerged at the posterior margin of the acromion process. A portion of the acromial end of the scapular spine was fractured and the acromion was abraded by the bullet. The supra-spinatus and infra-spinatus muscles are atrophied by disuse. The pectoral muscles ofthe right side also show diminished volume and strength from the same cause. The humerus, although susceptible of slight rotation on its axis, is held fast to the scapula by fibrous adhesions about the scapulo- humeral articulation, and cannot be extended from the body. The scapula is also hound to the costal walls by adhesions, resulting from inflammatory action. The functions of those muscles, vessels, and veins presiding over the nutrition and efficiency of the right forearm and hand are not materially impaired. The hand is well used. The right side of the chest, especially under the scapula, is dull on percussion, and the respiratory action is feeble and expiration is prolonged, with well-marked pectoriloquy. The respiratory action of the left lung is exaggerated. The subject suffers from cough and dispncea on slight over-exertion or excitement. The respiratory action is largely abdominal, the walls of the chest exhibiting little motion. The face is pale, and the entire physical aspect is one of debility. The clinical thermometer shows 99£ degrees. The wound reopens from time to time for escape of exfoliated bone. From the fact that the bullet passed so near the thoracic walls, if not really penetrating them at the period of primary lesion, 1 form the opinion that from the contiguity of a severe wound the pleura and lung became seriously impaired, and it is now my view that the subtending pleura and lung tissue are bound to the costal pleura by adhesions. The pensioner alleges that immediately after being shot blood was freely raised and expectorated. The physical signs are rather those of hepatization of the middle lobe of the lung, with pleuritic adhesions. I find no symptoms of hydro- thorax. The respiratory action at the lower lobe still remains, although feeble; disability total." Examiner J. C. Rutherford, September 4, 1S73, reports: "Right shoulder completely shattered, with considerable ofthe scapula. Complete anchylosis of the shoulder joint; arm firmly flexed at the side ; has but little use of the right hand ; often has abscesses form on his back near the shoulder, which are very painful and debilitating. Pensioner says, in his declaration, the wound has discharged a greater portion of the time, and thirty-one pieces of bone have been extracted." This pensioner was paid to June 4, 1874. Balls sometimes traversed the upper dorsal region in close proximity to both scapulae, but fracturing only one : Case 1439.—Private L. Mills, Co. A, 3d Maryland, was wounded at Antietam, September 17, 1832, and sent to Wash- ington, to the Patent Office Hospital, September 28th,.and thence to Carver Hospital, January 17, 1883. He was discharged March 26, 1863, for disability, Surgeon O. A. Judson, U. S. V., certifying that there was: "A wound of both shoulders by gunshot, disabling the patient in the use of each of his arms." Examiner T. B. Smith, of Wash- ington, reported, March 26,1863 : "The ball entered behind the left shoulder joint, traversed the back beneath the scapula, and was cut out from the posterior part of the upper third of the right arm. The ball was removed five months after the reception of the injury. The general health is good. A large abscess formed beneath the right scapula, and a sinus fourteen inches in length." Assistant Surgeon E. F. Bates, U. S. V., contributed . to the Museum the flattened musket ball that inflicted the fracture in this case, and had split probably on the r in. .i.e.-itouiid ' . musket ball, with spine of the left scapula, and passed across the back beneath the right scapula, and down the right arm to fragment! C Spec. uear tne middle of the external aspect of the deltoid, whence it was extracted by Dr. Bates. The projectile is 295. l-l. represented in the adjoining wood-cut (FlG. 378). There were reported twelve examples of shot fractures of both scapulae unattended by penetration of the thoracic cavity ; three fatal, and nine terminating favorably. These cases were attended by exfoliations and necroses of greater gravity than those in which 1 Preparations of shot fractures of the scapula are probably not infrequent in such collections as those at Netley, at Val-de-Grace ; but compara- tively few are recorded in the catalogues of other museums of pathology. At the Edinburgh Museum (Cat, 1836, p. 24) there are two specimens (199 and 201 XX, D), from the battle of Corunna. In the Hunterian collection there are also two specimens, numbered 2920 and 2926, one described at Vol. V of the Catalogue (IS-1!). p. 2-1, and the other in the first supplement (1893), p. 92. The St. George's Hospital Museum has a specimen of shot perfora- tion of the left scapula (Cat, 18C6, p. (i.i), numbered 215, of Series I. In the Guy's Hospital collection there is one specimen, marked 109736, described on page 07 of Dr. Wilks's catalogue of 1863. In the Pennsylvania Hospital Museum are two preparations of shot fractures of the scapula (Cat, 18C9, p. 17; compare also Proc. Path. Soc, Phila., June 27, 1806, Vol.11, p. 237). In the Museum of the Boston Society for Medical Improvement (Cat, 1847, p. Ti), specimen IGl is from a sailer of tho frigate Guerriere. whose shoulder blade was shattered by a grape-shot. In the pathological cabinet ofthe New York Hospital (Hay's Cat, 18GO. p. i4>. preparation 90 is a shot fracture of the relit scapula. SECT. 11.1 SHOT FRACTURES OF THE SCAPULA. 487 only one shoulder blade was interested; yet the mortality from this form of injury was not lar^e.1 Fractures of the spinous processes of the upper dorsal vertebrae were noted in most of the cases that were reported in detail. Cask 1440.—Private O. W. Stacks, Co. C, 17th Iowa, aged 28 years, was wounded at Tilton, Georgia, October 13, 18.34, and was treated in hospital No. 1, Chattanooga, from November 1st to Gth, when he was furloughed. On February 24, 180"), he was sent to Keokuk. Surgeon M. K. Taylor, U. S. V., noted: "Compound comminuted gunshot perforating fracture of both scapulae. Ball entered posteriorly beneath the spine of the right scapula, and emerged posteriorly above spine of the left scapula." The patient was discharged August 23, 1835. and pensioned. Examiner W. L. Orr, of Ottumwa, November 16, 1867, reported: "The original wound was caused by a musket ball, which struck the spine of the right scapula about three inches back of the acromion process, shattering the bone extensively, passed through the spinous process of the first dorsal vertebra, and emerged through the superior costa of the left scapula. Exfoliation of the right scapula is now going on, rendering muscular exertion of the arm impracticable." Paid June -1. 1S7 1. The next case is remarkable for the length of tlie seton-track the projectile is reported to have described: Case 1441.—Private A. Wilson, Co. A, 163d New York, aged 3'.) years, was wounded at Fredericksburg, December 13, 1802. He was sent to Stanton Hospital on Christmas day, and remained there until March 27, 1803, when he was transferred to Ladies' Home Hospital in New York. He was sent to the Invalid Corps, July 20, 1803. Surgeon A. 15. Mott, U. S. V., reported: " He w as wounded by a shell, which grazed the acromial process of the left side, passing along the upper border of the scapula, across the vertebral column opposite the second and third dorsal vertebras, then along the upper border of the scapula of the right side, fracturing its spine, making a wound six inches in width and sixteen in length. Remained in hospital at Falmouth for two weeks, when he was sent to Stanton Hospital, remaining there until transferred to this hospital. The wound had healed up, except near the fracture of the spine of the right scapula. The wound was kept clean, and the patient was put upon tonics. On May 8, 183'!. the wound \\;is healed, but the cicatrix was very sensitive to the touch." This soldier was discharged July 11, 180."), and pensioned. Examiner E. Bradley reported, July, 1805, that: "A piece of shell hit him just above the spine ofthe right scapula, and, passing through the tissues and directly across the back, fractured the spine ofthe scapula; the muscles were severely toru and injured. The wound was healed, but the motions of the right arm were interfered with." Examiners McCollom and Leighton reported, September 8, 1873, that "the right scapula was fractured, impairing the free action of the arms." Case 1442.—Corporal F. Schwab, Co. A, 44th Illinois, aged 43 years, was wounded at Kenesaw Mountain, June 27, 1804. He was taken prisoner, but after his exchange, March 24, 1865, he was sent to Camp Chase, and thence to Tripler Hospital, at Columbus. Surgeon I. D. McKnight, U. S. V., reported: "A gunshot wound of the posterior walls of the chest, fracturing both scapulae." The patient was discharged May 9, 1865, and pensioned. Acting Assistant Surgeon J. M. Evans reported: "A wound of the posterior walls of the chest, fracturing both of the shoulder blades and the spinal processes of the fifth and sixth vertebrae, * * causing lameness to such an extent that he will be unfit for military duty." Examiner G. P. Wood reported, October 12. 1805: * * "A ball struck the right shoulder, injuring the scapula?, and breakiug the spinous processes of the dorsal vertebra, weakening the shoulder and back." This pensioner was paid June 4, 1874. Case 144 5.—Private W. P. Chase, Co. D, 2d Massachusetts, aged 25 years, was wounded at Antietam, September 17, 18 12, and admitted to hospital at Camp Curtin on September 20th. Acting Assistant Surgeon J. P. Wilson reported: "Gunshot wound of both shoulders." The patient was discharged and pensioned November 11, 1862. Acting Assistant Surgeon J. B. Crawford reported that: "The ball entered over the middle of the left scapula, fractured the spinal process of the fifth dorsal vertebra, and made its exit at the lower border of the right scapula." Examiner O. Martin, of Worcester, October 10, 1804, reported: "The ball passed through the centre of the left scapula, and out through the right near its lower angle. The right scapula is diseased from the injury, and pieces of bone are being discharged, with large quantities of pus. There is no defect in the motion of the shoulder joint." Subsequent reports state that elimination of necrosed bone continued. This pensioner was paid June 4, 1874. Case 1444.—Private S. McMurray, Co. C, 11th Pennsylvania Reserves, was wounded at South Mountain, September 14, 1832. December 3, 1832, Surgeon C. W. Joues, U. S. V., reported that: "A ball entered the right scapula, causing partial anchylosis of both shoulder joints." He was discharged and pensioned. Examiner A. M. Neymau reported, January 30, 180'J: '" The left ann is seriously disabled for work of any kind; the disability is caused by a gunshot wound through the bodies of both of the scapulae; the disability will probably increase; it has increased since the last examination." This pensioner was paid June 4, 1874. Cases 1445-1448.—Private J. Shank, Co. F, 2d Infantry, aged 25 years, was shot through the left shoulder at Rappa- hannock Station, November 7, 1803. Surgeon D. W. Bliss, V. S. V., reported that: '"The missile passed through the muscles ofthe back, and emerged through the right shoulder, fracturing the spines of both scapulas." This soldier was returned to duty July 30, 18134, and is not a pensioner.—Private J. Powell, Co. F, 30th Colored Troops, aged 39 years, received at Petersburg, July 30, 1834, "A shot wound of the right and left scapulae." Surgeon E. Bentley, U. S. V., reported that this soldier was returned to duty February 1, 1885; not a pensioner.—Private W. H. Perry, Co. H, 33th Massachusetts, was struck at the Wilderness, May 6, 1834, by a musket ball, and Surgeon P. A. Jewett, U. S. V., noted that both scapulae were injured by the missile. This soldier was returned to duty October 2, 1834, and was not pensioned.—Sergeant N. Brown, Co. C, 7th Colored Troops, aged 21 years, was hit at Deep Bottom, August 14, 1834. Assistant Surgeon Fly McClellan, U. S. A., reported that: " The ball fractured right and left scapulas. The patient convalesced, aud returned to duty December 12. 1834." Not a pensioner. 1 References to shut fractures of both scapula; are exceedingly uncommon in authors: Bonet (Corps de Medecine et de Chirurgie, Genevae, 1C79, T. II, Obs. 49, p. 84; cites a case observed by Borel, in which both scapulas were shattered by a bullet. -188 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. In the three fatal instances of shot fractures involving both scapulae,1 the patients succumbed, five to eight weeks after the reception of their injuries, from hospital gangrene or pyaemia. An abridged memorandum of these cases is appended: Casks 1449-1451.— Private R. J. Ives, Co. B, 189th New York, aged 33 years, was wounded at Hatcher's Run, March 29. 180.5. was taken to a Fifth Corps field hospital, where the ball was extracted. On April 3d, he was sent to Washington to Harewood Hospital. Surgeon R. B. Bontecou, U. S. V., reported: "A gunshot wound, the ball having entered over the middle of the superior edge of the right scapula, and was extracted near the middle of the left scapula; the left scapula was badly fractured and the right slightly injured. On admission the condition of the injured parts and the constitutional condition of the patient were tolerably good. The patient did tolerably well until April 20, 1865. After that date the parts became gangrenous, the whole length of the wound being involved in the sloughing. The patient sank, and died May 16, 1865."—Private D. Way, Co. K, 1st New Hampshire^ Cavalry, received, at Petersburg, June 15, 1864, "Shot fractures of both scapula;. He died July 20, 1864," as reported by Assistant Surgeon E. McClellan, II. S. A.—Private N. T. Flewellyn, Co. E, 31st Maine, aged 22 years, was wounded at Spottsylvania, May 12, 1834. Surgeon T. R. Crosby, U. S. V., reported a "shot fracture of both scapula?." Death, July 10, 1864. Preparations of shot fractures of the scapula, already illustrated, are enumerated on page 481. Some further examples will be adduced, Plate XLV opposite representing one of the most remarkable of those in the Museum: Case 1452.—Private X. 0------, Co. D, 1st Florida Cavalry, was wounded at Mission Ridge, November 25,1863, and was admitted to Prison Hospital, Nashville, on December 7th, and thence transferred to hospital No. 1, January, 1834. He died of pneumonia, January 27th. Surgeon C. W. Hornor, U. S. V., noted : "Post-mortem twenty-four hours after death: Fxternal appearance, moderate emaciation, with a general ecchymosed appearance of the back. On examination of the wound, it was found that the ball which produced it passed through the spine of the scapula." The specimen (FlG. 379) consists of "The right scapula, the posterior portion of the spine carried away by a bullet, which appears to have passed from below upward. Two slight fissures exist in the lower plate. The whole posterior of the right~scapula!C Spec aile.1""6 surface of the bone shows marks of periosteal disturbance." The specimen was contributed by Acting Assistant Surgeon Preston Peters. Case 1453.—Private W. A. S------, Co. B, 13th Indiana, aged 27 years, was wounded at Petersburg, July 30, 1864. He was sent to a Ninth Corps hospital, where Surgeon T. Christ, 45th Pennsylvania, reported: "Gunshot wound ofthe thorax, removal of pieces of bones." The wounded man was sent, on the following day, to City Point, and thence, on August 3d, to the Douglas Hospital, at Washington. Assistant Surgeon W. Thomson, U. S. A., reported: "This man was struck by three musket balls. One entered the left side an inch below the border of the left axilla, and escaped near the acromial extremity of the clavicle. A second hall penetrated the left supra-spinous fossa, and was removed after death. Striking the spine it caused remarkable lissuring of its base. A third ball, splitting on a rib, had penetrated the thoracic cavity between the ninth and tenth left ribs, and at the autopsy one-half of the missile was found just within the pleural cavity, and the other portion in the apex of the left lung. The autopsy revealed the usual evidences of traumatic pleuro-pneumonia." The scapula, forwarded to the Museum by Dr. Thomson, and represented in Plate XLV opposite, is described by Dr. Woodhull (Cat. Surg. Sect., 1866, p. 74) as "fractured by a bullet, which first impinged against its anterior border just below the glenoid cavity, and then struck the spine at the junction of the acromion, and was extracted from the supra-spinous fossa. A deep longitudinal fracture nearly separates the spine from the dorsum of the bone. The coracoid process is nearly split off, and the whole inferior plate is occupied with fissures, none of which directly communicate with the original fracture, but which together nearly destroy the bone." One of the remotely fatal cases of shot fracture of the scapula was in the person of a medical officer: Case 1454.—Surgeon C. Newhaus, 29th New York, aged 43 years, received, at Bull Run, August 30, 1852, a gunshot wound of the right shoulder, which fractured the clavicle and the acromion process of the scapula. He was mustered out on November 13, 1862, and pensioned. In his affirmation, April 8, 1864, he stated that: "After his removal from the hospital on the battle field to Washington, he was treated by Assistant Surgeon Staehly, ofthe 7th New York. He remained iu Washington fifteen days, when he was removed to Brooklyn." Dr. B. F. Staehly, late Assistant Surgeon 7th New York, certified, in Novem- ber, 1864, that this was a shot injury "causing a double fracture of the right clavicle and perforation ofthe scapula," and that it is his opinion " that said injury necessarily must impair the mobility of the right arm in a high degree, even if healed in the most, favorable manner." Examiner C. Rowland, of Brooklyn, reported, November 4, 1864: "The above applicant alleges that he was wounded by a ritle ball entering under the right clavicle, and making its exit near the acromion process of the right scapula, causing a partial loss of the upward motion of the arm. He alleges that he cannot lift any weighty substance. It is a serious disability in manual labor, but, in his profession, will not incommode him very greatly." This pensioner died July 23, 1833. The cause of his death is not known at the Pension Bureau. 1 Specimens 699 and 847, Section I, A. JI. M., mounted together, afford a fine illustration of shot fracture of both scapulae; but the preparation cannot easily be portrayed either by engraving or photography. Dr. Paul Bkck Oodhaud contributed three specimens with an abstract, which is printed at page 435 of the First Surgical Volume. Compare Cat. Surg. Sect, 186 ">, pp. 60 and 75, and the remarks on pp. 435 and 436 of the preceding snrirical volume. «.*■ '' ¥ ,4?'*& /-•■•" fA>. '*■■ :■■- * *.-,. ■■■■■ , ... ;.i&:-£i '::.•■ *-'-:i%. '•■•/•:y ' REMITfE:- '» .■■"ii 'A>. ! "i::;, :'!"' ^-'it'.-.-u .■ i .;■■■ ;.'., 1864. .--IVvato N. '.'" : k'>v L.:. 8. \ oula. ;;■'.-. -.1 u- •';;-tr, J dy ;><> I■■ ., Vtl<)i(inl .ff the ;i,<.ii:, « ■■*«!«'", <>!3 AuffUSt iid, 1i -v: rt struck :. ilm-h '"filial csn./n ; •..! :'' ■•".uiiie it, < ■. ■ ■''. .:;i.'h and 1.1 , ■'.■ :n the . ; :-\ ■■•■■ • .:< i ■■ ■ i. ;,-ii it lie.if Med. and Surg. Hist, of the Rebellion, rait II, Vol. II. Chap. IX. Ward phot. Am. Photo-Relief Printing Co.. Philada,. PLATE XLV. COMMINUTED SHOT FRACTURE OF THE LEFT SCAPULA. No. 3585. SURGICAL SECTION. SECT. II.] SHOT FRACTURES OF THE SCAPULA. 489 FIG. 380. —Right scapula coated with osteophytes after shot fracture. Spec. 2792. These fractures, as observed in fatal cases, are, of course, of almost infinite variety. According to the part implicated, whether body or apophyses, and the date when the patient succumbs, the recent comminutions, the attempts at repair,1 or the destructive changes, present unlike appearances : Case 1455.—Sergeant F. H. H------, Co. A, 121st Pennsylvania, was wounded at Gettysburg, July 1, 1833, and sent, July 13th, to Broad and Cherry Streets Hospital, Philadelphia. Acting Assistant Surgeon H. M. Bellows reported : "A ball had entered on the right side ofthe chest over the third rib, two inches from its sternal extremity, passed around the chest, and had escaped behind, through the inner border of the scapula, about two inches above its apex. On admission, he was anaemic and very much broken down in health; his pulse was feeble and frequent, his tongue furred, and his countenance was of a dusky hue. The wound of entrance looked well ; but that of exit was sloughing and discharging ichorous pus freely, and the soft tissues over and around the scapula were boggy. Milk-punch and beef-essence, with tonics, were freely administered, and the wounds were dressed with fermented poultices. July 18th, the sloughing continued, with indications of erysipelas. Crucial incisions, three inches in length, were made through the wound, and the deeper tissues were found to be involved. The parts were cauterized with nitric acid. On July 22d, he had several chills, followed by profuse diaphoresis and vomiting. Sinapisms were .applied over the abdomen, and one drop of creasote was given in mucilage, as required. July 25th, the patient has been vomiting daily, and suffering from chills, followed by great exhaustion. This condition con- tinued until August 2d, when he died. A post-mortem examination was made eight hours after death: In each lung a few scattered tubercles were found at the apices, with some hypostatic congestion at the bases. All the other organs were healthy. On examining the course ofthe wound, it was found that the ball had run around on the upper border of the third rib and passed out behind. A large abscess occupied the under surface ofthe scapula, which bone was, in part, denuded of its periosteum. There was another abscess in the superior spinous fossa; the coracoid process was necrosed. Death had evidently resulted from extreme exhaustion dependent on his condition." The specimen (Fig. 380) was forwarded to the Museum by Acting" Assistant Surgeon W. V. Keating, and consists of " the right scapula fractured on the anterior border near the inferior angle. * * The fractured edges are necrosed, and both surfaces of the lower portion of the scapula are coated with an osseous layer."— Cat. Surg. Sect, 1866, p. 74. In the foregoing case the patient survived a month; in the next, a fortnight only : Case 14."6.—Corporal C. D. S------, Co. H, 100th New York, while on picket at the upper end of Folly Island, on the night of April 10, 1853, was wounded and taken prisoner by a scouting party ofthe enemy. Surgeon F. L. Dibble, 6th Connec- ticut, reported: 'As his wound was severe, he was left by the enemy on the field, and was taken to the regimental camp three hours afterward. On April 11th, he was removed to the hospital steamer Cosmopolitan by Surgeon M. S. Kittenger, 100th New York, and his wounds were examined. A conical rifle ball had entered over the anterior superior edge of the deltoid just above the acromial end ofthe right clavicle, and, passing backward and inward, had emerged at the middle ofthe spine ofthe scapula. The scapula was extensively injured and several fragments were extracted, one of them being nearly an inch square; they were chiefly portions ofthe spine of the scapula. The degree of injury to the clavicle was not accurately ascertained. The shoulder joint was thought to be uninjured. The haemorrhage from this wound was inconsiderable. A second wound, also from a rifle ball, entered at the middle of the under surface of the left heel, passed upward and a little inward, shattered the calcaneum and the inner malleolus, and made its exit above the latter prominence. Amputation was performed by the circular incision just above the malleoli, the condition of the soft parts not justifying the operation of Mr. Syme. The foregoing was transcribed from a report by Surgeon G. A. Otis, 27th Massachusetts, in charge of the steamer Cosmopolitan. The patient was removed from the transport into hospital No. 1, Beaufort, April 16, 1863. On that day, and the succeeding one, both wounds remained in good condition, the stump showing evidence of immediate union of the flaps. The third day after admission, his condition was not so favorable, and the stump commenced to have an ashy appear- ance and was highly sensitive. Sloughing of the integuments to a considerable extent followed, and the surface of the wound never afterward assumed a healthy appearance. All this time the wound in the shoulder discharged profusely, and quite a number of pieces of bone were removed. On April 25th, a severe rigor seized the patient, followed by heat of the skin and great perspira- tion. During the day the skin and conjunctiva took on a yellow hue, and, on the 26th, he experienced another chill aud complained of pains in the abdomen. At this time he became delirious, the delirium being low and muttering. On April 27th, pneumonia set in, and the cellular tissue of the right arm became infiltrated and greatly distended with fluid. He grad- ually sank until April 30th, when he died. After death I removed the clavicle and the remains of the scapula, which I send with this." The specimen (Fig. 381) exhibits "the right scapula, struck near its acromial end by a bullet which emerged through its spine, shattering a large portion of the bone. The joint was opened, and the glenoid cavity slightly fractured."—Cat. Surg. Sect, 1866, p. 96. In this case, it was surmised that the shoulder joint was not interested primarily, and 1 Observations of regeneration of the scapula in man have been recorded by CIIOI'AUT and Klexcke, and RUDOLrm and KORTUM report the same phenomenon in the horse. (See Wagner, Vber den Hcilungsprocess nach Resection und Exstirpation der Knochcn, Berlin, 1853, S. 29.) 62 Fig. 381.—Shot fracture of tho right scapula. Spec. 1188. 4', m ) INJURIES OF THE UPPER EXTREMITIES. [OHM'. IX in the succeeding case, it would appear to be certain that the original lesion did not extend to the articulation. The subject of arthritis consequent on injuries in the vicinity of joints must be reserved for future consideration. Unhappily, as will be more apparent in treating of injuries of the other large joints, the examples were so numerous, that it is necessary to avail of every opportunity of introducing illustrations, to be referred to in the subsequent general discussion : Case 1457.—Private G. F. Watson, Co. K, 7th Wisconsin, aged '27 years, was wounded at the Wilderness, May 5, 1864. Surgeon C. N. Chamberlain, U. S. V., reported, from a Fifth Corps hospital, "a gunshot wound of the back." On Mav 12th, the patient was admitted into Douglas Hospital, Washington. Assistant Surgeon W. Thomson, U. S. A., reported: "This soldier was struck, on May 5th, by a conoidal ball, which fractured the scapula. He died, July 28th, of profuse suppuration and chronic diarrhoea. At the necropsy, the mucous membrane ofthe large intestine was found thickened and ulcerated." Dr. Thomson contributed the specimen (FlG. 382) of "the right scapula, fractured in the supra-spinous fossa, and the upper portion ofthe humerus, the head of which is entirely absorbed. The joint does not appear to have been implicated in the original injury, but became destroyed by the resulting inflam- mation. There is a border of necrosed bone at the seat of fracture, and a slight osseous deposit near by, but no attempt at repair in the joint."—Catalogue of the Surgical Section, p. 96, 1836. FlG. :i8 ?.—Shot fracture of the right scapula, with consecutive traumatic arthritis. Spec.3581. In a case of shot fracture of the scapula, after unavailing temporization with styptics, ablation of the limb at the shoulder was practised, as a preliminary measure to extirpa- tion of the shoulder blade,1 an operation the patient's condition did not permit: Case 1458.—Private I. 13- -, Co. B, 60th Ohio, aged 19 years, was wounded at Po River, May 9, 1864. He was sent to a Ninth Corps hospital, and thence to Washington on the 13th. Surgeon J. A. Lidell, U. S. V., from Stanton Hospital, reported : "Gunshot wound of left shoulder. Ball entered below the clavicle and border of trapezius muscle, and passing down- ward and backward, fractured the scapula. Secondary hsemorrhage took place on May 27th, 28th, and 30th, and was controlled on each occasion by the application of solution of persulphate of iron. Tonics and stimulants were administered, and ice dress- ings were applied. On the 29th, the ball was extracted through an incision made along the inner border of the scapula. On May 31st, hsemorrhage again occurred, and was so profuse, both from the wound as well as from the point where the missile was extracted, that amputation was considered necessary with a view of extirpating the scapula and securing the bleeding vessel, which was diagnosed to be either the subscapular or supra-scapular artery. After the patient had been placed under the influence of sulphuric ether, Acting Assistant Surgeon C. H. Osborne amputated the arm at the shoulder joint. The operation was accompanied by very little loss of blood, but the hsemorrhage had been so profuse previously, that the patient never fully rallied. Death supervened on the same day, May 31, 1864. The autopsy showed extensive stellated fracture of the scapula, and the supra-scapular artery was found divided near its passage over the bone. The internal organs were normal." An instance in which a musket ball wTas lodged beneath the scapula is not without interest. Such cases were not very uncommon ;2 and were very frequently mortal: Case 1459.—Private G. II. Hamilton, Co. E, 5th Maine, aged 20 years, was wounded at Rappahannock Station, Novem- ber 7, 1863. Surgeon D. W. Bliss, IJ. S. V., forwarded the missile that inflicted the wound to the Army Medical Museum with the following memorandum: "The ball entered the middle third ofthe right clavicle, producing a complete fracture of the same, and otherwise lacerating the contiguous soft parts; ball remaining in. Two days had elapsed from the time of his receiving the wound to his being received into this hospital, when he was very much prostrated, and had not recovered from shock. His shoulder was very much swollen, and the head of the humerus was dislocated downward into the axilla. His system failing to respond to the most stimulating and thorough treatment, he died on the 14th of November, five days after admission. On post-mortem, after twenty-four hours, the ball was found lodged beneath the scapula, completely enclosed in a portion of the uniform coat. The lungs presented a congested condition, but not sufficiently so to account for his death; neither can the cause of his death be looked for in the amount of lesion in the surrounding parts. It was apparently the result ofthe shock received, or of nervous prostration." The projectile, as shown in the wood-cut (FlG. 383), is a longitudinal half of a conoidal ball, flattened, with inverted edges. A smaller fragment is attached. (See Cat. Surg. Sect., 1833, p. 610.) Shot Fractures of the Scapida and Clavicle .simultaneously were usually, but not invariably, attended by lesions of the large adjacent blood-vessels or nerves, or of the pleural cavity or lung tissue. Two examples are subjoined of such contemporaneous 1 The case may be added to the long list of examples ofthe folly of awaiting a third ha)in irrhage before interfering. 2Compare, in the First Surgical Volume, CASES of G. W----, p. lb", W. II. Burns, p. 4w and jaundiced. Upon examination of the viscera of the thorax the right lung was found normal, but extensive exudation of yellowish-green curdy pus covered the surface of the left lung, which was glued to the ribs by recent inflammation of the pleura; the parenchyma of the lung was congested. The left side of the thorax contained about one quart of yellowish-green curdy serum. The heart was normal but not contracted, and contained no clot. The liver was slightly enlarged, and exhibited circumscribed spots of fatty degeneration. The spleen was enlarged and its substance apparently normal. The kidneys were somewhat above their normal size; substance friable; the capsule separated with unusual facility. The form of the pyramids, as shown by a longi- tudinal section, was encroached upon, and in some instances entirely obliterated by fatty degeneration, which was so apparent as to be seen by removing the capsule from any part of the surface. There was extensive burrowing of pus, and suppuration in both the supra- and infra-spinous fossa*, involving also the cervical glands, some of which suppurated. In the external jugular vein were found half a dozen oval, -white, opaque bodies, exuded beneath the mucous coat, near the upper valves, and about one-fourth of an inch in diameter. The vein was thickened in the vicinity, and softened; it was of a livid color, and con- tained a dark red, moderately firm thrombus, continuous throughout the diseased track, which was about three inches in length. The subclavian vein did not seem to have been implicated in the inflammation. The portal veins were of a bright red color, congested, and softened in the mucous coat. A few congested spots of inflammation were found in both the superior and inferior vena cava, particularly marked near its bifurcation into the common iliacs. In the middle portion of the vena cava were four or five deeply congested and elevated spots of irregular outline, one-sixteenth of an inch in diameter, encircled by a white ring, which appeared to be owing to the loss of sub- stance from the middle coat of the vein. This appearance may still be seen in a section from the vena cava (Spec. 6455)." Dr. French contributed an osteological preparation from this case (Fig. 384), which consists of "the right clavicle with its acromial end chipped off, and the acromion fractured at its junction with the spine."—Cat. Surg. Sect, p. 76. Case 1461.—Sergeant T. B------, Co. H, 5th Cavalry, was wounded at Gaines's Mill, June 27, 1862. He fell into the enemy's hands, was paroled, and sent, July 30th, to the Episcopal Hospital, Philadelphia. Acting Assistant Surgeon R. A. Cleeman reported: " Wounded by a musket ball, which entered the left shoulder about two and a half inches from the acromial process and just above the spine of the scapula; it came out at a point opposite the junction of the inner fourth with the outer three-fourths of the clavicle, producing a fracture of that bone. When admitted into the hospital he was in a low condition, with a chronic diarrhoea. The ends of the fragments of the collar bone were raised up by the side of the trachea, threatening to puncture the skin, which was very much inflamed. There was also extensive burrowing of pus over the great pectoral and supra-spinatus muscles. Owing to his condition, the ordinary apparatus for fracture could not be applied. The diarrhoea was checked and patient apparently improved; but the improvement did not last. The patient expired September 29, 1862 A post-mortem examination discovered the right lung filled with tubercles; the left was much smaller than the right, and affected in only two or three places with tubercle. The acromion was separated from the scapula and the clavicle broken; the diseased condition extended into the shoulder joint; the head of the humerus and the upper part of its shaft were carious. The first rib was diseased on its superior aspect, and the left lung adhered to its inferior aspect." The specimen (FlG. 385) consists of the "left clavicle, scapula, and upper half of the humerus. The clavicle is transversely fractured near the middle, the sternal half of the bone being much necrosed and exhibiting a certain amount of ensheathing callus on the internal surface. The head ofthe humerus is eroded, carious, and partly absorbed. The coracoid and acromial processes and upper part of the glenoid fossa are badly fractured, the place of the coracoid being occupied by a small irregular spike of new bone directed inward. The articular surface is carious and absorbed. The humerus was accidentally fractured through the surgical neck after death.'' (Cat. Surg. Sect., 1866, p. 96.) The preparation was forwarded to the Army Museum by Actin ' .MON'BALON (Sur un plaie d'arme a feu, avec fracture de l'omoplate et de la clavicule, etc., in Jour de mid. chir. phar., etc., Paris, 17ti4, T. XXI, p. 218) relates a case of shot fracture of the scapula and clavicle; four pieces of tbe scapula were immediately removed, a fifth not until the fifteenth day; recovery. FlG. 385.—Shot fracture of the left clavicle and scapu- la, with consecutive disease ofthe shoulder. Spec. 234. Assistant Surgeon A. C. Bournonville. ■\\r2 INJURIES OF THE UPPER EXTREMITIES. ICHAIMX. Excisions of Portions of the Scapula.—This subject has been adverted to in the Fifth Chapter of the preceding volume, and some cases of partial excisions of the scapula,1 iu patients who suffered also from wounds of the chest cavity, are there detailed. There were no examples of removal of the entire scapula,2 either with or without preservation of the arm. But there were reported not less than forty-nine cases of partial excision after shot fractures of the scapula, believed to be unattended by penetration of the chest. A few of these will be detailed, and the remainder will be tabulated: Case 1462.—Captain G. W. Lawton, Co. C, 4th Michigan Cavalry, was wounded in the right shoulder at Dallas, May 24, 1864. From a field hospital and a depot hospital at Chattanooga he was transferred, on June 10th, to the Officers' Hospital at Nashville. Surgeon J. E. Herbst, U. S. V., reported: "Gunshot fracture of the left scapula, the ball lodging; the parts were tumefied and painful, and the patient was somewhat feverish. On June loth, he was chloroformed, and the ball was extracted, and the scapula trephined through an incision two inches long, made through the integuments, the trapezius and iufra-spinatus muscles, about one inch external to the inner border of the scapula. Granulations sprang up readily, and a week after the operation the patient left the hospital on furlough. On October 21st he returned, and on December 1st he rejoined his command for duty." On July 1, 1865, Captain Lawton was mustered out and pensioned. In a letter from Hagerstown, Mary- land, dated June 14, 1866, Dr. Herbst describes him "as being in excellent health." Examiner L. 0. Woodman, of Paw Paw, Michigan, reports, "November 1, 1866: "A ball entered the right shoulder just below the clavicle and near the joint, passed through the scapula, and was extracted near its angle. The axillary plexus of nerves was injured by the missile, causing a partial paralysis of the right arm." In 1873, Examiner Keables, of Michigan, reported the arm as nearly useless. l The following examples were cited, viz : Cases of Pt. J. P---, H, 14th Indiana, p. 475; Pt. F. E. Bickett, F, 5th Connecticut, p. 562; Pt. Geo. R. JI----, E, 84th Pennsylvania, p. 563; Pt. Morris O----, D, 8th Infantry, p. 564. In the case of Bickett, Surgeon Bryant is mentioned as the operator, in accordance with the hospital report (see Cat. Surg. Sect, A. M. M., 1866. p. 7!)); but the editor has been informed by several persons who witnessed the operation that Assistant Surgeon Haruisox Allen, IT. S. A., was the operator, a fact confirmed by Dr. Allkn, personally, March 10, 1873. This, which furnished specimen 1090, was by far the most extensive of any of the excisions of the scapula reported with precision. 2 The tabular statement of excisions of the entire scapula, of Dr. Stephen Rogers (Am. Jour. Med. Set, 1868, Vol. LVI, p. 367), much copied in English and German works, includes 25 cases of total, and 31 cases of partial excisions. Among the 25 examples of extirpation of the scapula, Cases 10 (Oaktani Bf.y) and 15 (LARUEY) are identical, and only 24 total excisions are in reality noted, an error that would have been avoided had references been given in this otherwise excellent table. To the partial excisions specified in Dr. Rogers's table many instances might now be added, and the number of total excisions has increased to 41. The 17 cases of total excision that may be added to those enumerated by Dr. ROGERS are: I. A case by Professor XV. PlRRIE, who states (Princ. and Pract. of Surg., 3d ed., 1873, p. 812): " On the 18th of September, 1856, I removed from a female, seventy years of age, the whole of the scapula, leaving the upper extremity. The patient recovered slowly, with a tolerable use of her arm, but she fell into bad health, and died on the first of December." 2. An operation practised February 17, 1857, originally reported by II. SOUPART in the Ann. de la Soc. mid. de Gand (Siance du 17 Juillet 1857), and cited in JI. MlCHAUX's article, De I'ablation totale de l'omoplate, etc., in the Gaz. Mid. de Paris. 1866, T. XXI, p. 277. This was a removal of the scapula for malignant disease, after a previous disarticulation at the shoulder; there was fatal recurrence of carcinoma, and the patient succumbed July 12, 1857. 3. The same writer states (loc. cit.) that: "31. le Professeur Derouhaix (dc Bruxelles) m'a rapporte eo-alement le fait d'un individu auquel il avait successivement pratiqufe pour une tumeur de mauvaise nature, d'abord la resection de la tete de riuimerus, puis la disarticulation scapulo-humerale, et enfin, 1'extirpation totale de l'omoplate." The cancerous disease recurred fatally in the lungs. 4. LUCKE (A.) (Beitrage zur Lehre von den Resect, in Arch, der Klin. Chir., 1862, B. Ill, S. 306) relates that, in 1860, Professor B. von Langexbeck • having, in the case of a man of 23, exarticulated the humerus on account of an osteo-sarcomatous tumor, on the recurrence of the disease extirpated the scapula and an inch and a half of the clavicle, the patient surviving eighteen months. 5. A successful case, in the person of a man named Messick, with necrosis of the shoulder blade, is recorded in the Dublin Med. Press, November 13, 1861, under the title: "An useful Arm left after the Removal of the entire Scapula." The operator's name is not recorded. 6. BIRD (J. D.) (On a Case of Excision of the Scapula, Head of the Humerus, and part of the Clavicle, for Malignant Disease, in The Lancet, 1865, Vol. II, p. 696) records au instance of successful extirpation of the scapula, by two succes- sive operations, in the person of Ellen L----, injured by a fall; operations performed in 1863 and 1864, in which the head of the humerus, tbe entire scapula, and a portion of the clavicle were removed. 7. JACKSON (V.) relates (Amp. of the right arm at the Shoulder joint, with Excision of the Scapula, in Brit. Med. Jour. 1869, Vol. II, p. 322) an operation on Samuel C----, aged 35, " struck by an engine-buffer in 1864;" a fatal case. 8. * Hamilton (F. H.) states (Princ. and Pract. of Surgery, 1872, p. 395) that he excised the entire scapula in February. 1866, " for necrosis resulting from a gunshot injury," and that "the patient recovered with a very useful arm." He refers to a tabular statement in the Areio York Med. Jour., 1869, Vol. VIII, p. 440, where the case is numbered 59, without details. In Vol. Ill, p. 147, ofthe same journal, the case is alluded to. Iu the account in the Med. and Surg. Reporter, 1866, Vol. XIV, p. 372, of the proceedings of the New York Pathological Society, it is stated that: " Prof. Hamilton presented a scapula, which had been removed entire from a soldier who had been wounde'd at Fredericksburg by a shell. Necrosis of the scapula ensued, necessita- ting its entire removal with the acromion and coracoid processes. The patient has power to use the coraco-brachialis and biceps, also tolerably well the triceps and deltoid. He is able to carry the arm without a sling, although attachment of these muscles is simply to cicatricial tissue, there having been no formation of new bone." 9. An unsuccessful extirpation of the scapula, with ablation of the upper extremity in 1867, in the case of a boy of 12, is recorded by McLEOD (K.) (Case of Medullary Tumor of the Arm; Amputation of the Limb and Scapula, in Uie Edinburgh Med. Jour., 1869, Vol. XV, I, p. 567). 10. POLLOCK (G.) (St. George's Hospital Reports, 1869, Vol. IV, p. 223) publishes two cases of resection of the shoulder blade ; in the secoud, the case of O. G----, aged 47, the entire scapula was removed, with a fatal result; in the former, nearly the entire bone was removed. 11. Dr. D. 51. Schuppert has described. (Excision of Entire Scapula, with Preservation of a useful Arm, in New Orleans Jour, cf Med., 187(1. p. 90) an in>tuDCG of successful total excision of the shoulder blade, in the case of a woman of 36, Theresa B----. 12. Watson (P. II.) has recorded (Edinburgh Med. Jour., 1869, Vol. XV, p. 121) an "amputation of the scapula along with two-thirds of the clavicle, and the remains of the arm." 13. Hamilton (F. H.) (Amputation of Arm and Scapula for Colloid of Scapula, in the Medical Record, 1871, Vol. VI, p. 141) also removed the scapula with the upper extremity, in the case of G. Hanna, with a tumor following a blow from falling earth. 14. Logan (S.) recorded the case of P. Janvier, aged 33 (Excision of the Left Scapula subsequently to Resection of the Head ofthe Humerus ofthe same side, in Richmond Med. Jour., 1872, Vol. XIV, p. 131). Disease cf the bone had resulted from blows. The operation is said to have resulted successfully, and to have been a total excision, practised in 1871. 15 Mr C. Steele, at the meeting of the British Medical Association at Plymouth, in August, 1871, read an account of an "Excision of the Scapula," in the case of Charles Bees, a boy operated on, at the British Infirmary, for malignant, disease, unsuccessfully. Professor SPEXCE, who has done so much to advance our knowledge of the treatment of surgical affections in the region of the shoulder, records (The Dublin Jour, of Med. Sci., 1871. Vol. LV. p. 508) the case of John Dow, aged 68. whose right scapula Mr. Sim'.nce excised February 21, 1872. The patient recovered, and an iutercstiug plate ofthe app'-arances ofthe cicatrices and ofthe tumor removed accompany the paper. 17. JKAFFRKSON (C. S.) (Excision of the Scapula. and nearly the entire Clavicle for malignant Disease, in The Lancet. 1874, Vol. I. p. 75«i> recorcb a successful excision of the scapula in the case of Miss SECT. II.] EXCISIONS OF PORTIONS OF THE SCAPULA. 493 This case is detailed, because it must slightly modify a preceding statement1 respect- ing trephining of the shoulder blade. The next case is curious, as attended by a consec- utive luxation of the head of the humerus from traumatic arthritis: Case 14(i:!.—Private E. Post, Co. E, 11th New York, aged 35 years, was wounded at Bull Run, July 21, 1861, and received into Hallowell Hospital, Alexandria, on the following day. Assistant Surgeon W. Thomson, U. S. A., noted: "The ball entered between the superior and inferior angle of the left scapula. Erysipelas and profuse suppuration followed, and resulted, in a state of profound exhaustion. On a careful examination, by Assistant Surgeon II. L. Sheldon, on August 18th, the head ofthe humerus was found dislocated and beneath the clavicle, and the acromion and coracoid processes ofthe scapula were discovered to be fractured. An incision was made in the track of the ball beneath the spine of the scapula, and the bone was found with a track cut through its thickness, the spine comminuted at the acromion. A large portion of the acromion was removed, aud the displaced coracoid process was restored to its position. Numerous fragments of bone were removed, and the roughened edges of the divided scapula were resected with Iley's saw. The constitutional improvement consequent upon this severe operation was wonderful. On September 9th, the patient was seut to his home in New York in good condition, his wound having closed." The man was discharged on certificate of Surgeon R. S. Satterlee, U. S. A., on December 27, 1861, and remained a pensioner until November 8, 1865, when he died. The missile that caused the fracture in this case appears to have split upon the bone. Two small fragments of the ball, supposed to have been extracted at the time of the excision, were con- tributed to the Museum, in 1867, by Dr. Thomson, and constitute specimen 4948 of Section I.—See MS. Cat, 1867, p. 46. S----. aged 20, successfully operated on December 14, 1873. There are two other cases of total excision of the scapula tabulated by an anonymous writer in the New York Mulical Journal, 1869 (Vol. VIII, p. 434 et seq.). It is stated, on the authority of his nephew, that Dr. Twitchell, of Keene, New Hampshire, in 18:18, removed "the scapula, arm, and part of clavicle." The patient "died some months afterward from re-development of the disease." Dr. E. Krakowitzer is said to have removed, in 1868, "the scapula five years after amputation at the shoulder joint" for enchondroma ; the patient "died seven days after the operation, of exhaustion. * * The case was communicated by that surgeon, who will report in future in detail.'' Moreover, in the Med. Times and Gaz., 1857, Vol. II, p. 155, it is related that an "excision ofthe entire scapula has been performed lately, with success, by Dr. Crawford, of Ayr. Very little blood was lost. The patient was under the influence of chloroform for forty-five minutes." The references to the twenty-four cases of total excision of the scapula enumerated by Dr. Stephen Rogers are as follows: 1. (1803) Cuming (R.), a successful ablation of the arm, scapula, and clavicle, after an accidental shot injury, in a male adult. (See C. HUTCHISON", in London Med. Gatette, 1830, Vol. V, p. 273.) 2. (1S3.5i CROSBY (as reported by S. Rogers, Am. Jour. Med. Sci., 18C8, Vol. LVI, p. 367) extirpated the scapula in an adult, previously amputated near the shoulder, and recurrent disease proved fatal. 3. (1837) Mussev (R. D.) (Removal by Dissection of the entire Shoulder Blade and Collar Bone, in .Im. Jour. Med. Sci., 1837, Vol. XXI, p. 390), a successful case of repeated operations for malignant disease. 4. (18:18) McClellan (G.), in the case of a boy of 17 years, removed the scapula, arm, and part of the clavicle, with a fatal result. The case is described and the preparation figured in Dr. McClellas's work (Princ. and Pract. of Surgery, Phila., 1848, p. 412). 5. (1838) Gaetaxi Bey (Mem. de I'Acad. de Mid., 1841, T. IX, p. 9fi) describes a disarticulation at the shoulder, with extraction of the scapula and resection of the clavicle, in the case of a lad of 14 years, who recovered. This is the case frequently, but erroneously, ascribed to LARRET, in 1838, and is a flagrant example of the propagation of error in the careless reproduction of statistics. 6. (1841) Professor Rigaud (Extirpation du scapulum en totaliti avec la moitii externe de la clavicule, pratiquie le 9 Mai, 1841, pour un cas d'osteophyte gelatineux, Strasbourg, 1850, and Gaz. mid. de Strasbourg, 1844) reported a successful extirpation of the shoulder blade in a man 51 years old. 7. (1845) Mcssey (R. D.) removed successfully the arm and scapula, in a case of osteocancer. (See S. Rogers, in Am. Jour. Med. Sci., 1868, Vol. LVI, p. 368.) The patient is stated to have survived nine years. I can find no other published account of the case. 8. Lewis (W.) (New York Med. Jour., 1868, Vol. VIII, p. 437) had an unsuccessful amputation above the shoulder for machine injuries, the scapula being removed. 9. (1847) Fergcssox (W.) (Med. Chir. Trans., 1848, Vol. XXXI, p. 309) excised the scapula, in the case of a discharged soldier, aged 23, who had undergone amputation at the shoulder two years previously. 10. (1855) Professor B. von Langenbeck removed the entire scapula for malignant disease, in the case of a boy of 12 years. (See FOCK, Extirpatio et resectio scapulse nebst Mittheilung betreffender Beobachtungen aus der chir. Klinik des Hrn. B. Langenbeck, in Deutsche Klinik, 1855, B. VII, S. 38.) The case proved fatal three and a half mouths subsequently. 11. (1856) Heyfelder (J. F.) (Beitrage zur Operaliven Chirurgie, in Deutsche Klinik, 1857, B. IX, S. 188) recorded the fatal case of Jakow Trifanoff, aged 40; the entire scapula removed for caries. 12. (1856) Syme (J.) (On the Disarticulation of the Scapula from the Shoulder joint, read before the Med. chir. Soc. February 24, 1857, in Med. Times and Gaz., 1857, X. S., Vol. XIV, p. 249, and Lancet, 1857, Vol. I, p. 243, and Excision of the Scapula, EJinburgh, 1864, p. 11) recorded the first instance of removal of the entire scapula in Great Britain. The patient, a woman of 70, succumbed two months after the operation. 13. (1858) Jones (G. M), of Jersey, in the case of a girl of 15, removed the entire scapula for caries, preserving the arm. The case is related m'The Medical Times and Gazette, 1858. Vol. LXVII, pp. 633 and 657, and Med.-Chir. Trans., 1859, Vol. XLII, p. 7, with a drawing of the scapula. 14. (I860) NlKrCE, in the case of a man of 30, injured by machinery, successfully removed the left arm, scapula, and clavicle. (See Bulletin de I'Acad. de Mid., 1864-5, Vol. XXX, p. 723.) 15. (1860) Hammer (A), in the case of a girl of 18, relates a "Successful Extirpation of Entire left Scapula and acromial end ofthe Clavicle, with Preservation of the Arm," in the St. Louis Med. Reporter, 1866, Vol. I, p. 1. The disease recurred fatally nine months sub- sequently. 16. (1860) SCHUH (F.) (Abhandlungen aus dem Gebiete der Chirurgie und Operationslehre, Wien, 1867, p. 679, and Wiener Med. Wochen- schrift, I860) relates a successful extirpation of the scapula, in a child of 8 years. 17. (1862) Syme (J.) reports the case of T. G---, aged 43, who had already undergone excision of the head of the humerus, and who recovered, with perfect mobility of the upper extremity, after excision of the entire scapula and a portion of the clavicle. 18. (1862) BU6CH (XV.) (Lehrbuch der Topographischen Chirurgie, 1864, Abth. Ill, S. 19) successfully removed the scapula and a part of the clavicle in a young girl, whose arm had been amputated previously for cancer. 19. (1863) Syme (J.) (Excision of the Scapula, Edinburgh, 1864, p. 30) recorded yet a third case of extirpation of the scapula. In this, the case of Mr K----, aged 40, a portion of the clavicle, and the arm, were removed, as well as the scapula. 20. (1864) BUCK (G.), in an adult male, removed the scapula and part of the clavicle, the arm having been previously exarticulated. Recovering from the operation, the patient succumbed some months afterward from the recurrence of cancer (S. ROGERS'S table, and New York Med. Jour., 1869, Vol. VIII, p. 440). 21 (1864) Professor MICHAUX, of Louvain, in an extended memoir De I'ablation totale de l'omoplate en conservant le reste du membre supirieur, in the Gaz. Mid. de Paris, 1866 (Nos. 16, 17, 18), has related the case of Theodore Laurens (Enciphalo'ide de l'omoplate; resection totale de l'os, avec conservation du membre supirieur, etc., loc. cit, T. XXI, p. 313), a lad of 15, who recovered from the operation, but died ten months afterward from recurrence of cancer. 22. (1865) Sir XV. FERGUSSON relates a second case of tempo- rarily successful extirpation of the shoulder blade in the case of a girl of 19 (Removal of the Entire Scapula for malignant disease—Case now under treatment, in The Med. Times and Gazette, 1865, Vol. II, p. 87, and at p. 574, again, where a report of the further progress of the case is promised). 23. (1867) A third operation by Sir XV. FERGUSSON was on a man of 40, with a tumor resulting from injury (Removal of the Scapula, Upper Extremity, and Part of the Clavicle, in Med. Times and Gazette, 1867, Vol. II, p. 465, and The Lancet, 1867, Vol. II, p 552); the case resulted fatally on the third day. 24. (1867) Rogers (S.) (Case of Excision of the Entire Scapula, etc., in Am. Jour. Med. Set, 1868, Vol. LVI, p. 359) removed successfully the entire scapula, in a girl of 7, and reported the case with the important memoir that has been so frequently cited. 1 First Surgical Volume, p. 564: "No instance was reported of trephining the scapula." The operations cf MARE6CHAL and DUBRUEIL are referred to in that connection. 194 INJURIES OF THE UPPER EXTREMITIES. [('MAP. IX The excisions were for tlie most part confined to the apophyses.1 In tlie thirty-six eases in which the parts removed were specified, the acromion, or portions of the spine, were removed in thirty, the coracoid in one, and portions of the body of the bone in five. The following is an example of a successful removal of the upper angle: Case 1464.—Private 13. Lammond, Co. H, 159th New York, aged 43 years, was wounded at Fisher's Hill, September 22, 1S64. He remained at a field hospital for eight days, and was then sent to Sheridan Hospital, and thence, on October 10th, to Mower Hospital. Surgeon J. Hopkinson, U. S. V., noted: "Gunshot wound of right shoulder. The ball entered anteriorly near the middle of the clavicle, passed beneath that hone downward and backward, and came out through the superior angle of the scapula. The soft parts became swollen and painful; the bone was necrosed and the wound discharged profusely. The patient was chloroformed, and Acting Assistant Surgeon J. M. McGrath, on October 14th, excised the superior angle of the scapula through a A-shaped incision made along the superior and internal border of the scapula, four inches long in each direction. Three and a half inches of bone were removed. Prompt reaction followed, and the patient made good progress after the operation." On June 10, 1865, he was discharged and pensioned. Examiner C. Rowland, of Brooklyn, August 8, 1865, reported: * * "Many pieces of bone have been extracted. The arm is painful and much impaired in its motion." This pensioner was paid September 4. 1873. The Museum possesses a specimen,2 figured on page 562 of the preceding surgical volume, from a patient from whom Dr. Harrison Allen removed the greater portion of the left scapula, necrosed after shot fracture; and an instance of removal of the body of the scapula by Professor F. H. Hamilton, practised after the War, and consequently not reported to this Office, will be discussed further on.3 But by far more common were those cases in which portions of the acromion, or of the spine, were removed: Case 1465.—Private W. Everitt, Co. F, 83d Pennsylvania, aged 22 years, was wounded at Malvern Hill, July 1,1862, and conveyed to Union Chapel Hospital, Washington. Acting Assistant Surgeon W. H. Butler noted : "A ball entered the left shoulder anteriorly, two inches from its outer aspect, and apparently passed below the clavicle, between the coracoid and acromion processes, shattering the latter at its junction with the spine of the scapula. Six days after the reception ofthe injury the ball was excised. On July 9th, when admitted, the patient experienced but little pain while quiet, but considerable pain on motion. Cold-water and simple-cerate dressings were applied. Healthy suppuration was going on steadily. Several days after admission, the patient complained of increasing pain. On July 15th, pieces of clothing were extracted. On the 17th, Surgeon R. H. Coolidge, U. S. A., assisted by Surgeons Stone, Bliss, Page, and Bigelow, decided to operate. The acromion was dissected out, and the spine was cut close down and tapered down, to remove all roughness, by bone forceps. Two arteries were ligated. The flaps were brought together with four deep stitches, and long and broad strips of adhesive plaster from the arm to the opposite shoulder. The strips were renewed daily, and sufficient cold-water lotions were used to keep the parts moist. From July 21st, some tendency of the pus to burrow began to show itself. This was prevented by compresses. The man was discharged from service on September 3, 1862," and pensioned. Examiner J. Ross, of Knox, Pennsylvania, reported, September 6, 1873: "No power to raise his arm. Has but little use of the arm, as it rests close to his body, and cannot be moved without pain. Is unfit to perform labor, and ought to have his pension increased." 1 Very few examples of excision of the scapula for shot wounds are found in the annals of military surgery: Champion (L ) (Traiti de la risection des os caries dans leur continuiti, ou hors des articulations, Paris, 1815, p. 47) remarks: "J'ai ete dans le cas d'enlever avec le ciseau la moitifi interne de I'epine de l'omoplate, laquelle etait carice depuis plus dun an par suite d'un coup de feu,'1 and adds: " En 1796, j'avais d6ja seconde M. S0M.meillier, chirurgien a Ancerville, dans l'excision dc Tangle inferieure du meme os." The cases of Velpeau (Nouv. elim. de mid opirat, 1819, T. II, p. 571) and Legouest (Traiti de chirurgie darmie, 1872, 2me 6d., p. 325), and the case tabulated by Matthew (I. c, Vol. II, p. 3(18) have already been noted on page 565 of the First Surgical Volume. NEUDOUFER (J.) ( Von der chirurgischen Abtheilung des K. K. Garnison-Spitalcs No. 1, zu Prag, in Ocster- reic'i. Zeitschr. fiirprakt. Heilkunde, 1862) resected, in 1892, a portion of the acromion and of the body of the scapula, in the case of a Jaeger, who, in an attempt to commit suicide, shot himself through the pectoralis major and shoulder, shattering the scapula. The patient recovered without any untoward circumstances; but the functions of the arm remained limited. Loffler (F.) (Generalbericht, u. s. w., 1867, S. 166) relates the case of E. Rice, 4th Prussian regiment, wounded at Diippel, April 6, 1864; fracture of scapula and clavicle; secondary haemorrhage; resection of portion of the scapula; ligation of the subclavian; death. Dr. Loffler adds: "The bony lesion in this case was of little importance. To prevent, as for as possible, the cause of a fatal issue, namely, secondary bleeding during the period of suppuration, it is well, in cases of deep shot wounds of this kind, to apply ice, if it can be had, for as long a period as possible, whether the osseous lesion be important, slight, or inappreciable. It has been a question if it may not be best in such cases, in order to arrest the bleeding, to excise the scapula from the infraspinous fossa, to search for the bleeding subscapular}- artery and to ligate at the seat of injury. As may be imagined, it is exceedingly fortunate if the operation fulfils its object." FISCHER (H.) (Kriegschir. Erf., 1872, S. 142) records the case of Dumont, 76th French regiment, wounded August 6, 1870; the entire upper half of the comminuted scapula was resected, and the patient recovered with anchylosis ofthe shoulder joint. Beck (B.) (Chir. der Schussverletz., 1872, S. 898) details three cases of excisions of portions of the scapula. In the case of S----, 78th French line, the acromion and part of the scapular spine were excised; the patient recovered with good use of his arm, but died shortly afterward of dysentery. In the second case, the spine of the scapula was removed; and in a third, the acromion process was excised; there was extensive suppuration in the two latter cases ; but the patients recovered. The four cases reported by M. CHIPAULT (Fractures par armes a feu, 1872, p. 82) have already been cited in the First Surgical Volume, p. 565. MUXDY and MOSETIG (Service* mid.- chir. de I'ambulance du corps legislatif, in Gaz. des Hop., 1871, No. 149) report a successful case of secondary excision of a portion of the scapula for necrosis. Leisrixk (H.) (Notizen aus dem Reservelazareth Seemannshaus in Hamburg, in Archiv fur Klin. Chir., 1872, B. XIII, p. 682) relates the case of C. Th----, of the 17th Dragoons, wounded August 18, 1870, through the right shoulder. On December 6, 1870, one-half of the scapula was excised; on the next day transfusion of blood was made; the patient died nine days after the operation. 2 Catalogue of the Surgical Section of the Army Medical Museum, 1866, p. 79. 3 Vide Med. and Surg. Reporter, 1866, Vol. XIV, p. 372, and New York Med. Jour., 1869, Vol. VIII, p. 440. EXCISIONS OF PORTIONS OF THE SCAPULA. 40;"; Many of the operations in this group were for necrosis following shot fracture, and bore more resemblance to the usual proceedings for the extraction of sequestra, if I may quote Mr. Holmes's discriminating language,1 than to formal operations for excision. Although the removal of portions of dead bone was commonly a simple and inoffensive procedure, it was sometimes attended by fatal results. Cask 1466.—Corporal S. A. Durburn, Co. 1), 49th Ohio, aged 24 years, was wounded at Dallas, May 27, 1864, and sent to Nashville, thence to Louisville, and subsequently to Columbus. Assistant Surgeon G. Saal, TJ S. V., from the Seminary Hospital, noted: " Gunshot wound of left shoulder. Ball entered near the head ofthe humerus, fractured the acromion process and spine of the scapula, and passed out at its inferior angle. When admitted, on June 17th, the patient was prostrated from secondary hemorrhage, and his pulse was hardly perceptible. An injection of persulphate of iron was thrown into the wound, and the hemorrhage was thus controlled. Stimulants and beef tea were freely administered. A counter opening was made, giving relief to the local symptoms. The greater part of the spine of the scapula being in a necrosed condition was removed, together with a portion of the acromion process, by Acting Assistant Surgeon W. II. Drury. On June 25th, symptoms of pyasmia set in. From the effects of this the patient died on June 2d, 1864." Other detailed cases, of which the following may serve as an example, amounted to little more than extractions of primary sequestra: Cask 14:17.—Private J. Flick, Co. C, 5th New Jersey, aged 30 years, was wounded at Chancellorsville, May 3, 1863. He was sent to Campbell Hospital, Washington, and transferred, May 17th, to Central Park Hospital. Acting Assistant Surgeon S. Smith reported: "Gunshot fracture ofthe right scapula. The wound is located just beneath the acromion process and extends backward and downward in the direction of the spine of the scapula. A probe detects loose pieces of bone. On May (?), the patient was etherized, and the wound laid open freely in the course of the spine of the scapula to the extent of four inches, exposing a large number of fragments of bone, pieces of clothing, and a flattened minie ball. The pieces of bone removed consisted of nearly the whole acromion process and portions of the spine of the scapula. The tissues were found to be very much contused. The cavity was cleansed and filled with lint. The patient did well after the operation. There was profuse discharge from the wound. On December 1, 1863, when this soldier was discharged, the wound had not completely healed, and the motion and strength of the shoulder joint was considerably impaired." This man is a pensioner. Examiner W. M. Chamberlain, of Xew York, reports, July 7, 1864 : "A ball entered behind right acromion and issued near inferior angle of right scapula, causing extensive fracture thereof. The scapula is still much enlarged. The arm cannot be fully raised, is somewhat atrpphied and much debilitated." The New York Examining Board reported, September 5, 1873: "There is a large cicatrix over the spine of the right scapula, thin, depressed, and closely adherent. It interferes with the movements of the shoulder joint. Disability rated one-half." Table 'XIX. Summary of Forty examples of alleged Excisions of Portions of the Scapula after Shot Lnjury. Name, Age, and Military Description. Adams, P., l't., II, Cth New Hampshire. Bridemyer, C, Pt., E, 70th Indiana. Clinton, M., Corp'l, F, 21st Georgia. Conley, T., Pt., B, 7th Mich- igan, age 21. Covey, It., Pt., I. 29th Penn- sylvania, age 27. Coughlin, P., Pt., G, 20th Massachusetts, age 21. Crosby, P. L., Pt., F, 14th Infantry. Decker, J., Corp'l, H, G8th New York. Doyle. A. H., Sergeant, K, Ubth Massachusetts. Findley, W., Pt., E, Ohio, age 20. 94th Julv 2 18li4. June 15. 1864. August 14, 1861 July 2, 1863. May 6, 1864. June 20, 1864. August 29,1862. Dec. 13. 1862. May 14, 1864. Nature of Injury. Gunshot fracture of the left scapula. Gunshot fracture of the left scapula. Comp'nd comminuted fracture of the right scapula hy a musket hall which lodged in the neck. Shot fracture of the left scapula; minie ball. Compound fracture of the spine of the right scapula by a miniG ball. Gunshot fracture of the right scapula. Conoidal ball passed through the left shoulder, fracturing the acromion process and su- perior angle of the scapula. Gunshot fracture of the spine of the left scapula. Musket ball fractured the outer third of the spine of the right scapula. Gunshot fracture of the right scapula. Opera- tion. July 2, 1864. June 15, 1864. Date of injury. Aug. 14, 1864. Jan. 24, 1864. May 6, July 3, 1864. May 14 1864. Operation and Opeuator. Excision of the acromion pro- cess. Excision ; Surgeon J. Bennett, 19th Michigan. Partial excision of the scapula and extraction of the ball. Excision of the acromion pro- cess; Surgeon G. Chaddock, 7th Michigan. Excision of a portion of the spine of the scapula; Surgeon H. Palmer, U. S. V. Excision..................... Excision of the acromion pro- cess ; Surgeon A. F. Sheldon, U. S. V. Excision of a portion of the spine of the scapula. Excision..................... Disch'd June 12, 1865. Atrophy of the deltoid muscle; motion of arm slightly impaired. Duty, September 10, 1864. Not a pensioner. Undetermined. Discharged January 18, 1865. Not a pensioner. Discharged September 5, 1864. Anchylosis of shoulder joint. Disch'd July 14, 1865. Fistulous opening near seat of wound; motion of arm restricted. Died July 20, 1864, from exhaus- tion. Disch'd Jan. 19, 1863. Partial anchylosis of shoulder joint. Veteran Reserves, June I, 1863. Arm useless for manual labUr; inability to flex forearm. Discharged November 29, 1864. Unable to elevate the arm or move it at the shoulder without assistance; tendency to inflam- mation about seat of inj my. 1 In his excellent paper on Excision of Bones and Joints, in the second edition of the System of Surgery, edited hy him, 1871, Vol. V, p. 669. 496 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. Name, Ac.b. and Military Di.s< mi'Tiox. Datk of Injury Nature of Injury. Date of Opera- tion. Operation and Operator. Result. Fogle, M., Pt., I, 118th Penn- s\ Ivania. Gates, S. H., Capt., K, 50th G eorgia. Graham, J., Pt., F, 11th Pennsylvania Reserves. Henderson, W., Pt., D, 36th Wisconsin, age 18. Hinks, 10. A., Capt., C, 19th Massachusetts. Johnson, E., Serg't, C, 50th Pennsylvania. Keller, D. J., Pt., K, 24th Michigan, age 18. Killam, G. XV., Pt., K, 3d Vermont. King, J., Pt., H, 155th New York. -McGee, J., Pt., C, 32d Maine. McManus, M., Pt., G, 149th New York, aged IS). Moore, J., Pt,, K, 26th Ohio. Owen, E. P., Corp'l, A, 50th Illinois, age 22. Palmer, A. IL, Pt., G, 100th New York. Parish, G., Corporal, E, 2d Michigan. Picard, G., Pt., E, 102d New York. Ritchey, L., Pt., II, 7thIowa. Rollo, A., Sergeant, II, 8th Michigan. Mav 7, 18*64. Mav 12, 18*64. May 9, 1864. Sept. 29. 1864. June 3, 1864. June 3, 1864. July 1, 1863. Aug. 21, 1864 June 3, 1864. June 22, 1664. July 3, 1863. June 14 1864. Oct. 5, 1864. Aug. 21 1863. Nov. 24 1863. Sept, 17 1862. Nov. 7, 1861. May 12, 1864. Satterfield, A., Pt., E, 1st July 3, Maryland, E. S. 1863. Shidler, S., Sergeant, E, 11th Ohio. Sommers, J. C, Sergeant- major, 5tk Louisiana. Sowrs, A. H., Pt., E, 21st Indiana, age 22. Stevens, P., Pt., E, 51st Iowa, age 44. Swinton, G., Sergeant, D, 95th New York. Thomas, J., Corp'l, G, 46th New York. Thompson, E. C, Sergeant- major, 57th Pennsylvania, age 26. Tolmay, J., Pt., K, 11th New Hampshire, age 22. 38 Walker, J., Pt., H, 40th New York. Wilson, C, Pt., C, 7th New Jersey. Winslow, C, Lieutenant-col- orel, 5th New York. Nov. 25, 1863. June 14, 1863. Dec. 16, 1864. May 17 1863. June 2, 1864. May 18, 1864. May 5, 1864. Mav 18, 1864. Mar. 30. 1865. July 3, 1863. June 2, 1864. Gunshot fracture of the right scapula. Gunshot injury of the right scapula. Fracture of the acromion pro- cess of the left scapula by a mini6 ball. Shot perforation of the right shoulder, with fracture of the acromion process. Gunshot fracture of the spine of the right scapula. Shot perforation of the left shoulder by a mini6 ball. Fracture of the right scapula and dislocation of the humer- us by a fragment of shell. Shot fracture of the upper bor- der of the left scapula; mis- sile lodged. Gunshot fracture of the left scapula. Fracture of the right scapula by a minifi ball. Gunshot fracture of the acro- mion process of left scapula. Comminuted shot fracture of the lower portion of the right scapula. Mini6 ball perforated the left shoulder, fracturing the clav- icle and scapula. Shell laceration of the face and left shoulder, with fracture of the scapula. Shot fracture of right scapula by a mini6 ball. Gunshot fracture of the right scapula. Gunshot fracture of the left scapula. Severe fracture of left scapula by a shell fragment. Fracture of the right scapula by a musket ball. Gunshot fracture of the acro- mion process of right scapula. Gunshot wound of the left shoulder. Shot fracture of the spine of the right scapula. Fracture of the left scapula by a conoidal ball. Shot fracture of the spine of the right scapula. Conoidal ball fractured the left scapula. Shot perforation of left shoul- der, with fracture of the acro- mion process of the scapula; also fracture of the inferior angle of the maxilla. Gunshot fracture of the spine of the right scapula; conoidal ball. Shell wound of the left shoul- der, fracturing the scapula. Conoidal ball fractured the right scapula. Conoidal ball comminuted the spinous process of the left scapula and carried away a portion of the acromion pro- cess. May 7, 1864. Excision . Mav 9, 1864. Sept. 29 1864. June 3, 1864. June 3, 1864. Aug. 21 1864. June 3, 1864. July 3, 1863. July 2, 1864. Nov. 30 1861. Aug. 21, 1863. Nov. 24, 1863. Mav 12, 1864. July 4, 1863. Nov. 25, 1863. Dec. 20, 1864. June 9, 1864. May 18, 1864. May 5, 1864. May 18, 1864. Mar. 30, 1865. Excision of the outer end of the acromion process. Acromion process removed; Surg. W. Lyons, 11th Penn- sylvania Reserves. Excision of acromion process; Surgeon D. W. Maull, 1st Delaware. Excision . of a portion of the scapula; Surgeon J. F. Dyer, 19th Massachusetts. Excision of spine, a portion of the acromion process, and a large portion of the body of the scapula; Surg. D. Mer- ritt, 55th Pennsylvania. Excision of the upper portion of the scapula. Extraction of the missile and removal of three inches of the upper border of the scapula; Surg. G.T.Stevens, 77th N.Y. Excision; Surgeon F. Douglas, 170th New York. Resection.................... Excision of acromion process. Interrupted sutures applied and arm flexed on trunk. Excision of two inches of the lower portion of the scapula; Assistant Surg. G. XV. Burke, 46th Pennsylvania. Excision of one-fourth of spine of scapula at its superior bor- der; Surg.B.B.Breed, U.S.V. Removal of part of the scapula. Excision; Surg. J. P. Prince, 36th Massachusetts. Excision of a portion of the scapula. Excision of a portion of scapula; Surg. E. C. Franklin, U. S. V. Removal of the coracoid and acromion processes, together with the spine and head of scapula; Surg.W.C.Shurlock, 51st Pennsylvania, and A. F. Whelan, 1st Michigan S. S. Excision of the acromion pro- cess; Surg. (t. B. Lecompte, 1st Maryland, E. S. Excision of three inches of bone. Excision of the spine of the left scapula. Excision of the lower portion of the spine of the scapula; A. A. Surgeon M. L. Herr. Removal of a portion of the spine of the scapula; Surgeon A. Hammer, U. S. V. Excisiun of the spine of the scapula. Excision; Surgeon J. S. Ross, 11th New Hampshire. Excision of the entire acromion process and removal of frag- ments from inferior maxilla. Removal of the spine of the scapula; Surgeon J. S. Ross, 11th New Hampshire. Excision of a portion of the spine of the scapula ; Surg. H. F. Lyster, 5th Michigan. Excision..................... June 19, 1864. Excision of the acromion pro- cess. Died May 15, 1864. Furloughed May 16, 1864. Deserted February 11,1865. Not a pensioner. Veteran Reserves, April 1, 1865. Partial anchylosis of shoulder joint; muscular action much im- paired. Disch'd October 7, 1864. Motion of the shoulder joint much im- paired. Disch'd Marcli 22, 1865. Arm reduced in size and its motions restricted. Disch'd April 25, 1864. Unable to raise the arm or flex it at the elbow without assistance. Disch'd June 12, 1865. Motion of arm somewhat impaired. Died June 14, 1864, from erysip- elas. July 14, hsemorrhage to the ex- tent of sixteen ounces, from the supra-scapular artery. Died July 16, 1864. Veteran Reserves, March 7, 1865. Not a pensioner. Died July 30, 1864. Disch'd July 14, 1865. Motions of the shoulder impaired. Duty, September 5, 1864. Shoul- der lame and painful. Duty October 17, 1864. Atrophy of muscles of the arm and shoulder. Disch'd December 19, 1862. Not a pensioner. Returned to duty; unable to carry much weight on the shoulder. Died May 21, 1864. Died July 20, 1863. Died December 2, 1863. Detailed for duty as wagonmas- ter, March 8, 1864; loss of the use of the left arm. Died January 31, 1865. Disch'd October 31, 1864. Any effort at ordinary manual labor irritates the seat of injury. Veteran Reserves, April 25, 1865. Not a pensioner. Died May 22, 1864. Disch'd October 31,1864. Shoul- der joint weakened. Disch'd May 30,1865. Extensive adherent cicatrix, impairing the usefulness of the shoulder and arm. Discharged June 16, 1865. Not a pensioner. Duty. December 4, 1863. Not a pensioner. Necrosis of the head of humerus; symptoms of septic poison. Died July 7, 1864. SECT. II.] EXCISIONS OF PORTIONS OF THE CLAVICLE AND SCAPULA. 497 The forty cases noted in the foregoing tabular statement, six detailed immediately before, and three1 recorded in the First Surgical Volume, were returned as resections of the scapula; evidently with much latitude of interpretation, on the part of some of the reporters, as to what constituted a formal excision. In these forty-nine cases the opera- tions were practised on the right scapula in twenty-three, on the left in twenty-six. The date of operation was specified in thirty-nine cases. There were twenty-three primary operations, with six deaths; fourteen intermediary, with six deaths; two successful secondary operations. There was one death among the undated cases, making thirteen in all, or 27 per cent. Of the thirty-six survivors, twelve returned to full or modified duty, and twenty-four were discharged. In addition to these forty-nine cases of removal of splinters, of excision of portions of the apophyses or of the body of the scapula, or of extraction of necrosed sequestra, there were not less than forty-two cases of removal of portions of the acromion, or coracoid, or neck of the scapula, practised in operations that will be found classified with excisions of the head of the humerus. Partial Excision of the Clavicle and Scapula.—Ten cases were returned in this category; one is detailed, and the others are tabulated. Table XX. Summary of Nine Cases of alleged Excision of Portions of both Clavicle and Scapula after Shot Lnjury. Name, Age, and Military Description. Nature of Injury. Opera- tion. Operation and Operator. Holland, P. F., Pt., A, 3d Pennsylvania Reserves. King, A., Pt., C, 5th New Jersey. Northwav, XV. J., Pt., D, 79th Indiana. Page, R., Pt., I, 23d U. S. Colored Troops, age 25. Padgett, A. XV., Pt., K, 109th New York. Painter, A., Pt., C, 5th Ar- tillery. Palmer, W.H., Sergeant, D, 1st New York Artillory, age 23. Pate, J. M., Pt., K, 18th Texas Cavalry, age 22. Petrie, G., Pt., B, 162d New York, age 41. June 2' 1862. Nov. i 1864. June 24, 1864. July 30, 1864. May 2.: 1864. Dec. 13, 1862. Mav 31, 1864. Sept. 20, 1863. July 26, 1864. Musket ball perforated the right shoulder, fracturing the clavicle and scapula. Conoidal ball fractured the acromion process ofthe right scapula and the acromial end of the clavicle. Gunshot fracture of the left shoulder blade. Fracture of the right shoulder blade by a mini6 ball. Shot perforation of the left shoulder, with fracture of the clavicle and spine of the scapula. Gunshot fracture of the left shoulder blade* Comp'd comminuted shot frac- ture of the acromial end of the left clavicle and acromion process of the left scapula; ball lodged. Gunshot compound fracture of the left shoulder blade. Mini6 ball perforated the right shoulder, fracturing the clav- icle, the acromion process, and spine of the scapula. Nov. 5, 1864. June 24, 1864. Julv 30, 1864. May 25, 1864. Dec. 13, 1862. May 31, 1864. Sept. 21, 1863. Aug. 10, 1864. Removal of a portion of the clavicle and scapula. Excision of the acromion pro- cess and the outer fourth of the clavicle; Surgeon H. F. Lyster, 5th Michigan. Excision of the acromion pro- cess and portion of clavicle. Removal of the external end of the clavicle and the coracoid process ofthe scapula; Surg. J. S. Ross, 11th New Hamp. Excision; Surg. A.F. Whelan, 1st Michigan Sharpshooters. Excision of external half of the clavicle, the spine of scapula, and a portion ofthe acromion process; Surg. J. S. DeBenne- ville, 11th Penn. Reserves. Missile extracted and excision performed; Surgeon W. S. Thompson, U. S. V. Resection of the clavicle and coracoid process of scapula. Excision of portion of the acro- mion process, the acromial end of the clavicle, and the spine of the scapula; A. A. Surgeon C. C. Ela. Disch'd October 28,1862. Partial anchylosis of the shoulder joint. Discharged June 9,1865. Not a pensioner. Died July 26, 1864. Discharged June 8. 1865. Mod- erate use of the arm, with pros- pects of further improvement. Disch'd August 16, 1865. Arm disabled mainly by injury to the deltoid muscle, eausing adhe- sion at the seat of injury. Died January 1, 1863. Discharged May 18, 1865. Arm perished, and, together with the joint, totally disabled. Disch'd Oct. 11, 1865. Motions and power of arm impaired. Extensive consolidation of the tissues about the shoulder joint. There were two fatal cases in this group. The operations were primary in eight instances, and among these the fatal results occurred. The operations were practised on the right and left sides in equal proportion. The eight survivors were discharged fof physical disability. A tenth case of excision of portions of both clavicle and scapula, in 1 Cases of Private J. P----, p. 475, Private Bickett. p. 562, and Private G. R. M- G3 , p. 563. 49s INJURIES OF THE UPPER EXTREMITIES. [CHAP. ix. which the operative interference appears to have been extended and effective, is fully detailed on this page. Most of these operations were manifestly removals of splintered parts of the outer half of the clavicle—of the acromial process, and of the spine of the scapula. In two cases, however, the coracoid process was excised: Case 14(33.—Captain Abraham Kaga, Co. K, 20th Ohio, was Avounded at Raymond, May 12, 1863, and treated at a field hospital. Surgeon E. L.'Hill, 20th Ohio, reported: "A conical ball entered near the centre of the right clavicle, comminuting it and the acromion process and neck of the scapula, lodging just beneath the skin behind and external to the acromion. lie was put under the influence of chloroform early, and I removed the ball, and, enlarging both wounds, resected the clavicle, acromion, and scapula from the centre of the clavicle outward; two and a half inches of bone were removed, the remaining ends being squared off by bone forceps. The acromion, badly comminuted, was removed by detaching the fragments from the periosteum, which was left as far as possible. The articulating surfaces of the clavicle, acromion, and glenoid cavity, although broken, were not opened into the joint, and after trimming off by forceps, were left in apposition. Not less than two inches of the body of the scapula, the spine, and acromion were entirely removed. The operation was a very tedious and formidable one. But little blood was lost; the only artery cut, the circumflex, was secured at once. Although for an hour and a half under the anaesthetic, he bore it excellently, and l'allied finely. Considerable venous oozing continued for twenty-four hours from small branches. Assistant Surgeon Kay, 124th Illinois, in whose charge the wounded were left at Raymond, reported that this officer was doing well on the 28th of May. He was paroled with other wounded. On June 3d, I learned that he was doing well, and was anxious to be moved forward." Captain Kaga was discharged from service January G, 1884, and pensioned. Examiner J. Phillips, of Washington, reported, March 13,1887: "Exsection of the acromial end of clavicle, about one half its extent, and of the acromion process of scapula. The arm is much impaired in strength, and totally unfitted for manual labor. Disability total." Examiner F. Brewer, of Waynesville, Missouri, reported, September 13, 1873: '"'Fragments of this bone [the right scapula] are still discharged occasionally, and the right arm is practically disabled." This pensioner was paid September 4, 1874. The fifty-nine instances above alluded to constitute a large addition to the recorded statistical information on partial excisions of the clavicle and scapula for injury, but suggest few practical reflections on the subject that have not been referred to on pages 567 and 562 of the preceding volume. It may be remarked that the lines of incision, indicated by writers on this class of operations/ were not commonly followed in military practice, the position of the entrance and exit wounds, and relations of the detached or diseased portions of bone, regulating the direction and extent of the incisions. It must also be stated, that two instances of alleged extirpation of the scapula2 after shot injury came to the notice of the writer, but without such details as could warrant their incorporation with the official records. It is not necessary to modify the antecedent 1 HETFELDER (O.), Lehrbuch der Resectionen, Wien, 1863, S. 281. BCECKRL's translation of the same work, Paris, 1863, PLATE VII. 2 In a case-book of the Confederate Surgeon General's office, Dr. H. L. THOMAS, of Richmond, makes the following entry: "Surgeon B. G. DYSOItT, 3d and 5th Missouri, reports the case of F. H. Smith, Corp'l, Co. B, 3d and 5th Missouri regiments, wounded June 27,1864, in the left shoulder. Scapula taken out, head of humerus resected on the same day. June 30th, yet in field infirmary." It is, of course, impossible to judge of the nature of the operation thus briefly recorded. The complete excision ofthe scapula after shot fracture, by Professor F. H. HAMILTON, and (he published references thereto, are noted on page 492 (note, § 8). Dr. HAMILTON has had the kindness to send a memorandum of the case, which, with an extract from his note of transmittal, is appended: " * * I have delayed answering your note, hoping that L^ivould find the specimen. It was presented to the New York Pathological Society, and I have never seen it since, and I am unable to find it. The following has been copied from the Bellevue Hospital records. To the account given in the hospital record, I can only add that the periosteum was preserved, during the operation, with a great deal of care; but, up to the period when I last saw him, no bone had been reproduced. This fact I mentioned in my report to the Society. He was able to use his arm pretty well. I regret that I am unable to procure for you any more complete notes. Perhaps he is a pensioner, and you may find some account of his case in the pension records. * * If I learn anything more about the case, I will let you know." * * Enclosed in this note is the following extract from Bellevue Hospital records, First Surgical Division, 1866: "Excision of scapula; William Murphy, aged 33; native of Ireland. Was" admitted with the following history: At the battle of Fredericksburg, December 13, 1862, this patient received two wounds: a musket ball and buckshot entering just above the shoulder in front, and a grapeshot striking the scapula just below the spine. Six days after the battle, the head and several inches of the shaft of the humerus were removed, according to his statement. The wounds healed and remained so until about two months previous to his admission, when fistulous openings appeared over the scapula. When admitted he had limited motion in the arm; there were four or five fistulous openings over the scapula through which dead bone could be felt. No bone had ever been discharged. February 10, 1866, Dr. HAMILTON made a crucial incision over the scapula, and finding that almost the whole scapula was necrosed, he removed the whole bone. The tissues are very much indurated and vascular. A few ligatures were applied, and the wound filled with lint, and haemorrhage controlled by pressure. February 13,1866, dressings removed; suppuration free. February 19th, wound looks well; granulations plentiful and healthy. April 1st, wound almost entirely healed; has more motion of arm now than previous to operation." Following Dr. Hamilton's suggestion, careful search was made at the Pension Office. The name of '"William Murphy" appears on the Pension Poll not less than sixty times; but the following entry was believed to be identified with the case referred to by Dr. HAMILTON: "Private William Murphy, Co. G, 73d New York (transferred from Co. A, 163d New York), aged (in 1873) 40 years; wounded at Fred- ericksburg, December 13, 1862, and discharged and pensioned March 2, 1865." Examining Surgeon THOMAS FRANKLIN SMITH reported, May 15, 1865: "A grapeshot wound of left shoulder, destroying a portion of the scapula, and also of the shoulder joint, so that he is unable to use his arm." On September 10, 1866, Dr. T. F. SMITH reports: "The loss of almost the entire left scapula, the result of a gunshot wound. There is great flattening of the shoulder, and the arm and shoulder are very much atrophied and weak. The arm is of but little or no use." Examining Surgeon W. M. CHAM- UKKLAIN reported, August 29, 1869: " The head of the left humerus and a large portion of the scapula have been exsectetl. The arm is stationary at SECT. II.] SHOT FRACTURES OF THE CLAVICLE AND SCAPULA. 499 statement, that the annals of military surgery afford no instance of excision, for shot injury, of the entire scapula with preservation of the upper extremity; but there is a probability that Dr. Dysort's operation involved a large portion of the bone, and evidence that, in Professor Hamilton's case, a considerable part of the shoulder blade was successfully removed. It is proper, also, to refer to Mr. Cole's case,1 in India, the description implying that the scapula, with the upper extremity, was removed after a shot comminution. Although, as in shot comminutions of other flat bones, operative interference may occasionally be demanded,2 yet, weighing all the evidence, it is obvious that extensive excisions of the scapula for injury can seldom be required as primary operations.3 Reverting to the cases of shot fracture of the clavicle and scapula in which no formal operations were performed, some interesting complications may be remarked. False trau- matic aneurisms are common enough; but true aneurisms succeeding contusion by shot are very rare. A case classified in this group is believed to have been thus complicated. It is to be regretted that it was impracticable to trace its ulterior history: Case 1469.—Private E. Reynolds, Co. E, 7th Louisiana, aged 25 years, was wounded at Monocacy Junction, July 9, 1864, and received into Frederick Hospital on the following day. Acting Assistant Surgeon T. E. Mitchell reported: "A minie" ball entered the back part ofthe left shoulder in the suprascapular fossa, traversing the neck, perforating the scapula, fracturing the clavicle, and making its exit on the anterior part of the neck a little to the right of the median line, and one and a half inches below the pomuru Adami. The wounded man having been placed under care of Dr. Graves, Surgeon, C. S. A., progressed favorably. Under the application of cold-water dressings the anterior wound healed in the course of two weeks. On July 20th, the patient, while feeling over his neck, detected a buzzing sound, as he described it, to which he called the attention of the doctor, and which was at first sight supposed to be an abscess; upon close examination, however, it was found to be an aneurism of the subclavian artery between the omo-hyoid and scalenus anticus muscles, of small size and rather indefinite outline. The pulsation was quite perceptible, and the bruit was of a whizzing or purring character, which could be heard distinctly on auscul- tation as well as-felt by the hand. Yet the patient experienced no peculiar sensations, other than a slight pain in the forearm and elbow, with total loss of motion, except in the fingers. The pulse at the wrist was unaffected. On August 5th. when the patient came under my care, I discovered an abscess exterior to the artery, and in close proximity to the aneurismal tumor, but external to it. This had begun to form on August 1st, and was opened by Assistant Surgeon R. F. Weir, U. S. A. A few spicula? of bone were removed and a moderate quantity of bloody pus was evacuated: The wound healed nicely, and the patient required no other treatment than to be kept quietly on his back in bed. By August 20th he was well enough to be permitted to sit up with his arm in a sling. On August 28th, the fracture of the clavicle had united, the posterior wound had closed, and the patient was permitted to walk about the ward. From this time, the tumor evidently decreased in size. On November 9th, though all tumefaction had left the parts, it was found that the strong aneurismal sound still continued, put was more circumscribed, and limited to the region of the lowest part of the carotid. The thrill could be felt over a space commenc- ing from the clavicle, running upward nearly two inches, and transversely to a distance of one and a half, inches. The sterno- mastoid was apparently overlying the tumor, which was evidently again increasing, its pulsations becoming visible. It had also the shoulder joint and atrophied." The New York Examining Board, Drs. W. O'Meagher, C. Phelps, and P. Tkeadwell, reported, March 15,1871: " Inner extremity of clavicle dislocated upward." Dr. T. P. Smith reported, September 23, 1873: "There is a large adherent radiated cicatrix 5X5 inches over left scapula; there is great loss of bone substance; extension is impossible. This pensioner died June 24, 1874. The cause of his death is not known at the Pension Bureau. Further confirmation of the identity of this pensioner with the subject of Dr. Hamilton's operation has been found, since the foregoing memoranda were printed, in a special report by Surgeon E. P. VOLLUM, U. S. A., of examination of applicants for admission to the Veteran Reserve Corps, dated 115 Cedar Street, New York, February, 1867: "William Murphy was discharged from Co. G, 73d N. Y. Vols., as a private. He was wounded at Fredericksburg, December 13, 1863, by a grapeshot striking the posterior face of his left shoulder, carrying away some of the soft parts and shattering the scapula. At present, there is an extensive cicatrix occupying the back of the left shoulder, perfectly healthy in appear- ance, and the motion of the shoulder joint is considerably impaired. The man says that ho has experienced no bad effect on his general health from the wound, which took five months to heal up. Fragments of the scapula were removed by Surgeon A. B. MOTT, U. S. Vols., and Medical Inspector F. Hamilton. Passed for V. It. Corps." 1 Cole (J. J.), Military Surgery, or Experience of Field Practice in India, London, 1852, p. 110, Case XXVIII. The author states: " This injury appears to have beer* occasioned by a four-pounder. The ball impinged upon the head of the humerus, shattered it, smashed the acromion process, fractured the clavicle, and split the scapula to pieces. The shoulder joint is irreparably injured, tho extremity itself is forever gone, and demands to be removed en masse from the trunk." He goes on to describe the mode of operation for an amputation above the shoulder, including the extirpation of the shoulder blade and resection of the clavicle; but whether this operation was undertaken is not indicated; nor is any intimation given of the result of tlie case. • 2 LOHMEYEll (Die Schusswunden und ihre Behandlung, 1859, S. 193) remarks: " The splintering of the body of the scapula, as a rule, heals readily, and does not necessitate operative interference, though such treatment has been undertaken by B. v. Langenbeck." 3 On page 565 of the preceding surgical volume, some account is given of operations by MM. Chipault and CllARPIGNON, for excision of the shoulder blade, in the Franco-German War, and further information is there collated regarding this operation. But it does not appear to have found favor. Df.jime (H.) (Studien, 1861, B. II, S. 219), speaking of shot fractures ofthe scapula, in the Italian campaign of 1859, observed that: "Operative interference, resection, which has, now and then, been practised in earlier wars, did not, as far as I know, become necessary in the Italian War." The following references on excision of the shoulder blade may be consulted: Stern (L.) (fiber die Resection des Schulterblattes, Erlangen, 1852); FELSING fE. F.) (Die Resection des Schulterblattes, Giessen, 1863); PETRKQUIN (J. E.) Mim. sur une mithode opirat. propre a amputer l'omoplate, en respectant le moignon de I'ipaiile et conservant les mouvements du bras, in Bull, de I'Acad. de Med., 1859-60, T. XXV, p. 283); Pfbenger (A.) (Uber die Resection des Schulterblattes, WUrzburg, 1846). 500 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. been ascertained that the subclavian was not the vessel injured, but the carotid, being proven hy the fact that direct pressure over the course of the carotid, about three and a half inches ahove the clavicle, would cause a cessation of all thrill. The patient was transferred to Baltimore on December 23d. He had received no treatment for about a month, aud the tumor had remained about the same size for several weeks." Surgeon A. Chapel, U. S. V., from West's Buildings Hospital, reported, in this case: " Ball entered at the posterior part of the left shoulder, touched the left carotid artery, and escaped to right of the larynx, producing anuerism." The patient was transferred to the Provost Marshal, for exchange, February 11, 1865. The burrowing of pus in the dorsal and lumbar regions was another important com- plication in the cases of this group, and was returned as the cause of death in one instance. Pyaemia was specified as the cause of death in thirty-four of the three hundred and fourteen fatal cases; secondary hsemorrhage in eighteen cases; hospital gangrene in twelve; erysipelas in seven; tetanus in five, were the next most frequent causes of mortality. Nine patients were reported to have succumbed to secondary pulmonary trouble, five to variola, one to cerebro-spinal meningitis, twenty-six to fevers or bowel complaints con- tracted in hospital. In two-thirds of the cases, the causes of death were unspecified. There is little to be remarked regarding the treatment of shot fractures of the shoulder blade.1 After the arrest of bleeding, on the rare occasions requiring it, the removal of foreign bodies or of detached structures become such, it was only requisite to keep the parts at rest, supporting the arm by the side, that its weight might not further displace the mutilated fragments of the scapula. The conventional treatment of fractured scapula by an axillary pad and the bandage of Velpeau was seldom resorted to, if ever. The bibliography of fractures of the clavicle and scapula2 is meagre. The greater part of what has been published on excisions of these bones,3 has been adverted to in preceding references. A further statement, confirming the report that Professor Hamil- ton's excision of the scapula was an extirpation, is subjoined.4 'In Boyeu'S classical system (Traiti des mal. chir., 5me 6d., 1845, T. Ill, p. 150), in Patissier's article Omoplate (Diet des. sci. mid., 1819, T. XXXVII, p. 296), in Beraud's article with the same title (Diet de mid., 1840, T. XXII, p. 68), in Lonsdale's treatise (Pract. Treat, on Fractures, 1838, p. 191), and in many other general and special surgical works, something may be found on fractures of the scapula, but comparatively little on shot fractures. Petit and Desault, Gurlt, MALGAIGNE, and Hamilton treat fully of the subject, and two special dissertations are found in the Surgeon General's Library, namely: Brockeniiuus (G. A.) (Defractura colli scapulx et processus coracoidei, Jena;, 1862) and Putz (J.) (fiber die Bruche dis Schulterblattes, Greifswald, 1868); but references to shot injuries are exceedingly rare. Most ofthe cases detailed by military surgeons have been referred to in the preceding notes of this section. It inay be observed that the "judicious remarks " ascribed to Neale, on page 482, are almost literally translated from LeDuan (Traiti ou Reflexions tiries de la Pratique sur les Playes d'Armes a feu, 1737. p. 160), who devotes four pages to shot wounds of the clavicle and scapula. DESl'ORT (Traili des Playes d'Armes a feu, 1749, p. 296 et seq.), observing that shot injuries of the shoulder blade must be, for the most part, considered with chest penetrations, nevertheless has a separate-appendix, des plaies de l'omoplate, and details at length the case of a soldier, of the Roussillon regiment, wounded at the siege of Pizzighettone, by a cannon ball, that "tore away the arm, the upper half of the scapula, and the greater portion of the clavicle, besides fracturing the third lib." Happening to be in the trenches that day, Despgut was near the soldier when he was struck, and there was so much bleeding that, he says: "Jefis done la ligature de tous les gros vaisseaux." The patient was seen by the celebrated KERRIIV, and then sent on to a hospital at Lodi, whence M. DEL.URE informed DE3PORT: "qu'il avoit Hi fort bien gueri." If Desport really ligated the subclavian in this ease, he anticipated Keate's operation by more than half a century. The siege of Pizzighettone, a fortified place near Cremona, in the famous qnadilateral, was a part of the war waged in Lombardy, between Charles VI and the French and Spaniards, which began in 1733, and ended, iu 1735, with the cession of the Neapolitan provinces to Spain. Hence Desport's case of avulsion of tho arm, and portions of the clavicle and scapula, antedate the remarkable observation of ClIESELDEN (The Anatomy of the Human Body, 7th ed., 1750, Tab. XXXVIII, p. 321), the case of Samuel Wood, whose arm, with its scapula, was torn off by arope winding around it * * in the yearl737." 2Paulus iEciXEl'.v (sec Sydenham Soc. translation, Vol. II, p. 450); Pare (QSuvres completes, ed. Malgaigne, 1840, T. II, Liv. XIII, Chap. IX, p. 309); DuVerxey (Traiti des maladies desos, Paris, 1751, T. I, p. 221); DUMONT (A.) (Les fractures du corps de l'omoplate, Strasbourg, 1863); LOTZ- r.ECK (Die Fracturen des Schulterblatthalses, in Deutsche Klinik, 1867, B. XIX, S. 420); VON Pitha (Die chirurgischen Krankheiten der Extremitaten, Erlangen, 1868, S. 16): Akckk (B.) (Traiti inconograph. des mal. chir., 1865, p. 112, et planches 27, 28). The article Clavicula, in the fifth volume of tho Diet des Sci. Med., 1813, T. V, p. 3C8 (the sixty volume French dictionary), is by the celebrated PETIT, and that in the Diet de Med., 1834, T. VIII, p. 89 (the thirty volume dictionary), by Professor Laugier. But an exhaustive dissertation on lesions of the clavicle is published by Professor KlClIET, in the Nouv. Diet de Med. ct Chir. Prat, 1868, T. VIII, p. 1, with a bibliographical appendix by M. Despues. 3An additional case of extirpation of the scapula has appeared in the journals since the foregoing lines were put in type: Schneider (R.) (Extirpation der linken Scapula wegen tines Sarkoms, in Berliner Klin. Wochenschrift, Aug. 3, 1874; S. 377) removed, December 3, 1873, the entire scapula, for disease in a lad six years old. The wound healed; but, in March, 1874, the tumor reappeared, and the boy died April 20, 1874. 4 The references on page 492 (note 2, § 8) and on page 498 (note 2) were printed, and stereotyped, when the following letter was received (Novem- ber 24, 1?74) from Professor Hamilton: "I am unable to furnish you with any more complete account of the case of Win. Murphy (excision of scapula) than is supplied by the records of Bellevue Hospital. The operation was made in the presence of a number of medical gentlemen, and the fact that the entire scapula was removed does not admit of doubt. The person described in your mem. is, there is no question, the same us the man operated upon by me. Possibly the specimen, or some further account of it, may yet be found. If it is, it will be sent to you. If any bone was actually found by the pension examiners, corresponding to the scapula, then it was reproduced from the inflamed and thickened periosteum—all of which was left. This supposition is not improbable, although, when I last saw him, no portion of the bone had been reproduced.'' This interesting case affords, perhaps, a solitary example of a successful extirpation, for the results of shot injury, of the scapula, with preservation of the upper extremity. The operation was performed more than three years after the reception of the injury, and the pensioner survived more than eight years. SECT. III.] WOUNDS OF THE SHOULDER JOINT. 501 Section III. WOUNDS OF THE SHOULDER JOINT. Shot wounds only are to be considered in this Section. There were no reported instances of punctured or incised wounds implicating the shoulder joint,1 and the sprains, and luxations, and fractures from other causes than shot injury, that were recorded, will, as already intimated, be noticed in a future chapter. Classical authors commonly divide wounds of the joints into non-penetrating and penetrating. M. Legouest justly observes,2 that the former group might, with greater propriety, be designated "peri-articular" wounds, and several recent writers on military surgery have concurred in his opinion. The system- atic nomenclature further subdivides these wounds into those caused by pointed, or cutting, or contusing weapons.3 The latter, of course, are concerned in treating of shot injuries. The few general observations communicated regarding wounds of the larger joints must be relegated to a subsequent part of the work. The many facts reported respecting shot injuries of the scapulo-humeral articulation, treated either on the expectant plan, or by excision, or by amputation, and of operations at the joint demanded by injuries in its vicinity, will amply fill this Section. The reported examples of shot wounds interesting the joint, without injury of the bones, were comparatively few, comprising only seventy-two cases. There were thirteen hundred and twenty-eight cases in which the articular extremities of the humerus or scapula were primarily involved, and the results were ascertained in all save fourteen. In nearly one-half of the cases, excision of the head of the humerus was practised; in three- eighths of them, expectant treatment was adopted; in one-eighth, the limb was removed. The mortality in the three groups averaged nearly one-third. The categories of excisions and amputations comprise, however, by no means ail the instances of such mutilations that were reported. Excisions of the upper extremity of the humerus, and ablations of the arm at the shoulder, were often practised when the articulation was not immediately involved. For statistical purposes, it will be convenient to place these cases in three sub- divisions, corresponding to the treatment by expectant measures, excision, or amputation that were employed. There will then be added to the fourteen hundred cases of primary sjiot injury of the shoulder, nine hundred and twenty-eight cases in which operations were performed, at the articulation, for shot injuries in its .proximity. And thus will be ■The region of the shoulder joint, as remarked by Dr. M'Dowel (Cyclopsedia of Anat. and Phys., Vol. IV—I, 1847, p. 571), cannot easily be assigned precise limits. Anteriorly separated from the pectoral region by the "coraco-deltoid groove" of VELPEAU, defining the narrow space between the deltoid and great pectoral muscles, it is limited above by the projection of the acromion and outer end of the clavicle. Posteriorly, it is confounded with the scapular region ; inferiorly, it is bounded by the folds of the axilla. In this Section it is proposed to consider only wounds of the shoulder joint itself. The synonymy of " shoulder joint" is as ill defined as the limits of the region: "articulation scapulo-humirale" and "Schulter-gelenk" are the ordinary French and German equivalents. 2 Legouest (L.), Traiti de Chirurgie d'Armie, 2eme ed., 1872, p. 442. 3 Bonnet (A.). Traiti des Maladies des Articulations, Lyon, 1845, T. I, p. 254. 502 INJUEIES OF THE UPPER EXTREMITIES. [CHAP. IX. aggregated twenty-three hundred and twenty-eight cases, as nearly as can be ascertained from the returns, of shot injuries directly, or indirectly, involving the shoulder joint, to be discussed in this Section, comprising, it may be recapitulated, cases of wounds implicating tbe ligaments and strong tendons that strengthen them, the bursal sacs and synovial sheaths near the joint; cases of penetration of the joint without known fracture ; cases of Trarture of the articular extremities of the scapula and of the humerus, or of both; and cases of fracture of the shaft of the humerus, or of lesions of the soft parts of the region, in which amputations or excisions at the shoulder were practised. Wounds treated on the Expectant Plan.—Apart from the shot injuries of the shoulder complicated by lesions of the thorax, and those that have been classified with fractures of the clavicle and scapula, were five hundred and seventy-seven cases ill which the scapulo-humeral joint was interested by shot projectiles and operative interference was not attempted. Wounds unattended by Fracture.—-There were few instances of the penetration of the joints by shot projectiles without injury to the articular extremities of the bones. In more than fifty thousand cases of shot wounds of the upper extremity, but two hundred and twenty-five were recognized as wounds of the shoulder, elbow, or wrist, without frac- ture. Of these, seventy-two were returned as wounds of the shoulder joint without frac- ture.1 Some of them appear to be examples of contusions of the ligaments, cartilages, or synovial membrane, without actual penetration, of the joint, a form of injury which, as Generalarzt Beck has justly remarked,2 some surgeons have, without warrant, called in question. Others appear to have been fairly referred as shot penetrations of the articu- lation without osseous lesion. Six of the seventy-two cases proved fatal—in two instances from pyaemia, and, in the remaining four, death was ascribed to "the effects of the wound of the joint." Thirty-six of the patients were discharged from service for disability, in the shape of false anchylosis for the most part. Thirty were sent to their regiments, or to modified duty. Nearly all of the cases are reported briefly, and none with particulars that seem to require citation. Yet, while there were few detailed abstracts of such cases, the experience of all surgeons who had a large field of observation, proved that shot wounds of the soft parts in proximity to the shoulder joint3 were deserving of the gravest consideration.4 The reader cannot have overlooked the fourteen cases of exarticulations at 1 Losffler (F.) (Generalbericht uber den Gesundheitsdienst im Feldzuge gegen Danemark, 1864, Berlin, 1867, p. 280) remarks that, among the cases of wounds ofthe shoulder joint, "there was not a single one of injury of the capsule only; in all were either the head of the humerus, the acromion process of the scapula, or the head and the glenoid cavity injured." Yet an eminent authority, LONGMORE (T.) (Article Gunshot Wounds, in HOLMES'S System of Surgery, London, 1861, Vol. II, p. 73), assures us that: "Joints maybe contused or opened by projectiles, without apparent lesion of any portion of the bones entering into their composition; but these are exceptions to the usual order of such cases from gunshot." 2Beck (B.) (Chirurgie der Schussverletzungen, 1872, S. 575) observes: "The opinion of a few, that there are no shot joint-contusions, that, in cases of swelling of the joint with effusion, perforation exists, is entirely false, and can only be excused on the ground that these persons had not occasion to examine recent wounds, and to convince themselves of the fact that the joint was not opened, nor to watch the injury from the date of its infliction until its final development. In several instances—apart from digital examination, by which the wound track could be distinctly followed between the capsule of the joint and the outer covering—I have been enabled to clearly establish this by subsequent operation, and to satisfy myself of the fact by ocular inspection. For instance, in a case of shot wound of the shoulder, pronounced by several colleagues as penetrating the joint and indicating operative interference, I diagnosticated non-penetration, and convinced myself of the correctness of my opinion by the resection of the acromion, which became afterward necessary, finding that the capsule was iutact, and that the missile had passed over the entire length of the joint, against the shoulder blade." 3 SOCIX (A.) (Kriegschir. Erfahrungen, 1872, p. 102) says: "In like manner, the shot wounds of the integument and tissues in proximity of the joints deserve great attention, as we are never certain that the joint capsule has not been grazed or opened; or even if 4his had not been the direct result of the injury, that opening of the joint may not occur, secondarily, because of stagnation of pus in the shot canal. It is known that such articular injuries frequently exist, for a long time, without any special symptoms, until, all at once, acute suppurative synovitis, with all its attending hazards, supervenes." 1 XEL'DORFEK (J.), in treating of shot wounds of the shoulder, remarks (Handbuch der Kriegschir., 1872, S. 1126): "It occurs, that wounds that do not open the joints primarily, injure the same to such an extent that, in a short time, complete suppuration of the joint ensues; and, referring seemingly to a special case, he adds: "the joint was contused and wrenched, and filled with extravasated blood; but not penetrated; but for all that, more severely injured than from a simple penetration of the capsular ligament." SECT. III. 1 WOUNDS OF THE SHOULDER JOINT. 503 the shoulder on account of shot wounds in the neighborhood of the shoulder, tabulated on page 46S. Nor will the instances, to be noted further on, of decapitation of the humerus, for necrosis consequent on peri-articular wounds,1 escape attention. Dr. Hodges observes that anchylosis of the scapulo-humeral articulation from disease is of extreme rarity;2 and it might be inferred apriori that in a ball-and-socket joint, permitting move- ment, under normal conditions, in almost every direction, anchylosis should occur infre- quently. The laxity and capaciousness of the capsular ligament are in correspondence with the freedom of motion this articulation enjoys. Yet, if the reports of the pension examiners are correctly interpreted, it is not uncommon to find cicatricial bridles, or other lesions consequent on peri-articular shot wounds of the shoulder, seriously impairing the mobility of the joint. When the wounded are numerous after an action, precedence has to be accorded to the grave cases of shot fracture and of penetration of the great cavities, and those wounded in the upper extremities, unless their injuries are severe, may receive little immediate attention. But a comparatively slight shot injury near the shoulder, or, indeed, near any of the larger joints, readily excites inflammations of the most serious nature, if neglected. The proper treatment of shot wounds of this group consists in preventing, by support and immobilization of the arm, and cold lotions to the seat of injury,J the irritation and possible phlegmonous inflammation that might supervene, if the joint was not kept at rest and protected from all irritant causes. Wounds attended by Fracture of the Bones composing the Shoulder Joint.—There were returned fiv£ hundred and five cases of this description, in which operative inter- ference was not undertaken. The results were that about half of the patients were discharged for disability, less than a fourth were sent to their regiments, or to modified duty, and somewhat less than a third died.4 There were many examples in which the acromion, or coracoid, or borders of the glenoid cavity, or the head of the humerus were shattered, that reached a favorable termination. Some instances of these and other varieties of injury of this group will be detailed, and among them are some cases that have led military surgeons to doubt if operative procedures were invariably called for5 in shot fractures at the shoulder. An attempt to establish direct numerical comparisons between the results of expectant treatment, excisions, and amputations, after shot frac- 1 Legouest (L.) (op. cit, p. 443) has some very interesting comments on the gravity of shot wounds in the vicinity of the joints. He points out the probability of contusion, or of loss of substance, of the ligamentous or tendinous tissues, lighting up inflammation of the joint. He mentions how a "commotion profonde des elements de l'articulation " may likewise lead to arthritis. He comments on the inflammations that supervene when the soft parts about a joint are torn away by projectiles. In conclusion, he remarks: "Les projectiles, sans ouvrir immediatement les articulations, peuvent determiner la gangTene des tissus frappes: l'ouverture de la cavitfe articulaire survient consecutivement a la chute des eschares," and adds: "I'inflam- mation immediate ou consecutive de la capsule articulaire est l'accident le plus a craindre des plaies peri-articulaires." •Hodges (R. JI.), The Excision of Joints, Boston, 1861, p. 25 (The Boylston prize-essay for that year). Dr. HODGES states that, in 1855, there were "in the museums of London and Paris but four specimens illustrating such a condition." 3Socl\*.(A.) (Kriegschir. Erf., 1872, S. 102), treating of shot injuries in the vicinity of the scapulo-humeral articulation, declares that "in all doubtful cases, even, the joint must be kept steadied, and this is best accomplished by a fenestrated gypsum or silicated bandage. The limb should be elevated. I have the carbolized bandage covered with an ice bag until the wound is healed, and do not allow the patient to leave his bed until complete cicatrization has taken place." 4 The exact numbers are: Discharged, 247; duty, IIP; died, 139. 5 Professor Hunter McGuire, of the Jledical College of Virginia, in the course of " Clinical Remarks on Gunshot Wounds of Joints, delivered January 10, 1866, at Howard's Grove Hospital" (Richmond Med. Jour., 1866, Vol. I, p. 148), expresses the following opinion: " Gunshot wounds of the larger joints, involving the ends of the bones, almost invariably demand operative interference. When it occurs in the upper extremity, and the injury to the soft parts is not too extensive, the larger vessels of the limb being unhurt, and you think the patient's general condition justifies the operation, you should resort to excision in preference to amputation. I refer to the general health of the patient, because it is necessary to consider this, as well as the nature and extent of the injury, before deciding the character of the operation. I believe the shock and traumatic fever following excision of joints is greater than that of amputation. Recovery is certainly slower, and the system is never heavily taxed by suppuration. This is always profuse, even in the cases which recover most rapidly; and I found it usually necessary, not only to husband all the patient's strength, but to assist him, during the latter part of the .treatment, with tonics and stimulants. Another thing you must remember: this matter, which I tell you is so abundant, sometimes collects in the wound and seriously interferes with the cure. This is especially liable to happen when the wound is not dependent, and cleanliness is not observed. You should try to prevent it, or, if it docs happen, make a free and early opening and let it out. The results of this operation at the elbow and shoulder joints are usually very gratifying." 504 INJURIES OF THE UPPER EXTREMITIES. * [CHAP. ix. tures at the shoulder, would probably be undertaken only by some sciolist or dabbler in statistics, since the injuries involved are so variable in nature and extent that the terms of comparison cannot be fairly ascertained, and any strict application of the numerical method is impracticable. Such attempts have been characterized as caricatures of the inductive mode of reasoning. Yet, if the student will bear in mind that famous aphorism of Morgagni; "Non numerandce sed perpendendce sunt observationes," which was so useful a commentary on the uArs tota in observationibus" of Hoffmann, and will compare like cases, or. series of similar cases, carefully making such restrictions and qualifications as the various groups of facts require, the mass of information collected may be fruitfully studied. It has been thought best to include in this Section many cases in which fragments of bone, or of clothing, or other foreign bodies, were removed; such procedures being part of the proper dressing, and riot formal operations. Mr. Thomas Bryant has politely said1 that "the experience and knowledge of wounds of joints which the civil surgeon acquires must necessarily be somewhat limited, and it is to his military brethren that he generally turns for the information he may desire, as to the symptoms, results, and treatment of such injuries." In the particular group of wounds of joints under consideration, it is indubitable that the military surgeons have accumulated a great mass of observations, which, it may be hoped, will prove of use, when discussed by such writers as the one just cited and his compeers, although their imperative field duties may have compelled the army surgeons often to record their cases in a hasty and imperfect manner. The surgeons attached to armies early after the introduction of fire-arms, who have left us any account of their experience, have not failed to dwell upon the danger and mortality of shot injuries of the larger joints, citing many of their examples, as was the custom of the times, from the great personages thus wounded,2 yet, incidentally, mentioning some of the subordinates.3 In later wars, the fatality of these injuries was fully recognized and their danger perhaps overestimated. John Bell does not hesitate to pronounce all openings into inflamed large joints fatal;4 and, until recent years, few have called the rule in question, or presented 1 Bryant (T.) On the Diseases and Injuries of the Joints, 1859, p. 182. 2 Thus AMBROISE Paris (CEuv. compt, 6d. Malgaigne, 1841, T. Ill, p. 723) tells us that: " Toutes les playes faites aux grandes jointures, et principalement des playes contuses, estoient mortelles," and cites the case of a king of Navarre, shot in the shoulder joint, in 1560, and refers (op. cit, T. II, p. 311) to similar cases of .Monsieur de Guise and Count Philibert, all terminating fatalty. Desport (Traiti des playes d'armis a feu, 1749, Chap. IV, p. 235) treats des plaies des articulations, and, in speaking oi plaies de Varticulation de Vipaule, declares that: "elles sont presque toujours mortelles, lorsque le fracas est grand; cependant on peut tenter l'amputation a lambeau faite dans l'article." Ravaton deserves credit for early recog- nition that conservative measures might sometimes suffice in shot injuries of the shoulder. He cites a case (Chirurgie d'Armic. ou traiti de plaies d'armes a feu, 1768, p. 267) of a shot fracture of the shoulder treated on the expectant plan, and remarks: "Le succes avantageux qu'a eu le traite- ment de cette fracture de la teHe de l'humerus, celui d'un nombre d'autres de meme espece, que je'i vu depuis, prouve que le preccptc qu'on avait etabli les siecles derniers, d'amputer a l'article dans tous ces cas, preccpte que j'avois adopts, et que bien des chirurgiens suivent encore aujourd'hui, est sujet a plus d'une exception." And BILGUER, in his famous memoir on the rarity of the necessity of amputation (Halae, 1761), and La Makti- MERE (Mim. de I'Acad. de Chir., 1768, T. IV, p. 1) commenting on BILGUER, have something to say'regarding shot wounds of the shoulder, treated on the conservative plan. 3 Some of the older surgeons furnish observations on the expectant treatment of shot fractures of the shoulder, the only alternative for ampu- tation from the middle of the eighteenth century until the time of the MORE.vus and of Larrey. Thus, BOUCHER (Obs. sur des playes d'armes a feu complif/uies de fracture, aux articulations des extrimites ou au voisinage des ces articulations, in Mim. de I'Acad. Roy. de Chir., 1753, T. II. p. 587) remarks: " Les grands accidens ne demandent pas toujours les grandes operations;" and, on page 299, Obs. IX, relates the case of a lieutenant, wounded, at Fontenoy, through the head of the humerus, from whose shoulder M. GUFFROY removed, at varions periods, pieces of bone; the patient recovered. On page 301, he gives a similar case of a soldier wounded at llamillies. This was in 1753; and ten years later, J. M. Biloui.i; (Chir. Wahrnchmungen, 1763, p. 420} gives the case of a grenadier, wounded at Kesterlitz, in Bohemia, August 22, 1762, in which the head and shaft of the riirlit humerus and the glenoid cavity were shattered. Surgeon WlXKLER successfully extracted a number of fragments through an incision. Bilgueu (I. c, p. 420) further relates that Surgeon Brown preserved the arm, in cases of shot fracture ofthe shoulder, of two soldiers, named Pritzchke and Horn, wounded iu the Seven Years War, in 1762. A few years later, J. L. SCHMUCKER (Vermischte Chir. Schriften, Berlin, 1782, B. Ill, p. 301) relates a case e.f shot fracture of the head and neck of the left humerus and the glenoid cavity of the scapula, in which, in 1778, he dilated the posterior wounds and removed fractured pieces of bone; the patient made a good recovery. On page 82, he argues against the then accepted doctrine of "'amputating the limb in cases of splintering of the head of the bone, with the supposition that sphacelus of the member and death must otherwise ensue." Soon after, DOMGNON" (Sur une plaie d'arme a feu, in Jour, de mid., chir., phar., etc., 1786, T. LXVI, p. 47) described a case of shot fracture ofthe shoulder, where the head of the humerus, the acromion, and the acromial end of clavicle were fractured, in which, after removal of pieces of bone, the patient, a girl of 16, recovered with full use of the arm. 4 Bell (J.) (Discourses on the Nature and Cure of Wounds, 1795, Part III, p. 12): " The wounds of the joints are so dangerous by their high inflammation, that they may be fairly enough compared with wounds of the great cavities, * * neither can bleeding appease the inflammation, nor opium Sl'X'T. III.] WOUNDS OF THE SHOULDER JOINT. 505 ?eon the exceptions sufficiently weighty or numerous to invalidate it. But it is now known, in regard to the shoulder joint, at least, that favorable results may be obtained after shot penetrations, without resorting to formal operations.1 Some examples will illlustrate this: Case 1 ITO.-l'rivate J. Keenan, Co. II, GOtli New Vork, aged 137 years, was wounded May V>, 18G4, at the battle of Spottsylvania, and was sent to a Second Cups hospital, and thence to Douglas Hospital, May 27th, where Assistant Surg W. V. Norris, U. S. A., reported: "This man was struck by a musket ball, that entered a little below and in front of acromial process of the left scapula, and, passing inward and down- ward, comminuted the head of the humerus, and made its exit at the posterior fold of the axilla, The constitutional condition was satis- factory. The wounds were discharging pus. mixed with synovia, quite freely. A digital exploration indicated that the head of the humerus was almost pulverized; but that tliere were no considerable fissures extending into the diaphysis. Upon consultation, it was decided to make a free incision into the joint to permit the removal of fragments and a free discharge from the wound. But the patient earnestly deprecated any operative interference, and, in obedience to his wishes, he was put to bed and allowed a generous diet; while, except to keep the arm at rest, to facilitate free discharge from the wounds, and to apply dressings of cold water, no local treatment was instituted. Under these measures, the patient steadily improved. Fragments of necrosed bone occasionally came away. As convales- cence progressed, passive motion of the joint was made whenever the wounds were dressed. On January 20, 1865, the wounds were entirely healed. The patient had good use of his arm, and could perform most varieties of manual labor. The power of the deltoid was unimpaired, yet there was sufficient anchylosis to prevent the patient from putting his hand to his head or raising his elbow to a level with the shoulder. The result is certainly more satisfactory than the average result in excisions of the head of the humerus." A photograph ofthe patient was prepared at the Museum, July 9, 1865. A reduced copy is given in the annexed wood-cut (FlG. 383). This soldier was transferred to the Veteran Reserves May 1st, and dis- charged November 21, 1865, and pensioned. Examiner J. Neil, of New York, reported, April 17, 1855: "Shot fracture of the head of the left humerus, resulting in impeded motion of the joint in all directions, with partial muscular atrophy; disability three-fourths; likely to improve slowly." This pensioner's claim was suspended January 30, 1876, in consequence of no response having been received from him for two years. Case 1471.—Private J. Jordan, Co. B, 12th Ohio, aged 30 years, was wounded at South Mountain, September 14, 1862, and was admitted to hospital No. 1, Frederick, on the 16th. Acting Assistant Surgeon W. W. Keen, jr., made the following special report: '' The ball entered the right arm just below the neck of the humerus, antero-externally, and emerged immediately below the clavicle at the junction ofthe outer and middle thirds, fracturing, probably, the head of the scapula. On October 7th, erysipelas set in, with the formation of pus about the wound of entrance. Dressed with lead and opium wash; quinine, iron, and stimulants given freely. October 16th, erysipelas entirely disappeared; free discharge of pus from the wound of exit, and of a healthy character. 19th, condition decidedly improving; pus very healthy; sitting up. 23d, there is some passive motion, but it gives him pain to pass the elbow upward; head of humerus fractured; crepitus distinct; also a piece of the coracoid broken off; a small piece of the bullet was extracted. November 5th, shoulder painful, so that he cannot sit up; no union of fragments; some deep burrowitig of pus, which was evacuated by the introduction of a tent. 8th, strength failing somewhat, so that I increased the stimulants, the brabdy to one ounce every two hours, and ordered beef tea freely; pulse 120. 10th, somewhat stronger; pulse 102. 11th, pulse 98, and stronger." The patient was discharged the service December 2), V<2, and pensioned. Examiner James Putney, of Kanawha, West Virginia, reported, in 186:!. that: "His present condition is the result of a gunshot wound, the ball entering at the inferior posterior part of the deltoid muscle and coming out under the clavicle, fracturing the head of the humerus, producing anchylosis of the joint, and suppuration and exfoliation of the bone.'' Examiner T. F. Smith, of New York, reported, in 18/6, that the pensioner was unable to place his hand on his head, and that the arm was considerably weakened, with nearly complete anchylosis of the shoulder joint. The pensioner was paid Jane 4, 1874. relieve the pain,—nor bark nor diet support him under the vast discharge. XVv here pronounce more freely the opinion * * that openings into inflamed joints are fatal, and though there are in every book cases of anchylosed joints, we cannot but remember, that for one that has escaped by anchylosis, thousands have died. In this case—viz: of wounded joints—bleedings, poultices, and emollient fomentations constitute almost the whole that surgery can do. The wounds are to be dilated, the fragments of bone extracted, the patient laid quiet, and the limb as easy and soft as may be; nothing should be suffered to disturb him; he should have large opiates given him to abate the irritation and excessive pain ;—and thofigh bleeding may, perhaps, be allowable at first, yet our chief difficulty lies in supporting the strength of the patient during the tedious cure." 1 Still more clearly in the recent European wars than in our own. Thus, Beck (B.) (Chir. der Schussvrelelz, 1872, S, 528), who, as medical director of the Bavarian army corps, saw much field surgery, remarks: "Deducting the incurable cases, that required no further assistance from art, and those in which primary cxarticulation at the shoulder had been performed, we treated, in our field cr general hospitals, forty-six cases of injuries of this nature. In twenty-eight, expectant therapeutic measures were employed, with surprisingly favorable results, as only two of the wounded of this class perished; one, in consequence of tetanus, and the other, who hud been left in our hands, in a very bad condition, by French surgeons, was no longer a proper subject for an operation." 04 Fig. 386.—Results of conservative treatment in case of shot frac- ture of the head of the humerus. [From Photograph 02, Surgical Series, A. M. M.] 506 INJURIES OF THE UPPER EXTREMITIES. [CHAP. ix. Cask 1472.—Private 13. Buckley, 47th New York, aged 46 years, was wounded at Olustee, Florida, February 20, 1S('(1, taken prisoner, and sent from Camp Parole to hospital at Annapolis, where surgeon G. S. Palmer, U. S. V., reported: " Gunshot wound of right shoulder." This soldier was discharged January 16, 1865, and pensioned. He re-enlisted April 5, 1867, and the facts in his case are first reported on his examination for the Veteran Reserve Corps by Surgeon E. P. Vollum, U. S. A.: "A bullet entered under right acromion process, thence through head of humerus, and escaped near the angle of right scapula, after passing through that bone. A month after the injury, while a prisoner at Tallahassee, Confederate Surgeons Gidons and Clark removed several fragments of the head of the humerus. The injury and incisions repaired in eight months, when he was furnished by Dr. Hudson with an apparatus that kept the humerus well up in the glenoid cavity. This he wore for twelve months with very great advantage, and to it he attributes the restoration ofthe use of his arm. He now has all the motions belonging to the arm except raising the deltoid, aud this he has to about one-quarter the natural extent, and it is improving. There is about an inch of shortening. The injured arm is considerably wasted, but there is no pain in it." The soldier was passed for the Veteran Reserve Corps, after having been pensioned from January 16, 1885, to March 18, 1867. He was discharged a second time, April 2, 1869, and pension continued. On examination for renewal of pension, Examiner G. S. Gale, of New York, reported, July 17, 1869 : "The ball fractured the humerus near the head of the bone, and resection was made, with loss of two inches of bone, shortening of arm, and loss of motion at shoulder joint; the hand is useful in light work." Examiner P. Tread- well, of New York, reported, December 21,1869 : " The arm is of little use." Examiner J. T. Ferguson, of New York, reported, January 12, 1870: "For purposes of manual labor the arm is useless; flexion of arm extremely limited; there is little power in contracting the hand." Examiner T. F. Smith, of New York, reported, September 9, 1876: * * * " There has been no reproduction of bone; arm and hand are useless for manual labor; disability total." Case 1473.—Private G. Dayspring, Co. H, 54th Pennsylvania, aged 26 years, was wounded at Piedmont, June 5, 1864. On December 7, 1865, he was admitted into Harewood Hospital, Washington. Surgeon R. B. Bontecou, U. S. V., reported: "Admitted suffering from gunshot wound, antero-posteriorly, of right shoulder, ball perforating head of right humerus. The patient was taken prisoner, but was recaptured by the Union forces and sent to hospital at Staunton; was again captured by the rebels and taken to Richmond, and was placed in hospital No. 21, where he remained three months; was then paroled and sent to St. John's Hospital, Annapolis, remaining under treatment two months, and then was transferred to Camp Parole Hospital, remaining two months, and was again transferred to the Clairy ville Hospital, and about one month after his admission to that hospital was discharged from the U. S. service. The patient states that repeated search was made for the ball at the above- mentioned hospitals, but with exceptions of some spiculse of bones which were removed at intervals, the ball could not be found. On admission to this hospital the constitutional state of the patient was tolerably good, but the wound discharging profuse sanious pus. The wound was carefully examined, and the ball found lodged and impacted in the upper part of the anterior border of the right scapula, near its neck; the ball was extracted by Surgeon R. B. Bontecou, U. S. V., in charge of hospital, December 18, 1865. Anaesthetic, sulphuric aether and chloroform. The patient is doing very well, parts granulating finely, with fair prospects of a good recovery. The patient has, for some months, been a messenger in the Q. M. G. Office, with good use of his arm, but was annoyed by the constant discharge, which induced him to seek relief at this hospital." This soldier was pensioned from the date of his discharge, March 27,1865, Surgeon J. B Lewis, U. S. V., certifying on his discharge: "Paralysis of right arm, by reason of gunshot wound of right arm near the shoulder." Examiner J. Phillips, of Washington, September 25, 1866, reported: "Gunshot wound of right shoulder joint; there is retraction of the muscles of the shoulder, and he cannot raise the arm far from the side. The movements of the elbow and wrist are perfect." In September, 1889, Examiner W. W. Potter reported: "Portions ofthe humerus and scapula have exfoliated, and the movements of the joints are very much circum- scribed;" and in March, 1870, certifies that: "A number of cicatrices exist, evidencing necrosis of the humerus and exfoliation. Crepitus now present at acromio-clavicular articulation." On August 5, 1874, Examiner H. Richings reported that there was then almost complete anchylosis of the joint, there being the least possible motion discernible." This pensioner was paid to September 4, 1874. A photograph of the pensioner, made at the Museum in 1871, is numbered 306, Surgical Photograph Series. Case 1474.—Private B. Ockert Co. A, 103d New York, aged 30 years, was wounded at Antietam, September 17, 1862, and was treated in a farm house near the field for two weeks; thence removed to the Ninth Corps Hospital at Locust Point, where he remained under treatment until January 18, 1883. Surgeon T. H. Squire, 89th New York, reported: "A musket ball entered the skin just below the point of the acromion on the left shoulder, and came out in the hollow corresponding to the outer concavity of the clavicle, shooting over a couple of inches of skin, entering again near the middle of the clavicle, fracturing the bone at its most prominent point, and, passing on, grazed the skin of the next, doing no further damage. The shoulder joint does not appear to be opened, and the compound fracture of the clavicle seems to be the most serious part of the injury. The lungs are not implicated; patient doing well. Subsequent observation makes it conclusive that the cavity of the shoulder joint was opened. December 31st: to-day, with a small but 6trong forceps, I removed a piece of bone seven-eighths of an inch iu length and a half an inch in width from the inside wound at shoulder. It was doubtless the acromial end of the clavicle." He was transferred to hospital at Smoketown, Maryland. On April 27th, the patient was sent to hospital No. 1, Frederick. Assistant Surgeon R. F. Weir, U. S. A., reported: A rifle ball entered the shoulder half an inch external to the coracoid process, passed through the anterior portion of the joint, fracturing the head ofthe humerus, emerging two inches below the acromial end ofthe clavicle, fracturing this bone, and emerged at the anterior aspect of the neck. He remained all night on the field, was removed next day to a barn, and from thence to a farm house, where he remained two weeks. Patient states that several portions of bone were removed from the clavicle. The shoulder was paralyzed. The patient was removed to Locust Spring Hospital, where he remained three months; fragments of humerus and clavicle were removed from time to time. On admission to this hospital the wound over the clavicle was nearly closed; wound of joint healed : complete anchylosis of the shoulder exists. The patient is otherwise in good health." The patient was transferred to Jarvis Hospital, Baltimore, on June 16th, and was discharged the service July 20, 1863, for anchylosis of the shoulder consequent on the injury, and pensioned. Examiner W. W. Potter, Wash- ington, D. C, June 16, l87<>. reported: "Complete anchylosis of the left shoulder joint from a gunshot fracture of the head SECT. III. | WOUNDS OF THE SHOULDER JOINT. 507 of the humerus, with one and a half inches shortening of the arm. The middle third of the left clavicle was fractured at the same time, and some deformity of that bone now exists." Examiner R. G. Jennings, of Little Rock, reported, September 4, 1873: "Left arm two inches shorter than the other. Shoulder joint anchylosed; arm weak; muscles soft and flabby." This pensioner was paid June 4, lt-74. Cask 1475.—Private A. Boniface, Co. E, 140th Pennsylvania, aged 41 years, was wounded at Spottsylvania, May 12, 1864. Sent from a Second Corps hospital, three days afterward, to Washington; he was furloughed from Lincoln Hospital, and on October 19th received at a hospital at Pittsburg, where Surgeon J. Bryan, U. S. V., recorded: "A gunshot wound of the left shoulder, fracturing the scapula, clavicle, and humerus." This man was discharged December 29, 1864, for "Paralysis of arm ; ball entering upper portion of the left shoulder, and making its exit at the posterior surface of the scapula," and pensioned. The Pension Examining Board of Pittsburg reported, September 6, 1873: "Ball entered over acromial process of left shoulder, fracturing it, and passed out over the scapula. Power to elevate ami impaired; disability one-half." Examiner James J. McCormick, December 3, 1873, reported: "The form of the shoulder is changed. The arm can be raised only to a horizontal position. It can be drawn forward but not backward. The arm near the axilla measures half an inch less than the right arm." This pensioner was paid June 4, 1874. Case 1476.—Private B. Hilt, Co H, 20th Maine, aged 19 years, was wounded at Gettysburg, July 2, 1863, and was sent . to Satterlee Hospital on July 11th. Surgeon I. I. Hayes, IJ. S. V., noted: "Gunshot wound of the head of the left humerus." Acting Assistant Surgeon W. W. Keen, jr., made the following official report:- "The patient, occupation, farmer, in service one year, was admitted to Ward No. 2, July 11, 1863. A ball entered the arm externally one and a half inches below the acromion, and emerged under the middle ofthe left clavicle, completely shattering the head of the humerus. He states that no special inflammation followed the wound, and that prior to his admission nothing had been done save that cold water was applied. He had spit no blood. On admission the .wound of entrance was small, and not very freely open to the head of the bone; the wound of exit was large and deep. The clavicle was partially exposed on the anterior and inferior aspect, and granulating admirably. His strength was good; pulse rather quick, but good; ordered extra diet and milk twice daily; bandaged the arm to the chest to insure quiet, and inserted a sponge tent into the wound of entrance and applied cold-water dressings. July 18th, the discharge has been healthy, but his strength seems failing; he can only sleep sitting up, and his shoulder 'feels heavy.' The wound of entrance I dilated still further by the knife, and removed several loose pieces of bone; one piece covered with articular cartilage; ordered milk diet, punch, and egg-nog, and elevated the arm by a sling to relieve the 'weight' complained of. July 19th, pulse 123 and pretty good; appetite good; ordered tincture of chloride of iron, fifteen drops, and sulphate of quinia, two grains, three times a day, with three-eighths of a grain of morphia at night. July 22d, the pus is burrowing anteriorly above the axilla and in front of the joint. Made a counter opening down to the head of the bone, evacuating considerable pus, and removing some fragments of bone. August 1st, removed more bone; wounds are remarkably healthy. The exposed portion of the clavicle is pinkish and is being covered by the soft parts; the pus is abundant aud healthy, and his strength, appetite, and pulse are all improving." The patient was transferred to Cony Hospital, Augusta, June 17, 1864, and was discharged from service November 23, 1864—"gunshot fracture of the head of left humerus; disability total," being noted on his papers. Examiner James B. Bell, of Augusta, January 31, 1865, reported: "Complete anchylosis of the shoulder joint; wound still open and discharging freely; arm at present entirely useless, but its usefulness in time will be partially regained." Examiner F. G. Parker, Presque Isle, Maine, September 8, 1873, reported: "Wound of entrance two inches below and behind the head of the left humerus, fracturing that bone, and passing beneath the muscles; exit beneath the margin of and fracturing the clavicle. There are also cicatrices where pieces of bone have been extracted; general weakness of entire joint, and much atrophy of the muscles." The disability is rated total. This pensioner was paid June 4, 1874. Case 1477.—Private W. Heckles, 106th New York, aged 22 years, was wounded at Monocacy, July 9, 1864, and two days after sent to Frederick. Assistant Surgeon R. F. Weir, U. S.'A., reported: "Wounded by a minie" ball, which entered the right arm, posteriorly, at about the junction of the upper and middle third, and, the arm being elevated in the act of firing, passed obliquely forward, badly comminuting the humerus, and grazing the anterior rim of the glenoid cavity anteriorly, and emerged at a point about half an inch below and three inches from the humeral end of clavicle. Patient's general condition was good, his health robust. The wound of entrance was immediately enlarged, and all the loose fragments, several in number, removed, after which an angular tin splint was applied, having an opening iff the bottom, through which dressings were applied to the wound aud the pus allowed exit. The splint was suspended by cords from the cross-ties of the barrack. In this condition the patient continued, suffering no other complications than burrowing of pus through the tissues iu proximity to the wound, relieved always by free incisions, and the occasional exfoliation of small fragments of bone, until furloughed, February 9, 1865. At this date, necrosis was going on in the head and upper third of the humerus, small fragments of which had been removed. There was very slight motion in shoulder joint, indication of permanent anchylosis." This soldier was discharged May 9, 1855, and pensioned. Examiner H. C. Austin, of New York, reported, May 23,1855: "There is total loss of use of right arm, * * with anchylosis ofthe shoulder joint." Examiner B. F. Sherman, of Ogdensburg, reported, March 27, 1868: "Anchylosis ofthe shoulder joint, and disease of the shaft of the humerus, from which there is now, and has been most of the time, a constant discharge. Disability total." This pensioner was paid December 4, 1873. Case 1478.—Sergeant C. E. Sprague, 44th New York, aged 30 years, was wounded at Gettysburg, July 2,1863. Surgeon A. J. Ward, 2d Wisconsin, reported a " shot wound of the left shoulder." The patient was transferred to Camp Letterman, July 31, and to Satterlee, October 12th, where Acting Assistant Surgeon W. B. Jones recorded that "a minie ball entered the centre of the left shoulder joint anteriorly, passing backward and outward, emerging at the posterior part, completely shattering the head of the humerus. A few splinters of bone had been removed prior to entrance. A large abscess formed at the middle of left arm and was opened. August 5, 1863: Several large spiculae were removed from the anterior wound. August 10th: Several more large fragments were removed from both wounds. Upon probing, it was found that nearly the entire head and Burgical neck Were wanting." At four different dates, in August and September, like operations for removal of bone fragments 508 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. Fig. 367.—Cicatrices after a shot perforation of the left shoulder. [From a photograph.] are recorded, and, on October 3, 1863, the removal of "three large spiculae, part ofthe shaft, of the humerus," is reported. This soldier was discharged March 11,1^64, for "loss of left arm. Disability total." Examiner P. Stewart reported, August 4 1867: "Entire anchylosis of left shoulder joint, with considerable deformity." Examiner T. F. Smith, of New York, reported September 17, 1873: "Extension of shoulder joint limited, seven-eighths; muscles are atrophied; strength of arm materially diminished; disability total." This pensioner was paid December 4, 1873. Case 1479.—Lieutenant D. H. Cortelyou, Co. E, 6th New York Cavalrv, aged 22 years, was wounded at Bottom Bridge, June 3, 1884. He was sent to Armory Square Hospital, Washington, on June 10th. Acting Assistant Surgeon D. C. W. Van Slyck reported: "Gunshot wound of the neck and left shoulder by a musket ball, which entered the right side of the neck, at the base, and was extracted, on the field, from the outer aspect of the left shoulder. On June 13th, Surgeon D. W. Bliss, U. S. V., examined and probed the wound. The upper border of the left scapula was found to be shattered. A counter opening was made in the left supra-scapular space, and exit thereby given to a gathering of pus. Dr. Bliss was unable to decide at this time whether or not the shoulder joint was involved. On June 25th, a counter opening for exit of pus was made on the anterior aspect of the left arm two inches below the shoulder joint. Patient has had persistent diarrhoea since admission." On July 26th, Lieutenant Cortelyou went on a leave of absence. On November 24, 1864, he entered the Officers' Hospital at Annapolis. Here Surgeon B. A. Vanderkieft, U. S. V., removed, on several occasions, necrosed fragments of bone, constituting, according to the report, the major part of the head of the humerus. On March 18, 1865, the lieutenant was discharged the service. In December, 1867, he visited the Army Medical Museum, and a photograph was made, to illustrate the appearance of the injured shoulder. This photograph is copied in the adjacent wood-cut (FlG. 387). He had then a very useful arm. He was commissioned in the Ninth Cavalry, May 15,1867. He was promoted to a first lieutenancy, July 31, 1867. This officer was placed on the retired list, with the full rank of a captain of cavalry, December 15, 1870, on account of disabilities resulting from wounds received in action, in conformity with the act of Congress of August 3, 1861. (See Army Register, 1874, p. 168.) Acting Assistant Surgeon J. H. Longenecker, who had charge of the case at Annapolis, mentions that another abscess formed, in the early part of January, 1865, which, when incised, discharged over twenty ounces of pus. The photograph from which the cut is copied is 191 of the Surgical Series. Case 1480.—Corporal J. C. Hilberg, 5th Maryland, Avas wounded at Antietam, September 17, 1862, and sent to Camden Street Hospital on September 21st. Acting Assistant Surgeon E. G. Waters recorded: "A minie" bullet entered the left shoulder one and a half inches above the anterior fold ofthe axilla and one inch from the margin ofthe glenoid cavity, passed downward and outward, fracturing the bone at the surgical neck, extensively comminuting the shaft, and lodged under the integuments, on the outer aspect of the arm, six inches below the joint. The ball was extracted on the same day, and the arm sustained in a splint. September 23d: The arm was immensely swollen near the seat of injury, the tissues livid, and pus had accumulated in quantity. This was relieved by a free incision, and bran and yeast poultices." From a more detailed printed report of this case,1 it appears that, two weeks after the opening of the abscess, "lateral splints were applied, and the forearm was supported, iu a sling. In two months, union had become firm. February 6, 1863, the discharge had ceased; union firm, without super- abundance of callus. The contour ofthe arm was natural and the tissues healthy in appearance." The patient was transferred to Hammond Hospital, July 3, 1863. Assistant Surgeon G. McC. Miller, U. S. V., reported, August 18, 1883: "An abscess on the inner side of the arm, near the original wound." This was opened, and a large quantity of thin, fetid pus escaped. The abscess was reported healed on July 28th, but discharge was going on from the original wound. This discharge continued until October 28, 1853, when Surgeon A. Heger, U S. A., removed two pieces of dead bone, each about an inch in length, "cribriform, flat, and irregular in outline." On January 14, 1864, the patient was sent to Convalescent Camp. He was discharged April 29, 1834. and pensioned. Examiner W. H. Clendenin, of Baltimore, reported, October 22, 1858: "A wound, now open, on the left arm, near the shoulder. The ball entered the pectoralis major muscle, then passed through the axilla, traversing the deltoid and biceps muscles, shattering the humerus in its course. Wasting of the muscles and loss of power in the arm. Slight contraction of the fingers. Occasional neuralgia. Small spiculae of bone have passed, and more, I think, will come away." Examiners H. W. Owings, C. H. Jones, and A. W. Dodge reported, September 17, 1873: "Ball entered the inner triangle of. the left shoulder near the acromion process, and made its exit on the anterior aspect of the left arm, causing a compound fracture of the humerus, upper third, and necessitating a resection of four inches of bone. Cicatrix extensive and adherent to bone. I'se of arm very much impaired. Disability total." This pensioner was paid December 4, 1873. At the Pension Bureau, many cases are reported as excisions or resections that were examples merely of elimination or extraction of necrosed bone. Doubtless it is often difficult for the pension examiners to decide, at a period remote from the injury, on its precise nature; and an opinion is formed from hearsay, that may sometimes be contradicted 1 Daue (G. H.), Conservative Treatment in Gunshot Fractures, in Am. Med. Times, 1801!, Vol. VI, p. 209. SECT. III.] WOUNDS OF THE SHOULDER JOINT. 509 by conclusive recorded evidence. The case just reported, for example, has been cited as an illustration of tho propriety of abstaining from operative interference in some shot fractures of the shoulder. At the close of the subsection some remarks will be found on the expectant treatment of shot fractures at the shoulder. The next case introduces, incidentally, an ingenious apparatus (Pio. 388) improvised by Dr. George C. Harlan, and successfully employed in a shot comminution of the head of the humerus: Cask 1481.—I'rivate D. M. Moore. Co. I, 11th Pennsylvania Cavalry, aged 25 years, was wounded at Franklin, March 17, 1863, and was treated in the regimental hospital until April, when he received a furlough, upon the expiration of which he returned and served with his regiment until discharged, August 13, 1865, and pensioned. Surgeon G. C. Harlan, 11th Penn- sylvania Cavalry, made the following special report: "Wounded, while charging the enemy's pickets, on horseback. Gunshot wound by minie ball in right shoulder. Examined a few hours afterward at the regimental hospital in Suffolk. Compound comminuted fracture just below the neck of the right humerus. Bone much shattered, but vessels uninjured. Head of humerus entirely separated from shaft, and several small fragments lying loose between them. Shaft of humerus fissured below the wound, and head apparently split into several pieces. Ether was administered, and the injury carefully and thoroughly examined in consultation with Surgeons Hand' Humphreys, and Kncelaud. After some hesitation it was decided not to resect for the following reasons: It could not be determined that the joint was actually opened, as the fracture did not appear to extend through the cartilage. The injury extended so low that at least, four inches of the bone would -have been lost by an operation; the patient was young and healthy and in a favor- able condition for treatment, and should a secondary operation be necessary there would be a better chance of preserving the periosteum, loosened by suppuration, and reproducing bone. Cold-water applications were accordingly made. The next day tliere were constant oozing of blood, a good deal of tumefaction, and great pain at the slightest motion. To secure perfect rest and favorable position I applied along narrow splint to the outside of the arm, extending from a point four or five inches below the elbow to the wound, and con- tinued by an iron bracket to a point four or five inches above the shoulder, making extension from the first point by means of strips of adhesive plaster applied to the lower third of the arm, and counter-extension from the second by strips applied to the chest and back obliquely, and passing over a block above the acromion. A bandage was lightly applied over the arm and a splint from the elbow to the wound, which was left open for the application of cold-water dressings. This was frequently removed without disturbing the position of the limb. March 19th, oozing of blood much diminished; no increase of swelling; pulse a little accelerated; very slight febrile action. Scarcely any increase of temperature locally; no pain. 20th, scarcely any change; ordered sulphate of magnesia in small and repeated doses. 21st, skin aud pulse natural; bowels freely moved; a good deal of sanious discharge from the lower wound; applied poultice to this, and continued cold-water dressing to arm and shoulder. April 1st, suppuration well established, moderate, and healthy; several small pieces of bone extracted from the lower opening to-day; he has had little or no pain, and sleeps well without anodyne. April 9th, more bone extracted with forceps; to have ale at dinner, l^th, sitting up; discharge decreasing; some union of fracture. A few days after this date he was sent to his home in Pennsylvania on thirty days' furlough, and on his return was detailed as mail .carrier.. He continued upon this duty until the regiment was mustered out, after the war. There was almost constantly a slight discharge from the wound, and occasionally small pieces of bone were removed, only one requiring an excision. November 9, 1367, called at my office to-day; says his arm has given him very little trouble since he left the army; is now milling, but has been employed in farming, ploughing, etc. The last piece of bone came away about a year ago; can raise the arm to a right angle with the body, but not higher, from want of sufficient power in the deltoid; perfect motion in every other direction. On superficial inspec- tion no signs of the injury but four small scars, and a slight atrophy of the deltoid. No shortening of the arm was detected by careful measurement. A piece of lead the size of a split pea just underneath the skin about the insertion of the deltoid, and another lower down a little deeper. No tenderness produced by either." Examiner P. S. dinger reported, April 23, 1855 : "Was struck in the right arm, the ball penetrating near the shoulder joint and fracturing the os humeri. Anchylosis of shoulder joint; muscles agglutinated; wound open." A Board, convened at Lancaster, composed of Drs. W. Blackford and W. R. Grove, September 3, 1873, reported: "Wound open; arm emaciated." This pensioner was paid June 4, 1874. Case 1432.—Private B. Delihan, Co. I, 8th Louisiana, aged 28 years, was wounded at Petersburg, April 2, 1865. On May 12th, he was admitted into Hammond Hospital, Point Lookout, from Richmond. Surgeon G. L. Sutton, U. S. V., noted a "gunshot flesh wound of left shoulder." He was transferred to Armory Square Hospital in July, to Stanton Hospital in August, and finally to Harewood, where Surgeon R. B. Bontecou, U. S. V., reported: "Admitted, September 13, 1855, partially convalescent from gunshot wound of the left shoulder, the ball passing through, shattering the head of the humerus. On admission to this hospital the constitutional state of the patient and condition of injured parts were tolerably good; wounds still discharging pus and small fragments of dead bone. No operation was performed in this case, and it apparently was left to nature; patient is able to be about, and, although he has as yet no use of the left arm, the prospects of his having a good and useful limb are very favorable. The articular surfaces of the shoulder joint are not injured." The patient was released February 6, 1836, through the Provost Marshal. It has been observed, on page 503, that about one-third of the shot injuries involving the shoulder joint, that were treated on the expectant plan, proved fatal; and the subject Fig. 388.—Har- lan's bracketed splint for fractures of the upper ex- tremity of the hu- merus. [From a drawing ] 510 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. would be imperfectly illustrated without detailed accounts of some of the fatal cases. There was, of course, great diversity in the nature of these injuries. In some, the bones near the joint were shattered or fissured by large'projectiles, or their fragments; in others, missiles from small-arms penetrated the joint, grooving or comminuting the articular extremities, sometimes remaining impacted in the humerus or scapula, or embedded in tbe soft parts, but more frequently perforating the joint. Case 1483.—Private A. L------, Co. A, 95th New York, aged 21 years, was wounded at Spottsylvania, May 12, 1834. First treated in hospital at Fredericksburg, he was sent, on May 28th, to Lincoln Hospital, at Washington. Acting Assistant Surgeon A. Ansell recorded: "The patient, when admitted to my ward, was exceedingly emaciated and low from the excessive discharge which was taking place from the wound. He stated that the ball had hitherto eluded discovery, and I unsuccessfully endeavored to discover it. He had good, generous diet, quinine, and iron, yet he gradually sank, and died on June 23d. He had no signs of pyaemia." Acting Assistant Surgeon H. M. Dean made an autopsy, and furnished the following notes: "He had been wounded by a minie ball entering three-fourths of an inch below the steruo-clavicular attachment of the left clavicle, passing outward to .the left, and backward over the second rib, and was found embedded in the upper portion ofthe left humerus, anterior surface, close to the groove which receives the long head of the biceps muscle. The head of the humerus was found to be eu'tirely denuded and carious; as was also the articulating surface of the left scapula. A large cavity beneath the left scapula was found filled with a sanious pus. On opening the thoracic cavity, the right lung was found attached to the wall by slight fibrous adhesions, apparently recent; lower posterior portion of the right lung was congested; the rest of the lung was healthy. The posterior portion of the left lung was also congested, and in the anterior portion a few small abscesses were found; the rest of the lung was healthy. The right auricle of the heart contained a large black clot extending down to the ventricle, which became more fibrinous. The left ventricle contained a small black clot; * * spleen healthy; liver apparently healthy; brain healthy. The rest of the organs not examined." The specimen (FlG. 389) consists of the superior third of the left humerus six weeks after injury. "A conoidal ball, which entered three-fourths of an inch P , ., .. below the sternal attachment and passed over the second rib, is embedded in the humerus near the impacted in the head of bicipital groove. A piece of cloth driven before the bullet yet lodges with it. The articular surface is 2686.e iumerus" pec% carious, the shaft is necrosed in the line of fracture below, and there is no attempt at repair."—(Cat. Surg. Sect., A. M. M., 1883, p. 94.) Dr. Dean was the contributor. Case 1484.—Private Henry C. S------, Co. C 116th Illinois, aged 20 years, was wounded at Vicksburg, May 22, 1883, and was sent to Memphis on the hospital steamer City of Memphis, Surgeon W. D. Turner, 9th Illinois, in charge, noting a "gun- shot wound of the left shoulder." The patient was admitted into Gayoso Hospital on May 27th. Assistant Surgeon W. Watson, U. S. V., made the following record ofthe case: "Wounded bya round ball through the posterior border of the deltoid, ranging downward and forward, shattering the head of the left humerus. There had been an incision three and one-half inches long through the deltoid for excision of the head of the bone, in which union by first intention had already taken place. It had been closed by sutures and adhesive straps, and was in excellent condition. The patient stated that the operation was performed on May 22d, and two inches of the head of the bone were then removed. The prominence of the acromion process and an, apparent depression below it seemed to verify the statement, and, as the patient complained when it was handled, no further examination was deemed necessary. The wound was dressed with simple cerate and adhesive straps, and the arm supported by a broad sling. The symptoms continued favorable until June 8th, when the man had rigors aud fever, with symptoms of inflammation, which soon developed itself, forming an abscess on the inner side of the shoulder, which pointed and was opened just below the outer third of the clavicle; pus to the amount of six ounces was evacuated. The symptoms were relieved, but there was still some swelling ofthe arm; some diarrhoea. June 14th, another abscess is forming in the lower third ofthe arm; the discharge is very free from the opened abscess, but very little from the incision through the deltoid. Diaphoretics were administered, a solution of creasote injected into the abscess, and a pill containing two grains of opium and one grain of camphor given every four honrs to check the diarrhoea. June 19th, abscess opened and eight ounces of pus discharged; treatment continued. 20th, erysipelas made its appearance; considerable swelling about the elbow; patient looks haggard and exhausted. Twenty drops of muriated tincture of iron every two hours, with one ounce of wine, were given; tincture of iodine was applied to the arm, and compound solution of bromine injected into the wound. 21st, disease stationary; arm discharging freely; tongue dry; treatment continued. " 22d, symptoms unchanged, but general appearance of the patient is better. 27th, erysipelas has entirely subsided; the discharge is very free, and evidently from dead bone. Pills of citrate of quinia and iron were given every four hours; the wine was increased to two ounces, and tLe.abscesses were injected with the solution of creasote. 29th, the patient is slightly improved in his general appearance; treatment continued. July 3d, patient has failed and is now losing his appetite. Continued the pill of quinine and iron, and gave two ounces of whiskey every two hours. The treatment was continued, but the patient gradually failed until July 8th, when he died. Post-mortem examination showed that the head of the bone had been injured but not removed; the joint was entirely disorganized; the head of the humerus sphacelated, as also the glenoid cavity of the scapula. I am inclined to the opinion that had the excision been performed when the inflammation first developed, the chances of saving the man's life would have been increased." Dr. Watson forwarded the pathological prepara- tion, which consists of the "head of the left scapula and the upper portion of the humerus. A round bullet passed through the head of the humerus, which, in the specimen, is necrosed and much absorbed. The glenoid cavity is eroded and enlarged. The greater tuberosity is more spongy than natural, and numerous small foramina perforate every portion above the epiphyseal line."—(Cat. Surg. Sect., 1866, p. 95.) The specimen is numbered 2083 of the Surgical Section. SECT. III.] WOUNDS OF THE SHOULDER JOINT. 511 Tlie instances of shot injuries interesting the shoulder joint and chest cavity simul- taneously were not infrequent; but patients rarely survived such lesions,1 and the following mention of a case that did not terminate fatally until seven weeks after the reception of the injury may be regarded as exceptional: Case 1485.— Private William A------, Co. A, 1st Delaware, aged 30 years, was wounded at Farmville, April 7, 1885. He was removed from the field to City Point, thence to Annapolis, and on May 11th was transferred to Baltimore. Assistant Surgeon DeWitt C. Peters, U. S. A., reported: "Admitted to Jarvis Hospital May 12th, with a gunshot wound of the right shoulder. On admission, the original wound, which was about an inch below the acromial process of the scapula, was nearly healed, but there were several otlier openings which discharged a considerable amount of pus, and there was considerable burrowing of pus under the scapula and adjacent muscles, which discharged freely on pressure. Crepitus could easily bo detected in the joint, and tliere being a point of entrance and none of exit of the ball, together with the presence of symptoms of pneu- monia, it was supposed that it had fractured the humerus and lodged in the pleural cavity instead of lodging iu the muscles. About May 20th, his shoulder and arm were attacked with erysipelas, which was exceedingly obstinate, and finally extended to his mouth and fauces. All these symptoms grad- ually grew worse, until he died, May 28, 1835. An autopsy was made, twenty-four hours after death. On examination, the left lung was found very large, as though distended with air, but tho substance of the lung was normal. The lower lobe of the right lung was found hepatized, and the upper lobe intensely congested. The external border of the upper lobe was found to contain a cicatrix, evidently made by the ball in its course, and further examination revealed a mini6 ball in the right pleural cavity. The heart, liver, spleen, and kidneys were in a normal condition. Examination ofthe wound shewed that the head of the humerus had been pierced by the ball, disorganizing the glenoid cavity, fracturing the coracoid process ofthe scapula, and entering the right pleural cavity between the second and third ribs." Dr. Peters contributed the specimen, which is imperfectly represented in the adjacent wood- cut (Fig. 390), of the upper third of the right humerus. Dr. Woodhull remarks (Cat. Surg. Sect, Fig. 3S0.—Head of humer- 1866, p. 95): "The anterior portion of the head is carried away. * * The head is thoroughly "^x^s2m"S'10tlraC" carious." Surgeon D. W. Maul!, 1st Delaware, from a Second Corps hospital, Acting Staff-Surgeon J. Aiken, from City Poiut, and Surgeon B. A. Vanderkieft, U. S. V., from Annapolis, give brief reports of the early history of the case, mentioning, however, no particulars that are not comprised in the report from Jarvis Hospital. The four following are examples of fatal results from shot fractures implicating both bones of the scapulo-humeral articulation ;s the scapula suffering most in all. Three of the patients perished from pysemic* infection, and one appears to have succumbed from haemorrhage from the subscapular artery: Case 1486.—Private I. M. F------, Co. B, 12th New Hampshire, aged 34 years, was wounded at Chancellorsville, May 3, 1853. He was sent from a Third Corps hospital on May 9th to Harewood Hospital at Washington. Surgeon T. Antisell, U. S. V., recorded: "A fracture of the head of the humerus, the glenoid cavity, acromial process, and spine of scapula." Acting Assistant Surgeon W. A. Harvey reported more minutely: "A gunshot wound by a niiniJ, and admitted into hospital No. 1, Frederick, on tbe 25th. Acting Assistant Surgeon W. XV. Keen, jr., furnished the following notes of tbe ease : " A ball entered two inches below the spine of the scapula and emerged one inch and a half below the acromion, shattering the head and upper part of the neck of the humerus. October 10th : Great oedema of the arm, for which two lateral incisions six inches in length were made ; he had also a very bad bed-sore when he came under my charge. this date. October 19th : The arm has been bandaged up to the shoulder, with but little effect; no union has taken place, but his general condition is evidently improving. Iron, quinine, and stimulants were given, and the bed-sore was poulticed. October 26th : The slough is separated from the bed-sore ; the arm is in a rather befter condition ; his general health is better. He was placed two days ago on a water-bed. November 1st: Patient complained this morning, for the first time, of a pain in the right chest; on percussion, dulness of both upper and lower parts of the right lung was found, and, on auscultation, crepitus corresponding to dulness and bronchial respiration. Solution of acetate of ammonia, syrup of ipecac, and morphia were given, with brandy and water more freely. November 2d: The dulness has extended throughout the entire right lung, with large mucous idles corresponding heard rather faintly, and crepitation has begun in the lower lobe of the left lung; sputum rusty, pulse 120. and very feeble; respiration only 20, but labored. Diagnosis: Pneumonia with oedema and pleurisy; ordered dry and wet cups, and stimulants more strongly. After noon he sank more rapidly from the oedema, which greatly increased, and at seven ti'clock P. M. the patient died. Autopsy eight hours after death: Tbe right pleural cavity was filled with nearly a quart of serum and lymph. In the right lung there was an old tubercular cavity at the apex, as large as a walnut, with miliary tubercles throughout the upper lobe, as proved by the microscope; an abscess was found at the lower part of the lung; nearly all the rest of the organ was filled with serum, and sank in water. The lower portion of the left lung also sank in water. The heart was normal, but about one ounce of serum was found in the pericardium. The head of the humerus was found to be shattered and, in part, pulverized, and it was split for some three inches downward. The lower edge of the glenoid fossa was also splintered off and the cartilage gone entirely from its surface. Amputation had been deferred only because the patient's strength was not sufficient at any time to warrant it." The specimen (FlG. 393) consists of the upper half of the left humerus, one and a half months after injury. The head and surgical Fig. 39:).-Shot neck are shattered, and an oblique fracture, with little comminution, extends two inches down the shaft. The fracture of head .... i i i- /> ^ • -i i i • ■ of left humerus. head is carious and the line of fracture is bordered by necrosed bone, but there is no attempt at repair, except- Spec. 811. ing a minute deposit of callus at one point. It was contributed by Acting Assistant Surgeon W. W. Keen, jr., and the description is given in the Catalogue Surgical Section, 1863, p. 95, by Assistant Surgeon A. A. Woodhull, U. S. A. In the following, as in Case 1487, hsemorrhage was the immediate cause of death. In seventeen of the five hundred and five cases, mention is made of serious bleeding from the subscapular, suprascapular, and circumflex, or other large arterial branches; fourteen of these cases terminating fatally—all instances of intermediary hsemorrhage. Case 1491.—Private G. T. B------, Co. B, 12th South Carolina, was wounded at Gettysburg, July 2, 1863, and sent to Chester Hospital. Assistant Surgeon Brinton Stone, U. S. V., reported: "Admitted, July 9th, from the battle-field of Gettysburg. The wound was diagnosticated as implicating the shoulder joint. The patient's condition not justifying an operation, supporting treatment was resorted to, and he gradually improved until July 22d, when secondary haemorrhage occurred, apparently from a branch of the axillary artery. It was controlled by pressure; next day the haemorrhage returned, but was controlled; but owing to the loss of blood the patient died of exhaustion on the same day. The post-mortem examination revealed complete disorgan- ization of the shoulder joint. The anterior circumflex artery was found to have been opened by ulceration." The specimen is described by Dr. Woodhull (Cat. Surg. Sect, 1866, p. 94, No. 2068) as "The upper half of the right humerus, grooved in the greater tuberosity and posterior part of the head by gunshot, three weeks after the injury. The articulating surface is thoroughly disorganized. A fissure on the posterior portion of the shaft is curiously and delicately bordered by necrosis." The catalogue accredits the specimen to Dr. Fisher, but it appears to have been simply forwarded by him. The preceding abstracts (1470-1491) fairly represent the reports received of the five hundred and five cases of shot fractures at the shoulder, treated on the expectant plan. There will be an opportunity hereafter to compare the results with those of cases treated 1 MacCokmac (W.) (Notes and Recollections of an Ambulance Surgeon, 1871, p. 96) meniions this remark as made to him personally by the celebrated Generalstabsarzt StkOMEVEU, who had a Feld-Lazarelh at Floing, near Sedau, in September, 1870. 2 Hamilton (F. H.) (A Treatise on Military Surgery, 18G5, p. 392) observes : " In case a ball has entered the humerus near the shoulder joint, and it is proposed to save the arm without resection, the external wound should be made free, tho small loose fragments should be picked out carefully; and, for the rest, the case should be treated in the manner best calculated to prevent inflammation. Sutures, adhesive straps, bandages, and splints are inadmissible. Absolute rest and cool-water lotions are the important remedial agents. * * In general too much has been attempted; the bandages have been applied too tightly and perseveringly, and sometimes at the sacrifice of the limb. We employ, usually, in these cases a single splint, made of felt, leather, or gutta percha, long enough to extend over the top of the shoulder on the one hand and to the lower part of the elbow joint on the other, and broad enough to encircle one-third ofthe circumference ofthe arm." 65 r,l 1 INJURIES OF THE UPPER EXTREMITIES. [CHAP IX. by excision or amputation. Here, however, it should be remarked, that the small mortal- ity (of less than a third) given by the returns, as the result of expectant measures in shot fractures at the shoulder, must be considered with reference to the fact that the cases of least severe injury were usually selected for this mode of treatment. In analyzing the reports of the one hundred and thirty-nine fatal cases, it was found that the immediate cause of death was referred to pyaemia in thirty-seven instances,—to haemorrhage in fourteen,—to hospital gangrene in seven,—to phlegmonous erysipelas in five,—to tetanus in five. Nearly half of the fatal cases are thus accounted for. Of the remainder, some appear to have died from the effects of protracted suppuration, some from "surgical fever," others from intercurrent pulmonary disease; while, in many instances, no indication of the cause of death is assigned. In thirty-five of this series of cases, there were extractions of necrosed fragments of bone. In several of these, the missile, portions of clothing, or other foreign bodies were likewise removed. Six of these belong to tlie group of fatal cast's. Judging from the published reports of Confederate surgeons, in many instances necessarily hasty and fragmentary, as all battle-field returns must be, expectant measures after shot fractures at the shoulder were rarely trusted to by medical officers of the southern armies.1 The question whether excision or amputation afforded the best means of pre- serving life was mainly considered, and the possibility of a successful result without operative interference was seldom entertained. It was, indeed, at the date of the War, the generally accepted doctrine among military surgeons that a shot penetration of the shoulder joint involved the necessity of excision or of amputation;2 and, with less unanimity, this view is still maintained. While the naked statistics present the expectant method of dealing with shot injuries at the shoulder ■Read (J. B.) (Report on Wounds of Large Joints, made to the Confederate States Association of Navy and Army Surgeons, in the Southern Med. and Surg. Jour., 1866, Vol. XXI, p. 200). The reporter states that: " Gunshot wounds of the scapulo-humeral articulation are to be resected in all cases in which the head ofthe bone is injured, and the bloodvessels and nerves that pass to the arm are intact." After discussing excisions for shot injury, Dr. ItiOAD remarks (loc. cit, p. 200) : " Comparing the result of these cases with that of wounds of this articulation treated without excision, we find seventeen—three cures, six deaths, and five useless ankylosed limbs, and six cases in which the result is not stated." Some inadvertence or misprint must occur here, as twenty rather than seventeen cases are particularized. Such reports are misleading, ard distrust arises regarding the precision of the estimate on which may have been based the succeeding statement that: " The percentage is less than that given for amputations at the shoulder joint." McGuiliE (H.) (Clinical Remarks on Gunshot Wounds of Joints, in 7'lie Richmond Med. Jour., 1866, Vol. I, p. 148) observes: "Gunshot wounds of the larger joints almost invariably demand operative interference,'' and regards excision or amputation as the only alternatives in severe shot injuries at the shoulder joint. CllISOLM (J. J.) (A Manual of Military Surgery, 1864, p. 375), treating of shot injuries at the shoulder joint, discusses the relative advantages of excision and amputation, and regards excision or amputation as the only alternatives in severe shot injuries of the shoulder joint. WAKIIKX (E.) (An Epitome of Practical Surgery, 1863, p. 371) pronounces positively in favor of resection in compound fractures of the head of the humerus. NOTT (J. C.) (Contributions to Bone and Nerve Surgery, 18G6) and other Confederate surgeons who have written on shot injuries at the shoulder, refer to resections and amputations as the alternatives. Thus the anonymous compilers of A Manual of MHilary Surgery for the use of the Confederate States Army [reported to have been Drs. Talley, Peticolas, Peachy, and Duxx, medical officers actively employed in the Confederate hospitals] declared that: " If the shoulder or elbow joint be much injured, but the principal vessels have escaped, the articulating surfaces and broken portions should be excised." 2 Smith (S.) (Handbook of Surgical Operations, 3d ed., 1862, p. 208), a work "prepared at the suggestion of several professional friends, who early entered the medical staff of the Volunteer Army," reiterates, in a third edition, that " if the shoulder or elbow joint be much injured, but the principal vessels have escaped, the articulating surfaces and broken portions should be excised," restating the opinions cf many eminent authorities. Thus, Dui'UYTKEX (Lecons Orales de Clinique Chir., 1839, T. V, p. 476) teaches: "Quand une balle, en pen6trant dans une articulation en a d6chire largement les ligaments, laboure les surfaces osseuses. et brise ses surfaces en plusieurs fragments, les accidents inflammatoires les plus violents ne tardent point a arriver, et le malade y suecombe presque toujours ; aussi, le seul parti raisonnable a prendre dans ces cas-ld, c'est de pratiquer le plus tot possible l'amputation du membre, ou la resection des extreniites articulaires." Jobert (A. J.) (Plaies d'armes a feu, 1833, p. 23!;) declares : " En un mot, je n'ai vu aucune plaie d'armes a feu d'articulation, un peu etendue, pardonner aux blesses ; ils flnissaieut tous par succomber a 1 abundance de la suppu- ration et aux accidens inflammatoires, si une main hardie ne retranchait la partie qui etait l'origine de tant de maux." LAKUEY (H.) (Hist. chir. da siege de la citadelle (VAnvers, in Rec. de mim. de mid., de chir., &c, 1833, T. XXXIV, p. 282) writes : '" On avait etabli en prinoipe la neccssite de l'amputation dans tous les cas de plaies penetrantes des articulations par armes a feu, et ce principc, nialgre quelques faits cxceptionncls, s'est developpe dc jour en jour par I'experience." Ballingall (G.) (Outlines of Military Surgery, 5th cd., 1855, p. 396) observes : " Injuries of this joint from musket or grape sin.t are often a sufficient ground for the removal of the arm at its articulation with the scapula, or more frequently for the excision of the head of the humerus.'' Baudexs (Clinique des plaies d'armes a feu, 1836, p. 449) admits that "Quand, en pareille ciiconstance, on n'a pas eu recours il quelque operation chirurgicale, il survient des caries et des accidents articulaires qui a la longue sont mortels." Stromeyer (L.) [Maximen, u. s. w.. 18.VJ, p. C94) judges: 'According to my view, resection is indicated in every case in which injury of the bone with opening of the shoulder joint is ascertained." I.EGOl i:st (L.) (Traile de Chir. d'Armie, 18o:>. p. 624) said: "On pent dire que toutes les plaies des grandes articulations par les projectiles, nueessitent soit la resection, soit l'amputation immediate." Tlill'LKU (C. S.) (Handbook for the Military Surgeon, 1861, p 59) taught: "'If a wound of the humerus is limited to the head, exseet; if it extends to the shaft, amputate." It would be easy to multiply citations on this subject; but iterations will be avoided by presenting the comparisons between expectant measures, conservative treatment by excikion, and th« ultimate resource o, iilil itiia ofthe limb, at the coneln-ion of the Chapter sixt. in.] WOUNDS OF TTIK SlIOULDKli JOINT. 51 f) in a somewhat favorable light, a survey of the individual cases fails to increase our con- fidence in this mode of treatment. It is true that in more than two-thirds of the cases returned in this category, a happy result is alleged; yet, in some instances, the precision of diagnosis may be questioned; and, in others, such incisions and extractions of sequestra were made as were almost tantamount to excisions. There can be no question, however, that in exceptional cases of shot fraciuro al the shoulder, expectant treatment, under judicious supervision, may result most favorably. This had been surmised by Boucher, tSchmucker, and Guthrie; but few surgeons had the hardihood to abstain from amputation or excision. A remarkable example, however, is found upon the records of this office, in which, several years before the late "War, a good result was secured, in a shot perforation of the shoulder, without operative interference : Cask A1-.—Private Christopher C. Frnyser, Co. C, 1st Dragoons, aged 22 years, was wounded, May 27, 1856, at the Big Bend of Eogue River, in Oregon, in a fight with Indians. Dr. C. H. Crane, U. S. A., reported: "He was struck, at short range, bv a large round rifle ball of the so-called Harper's Ferry make. The head of the humerus was fractured, two or three pieces were detached, and the upper part of the shaft of the bone was broken in fragments. It was at first supposed that it would be necessary to amputate at the shoulder joint. But, owing to peculiar circumstances—the detachment being surrounded by a large number of Indians, and under fire for thirty hours; and as, furthermore, there was but little hsemorrhage, and but slight consti- tutional disturbance, nothing more was done than to remove all loose fragments of bone, pieces of clothing, and other foreign bodies, and to keep cold-water applications to the wound. This man continued to do well, and was transported, with other wounded men, by me, in a canoe, for a distance of fifty miles, on a river in which obstructions and rapids were numerous, and he had a rough transit. He was then transported over more than fifty miles of precipitous mountain paths, on mule-back, and, three weeks after the reception of the wound, he was placed, in good condition, in the post hospital at Fort Orford, Oregon. I saw him some months subsequently, at Fort Vancouver, Washington Territory, and his wound was nearly healed. He told me that a number of small pieces of bone had come away during the first two months; and that then the wound had healed. He had some use of his arm when I saw him. I afterward heard that he made a good recovery, and had an excellent use of his arm." Surgeon C. H. Laub, U. S. A., reported, from Fort Vancouver, that this soldier was discharged February 9, 1S.~>7. The records of the Pension Office show that lie went to his home in Fayetteville, North Carolina, and received his pension. The loss of the records of the Southern pension agencies, after the outbreak of the AVar, precludes the possibility of tracing the progress of the case. Dr. B. W. Robinson, of Fayetteville, wrote, in 1ST4, that the man had left that place. Scattered through the imperfect annals of military surgery, other instances may be found in which abstention from operative interference, after shot fracture at the shoulder, was judged expedient ;* but those in which the diagnosis was clearly made out, that had a favorable termination, are very rare; and the foregoing case has appeared to the compiler 1 Although the later have been numerous, some of the earlier were important. Among them is one related by DortSEY (J. S.), who, after remarking (Elements of Surgery, 1818, 2d ed., Vol. II. p. 312) that "injuries from musket balls penetrating the capsular ligament, attended with frac- ture and destruction of the head and adjacent parts of the humerus, and wounding the axillary artery, require immediate operation." states that "General Scott, of the United States Army, happily recovered from such a wound, and has a very useful arm." Whatever skepticism military surgeons of the present day may entertain, regarding the wound of the axillary artery of the venerated officer thus mentioned, they will feel indebted to Horsey for recording an account of the supposed nature of the injury. In the Memoirs of Lieut-General Scott, LL. 1)., written by Himself, 18f>4, Vol. I, p. 145, among the incidents of the battle of Niagara, or Lundy's Lane, the autobiographer relates the injuries of the commanding officer of the American forces. He was seeking to succor a brave soldier who had fallen at his side, and "had become a corpse as he fell," when, "in the next second or two, Scott, for a time, as insensible, lay stretched at his side, being prostrated by an ounce musket ball through the left shoulder joint. He had been twice dismounted and badly contused, in the side, by the rebound of a cannon ball, some hours before. Two of his men, discovering that there was yet life, moved him a little way to the rear, that lie might not be killed on tlie ground, and placed his head behind a tree—his feet from the enemy. This had scarcely been done, when he revived and found that the enemy had again abandoned the field Unable to hold up his head from the loss of blood and anguish, he was taken in an ambulance to the camp across the Chippewa, when the wound was stanched and dressed." The twelfth chapter of General SCOTT'S autobiography further describes the shot wound of his shoulder, and the opinions of Drs. PHYSICK, DORSEY, and GIBSON regarding it, and explains how the latter surgeon's advice denied him "tlie opportunity of sharing in Jackson's brilliant victories near New Orleans." A distinguished medical officer, who served with General Scott in Mexico and subsequently, informs the editor that: "He suffered occasionally from neuralgic pains in said shoulder." It appears certain that there was no anchylosis or aneurism. Surgeon PArEXDICK (SCIIMICKEU'S Vermischte Chir. Schriften, 1782. B. Ill, S. 301), of the Pomeiske dragoons, in the case of a soldier, wounded, November 21i, 1778, by a shrapnel shot in the left shoulder, causing great destruction of bone, treated the case by extracting fragments of the scapulo-humeral articular extremities, and the man made a satisfactory recovery. Guthrie (Commentaries, etc., 1855. 6th cd., p. 124; describes four cases of shot fracture at the shoulder treated conservatively: Lieutenant Madden, wounded at Badajos, in 1812, a musket ball lodging in the head of the humerus;—Masters, 40th Ilegiment, with a musket ball lodged in the head of the humerus, April 12, 1814, at Toulouse;—Private Oxley, 23d Ilegiment, a musket ball grooving the head of the humerus, at the battle of Toulouse;—and Lord Seaton, with a nearly similar wound, at the assault on Ciudad Kodrigo, January 19, 1812. All four recovered, with stiffness at the shoulder, but with useful forearms and some motion of the upper arms. GuTHKIK (Treatise on Gunshot Wounds, 1827, p. 482). referring to these cases, remarks : '• These cases may all be considered fortunate. I have seen others in which part of the head of the humerus came away, and the arm has been preserved. I have also seen such cases ultimately terminating in amputation. Tho only and unsuccessful case of the shoulder joint, after the battle of Toulouse, was of this nature." A few pages further on, GUTUUIE refers to the case of Burnet, 92d Regiment, Chitty, 95th Regiment, and a third similar case, of shot comminution of tho head of the humerus, at Waterloo, treated on the expectant plan, and vouches for the correctness. of the remarks which JOHN THOMsq.V (Report of Obs., etc.. after Waterloo, op. cit.. 181(1, p. 150) published regarding these cases. 516 INJURIES OF TITE UPPER EXTREMITIES. ICIIA1MX. of those volumes of special significance, as an early illustration of real expectant conserv- ative treatment of shot fractures at the shoulder, in which the propriety of abstaining from operative interference was justified by the results. Larrey and Baudens1 approved of an expectant treatment of these injuries under certain conditions. Professor Sedillot, Dr. B. Beck, and others,2 have adduced instances in which shot fractures at the shoulder have been managed advantageously without operative interference. The more recent European experience3 would appear, indeed, to justify surgeons in regarding the expectant treatment in these injuries more favorably than heretofore. Facilities for transportation, and propinquity to base hospitals, may partly explain the good results recorded by German and French surgeons in cases of shot wounds of this articulation. And it may be remarked, that sufficient time has not yet elapsed to admit of an approximative determination of the relative usefulness of limbs treated by expectation or excision in that campaign, after shot penetration at the shoulder. 1 Baudens (L.) (Clinique des plaies d'armes a feu, 183fi, p. 449) remarks: "J'ai vu souvent l'articulation scapulo-humirale traversfee par des balles; et dans un cas, le plomb Gtait demeur6 au milieu de la tete articulaire." SIMON (G.) (Prager Vierteljahrschrift, lOter Jahrgang, I, S. 168) relates a case in which a bullet healed in the head < f 1he humerus, without the latter forming an adhesion to the shoulder blade. Sedillot (Du traite- ment des fracture.s des membres par armes de guirre, in Arch. gin. de mid., 4e sir., 1871, T. XVII, p. 389) remarks: "La presence ou le passage d'une balle dans la fete de l'humerus n'empeehe pas le malade de conserver son membre, et, quoiqu'il soit parfaitement indique. d'extraire le projectile et les autres corps etrangers iibres, l'on possede des exemples de guerison dans des cas oil cette extraction n'avait pas 6t6 pratique^. Nous avons assisted a une disarticulation du bras, faite par Larrey, sur un invalide qui portait, depuis vingt ans, une balle enclave^ dans I'extr6mit6 spongieuse de la tete de l'humerus ou elle avait fini par determiner des accidents inflammatoires de la plus grand gravit6." 2 Beck (B.) (Chir. der Schussverletzungen, 1872, S. £80) observes: "By absolute rest, appropriate position, and corresponding bandages; by immovability; by constant application cf cold; by an anti-phlogistic regimen; by incisions, extended—in cases of severe tension of the capsule with perilous suppuration—even into the synovial sac. for the purpose of allowing the accumulated fluid to escape; by well-timed openings of burrowing abscesses ; by extraction of loose splinters or fragments ; by the administration of opium ; by subcutaneous injection of morphia in cases of severe pains, the injury may frequently be controlled, and even a cure, with usefulness of the limb, comparatively limited, indeed, may be accomplished, as we have frequently observed during the late war." Schult.er (M.) (Kriegschir. Skizzen, u. s. w., 1871, S. 30), after citing several successful cases of expectant treatment cf shot fracture at the shoulder, insists on the diagnostic importance of a knowledge of the precise position and attitude in which the injury was received, adding: "An allusion to this well known point would be superfluous, if it did not occur in every war that physicians, who never saw them before, have to treat shot wounds ; and, with the eyes of the layman, may mistake peri-articular wounds for joint penetrations, and even, as was lately illustrated in the Letter of Dr. VON Breuxixg in Deutsche Klinik, No. ?.8, 1870, are liable to open the joint to perform resection. Fortunately in this instance it was noticed just in time * * that the head ofthe humerus was uninjured." On the other hand, SOCIX (A.) (Kriegschir. Erf., 1872, S. 154), speaking- of the treatment of shot wounds cf the shoulder joint, observes : " 1 consider it an error to postpone resection, in case of suppuration of the joint, until it appear that life itself is periled. The two cases cited, in which 1 thought myself justified in so doing, were bitterly regretted." Similar testimony is borne by other surgeons. Thus: RLTPRECHT (L.) (Militariirztliche Erfahrungen, WUrzburg, 1871, S. CI) remarks: " Of the shot fractures of the shoulder joint, one case was fatal; phlebitis and purulent infiltration precluded an operation that ought, perhaps, to have been practised primarily." C'orsix (A.) (Hist, chirurgicale de I'ambulance de licole des ponts et chaussies, in V Union Mid., 1872, T. XIII, p. 12<5) cites live cases of shot fractures of the shoulder joint, with four deaths, and observes: "Des 4 blesses qui nioururent, 1 seul subit la resection de I'extr6mit6 articulaire de l'lium6rus. Tous suecomberent uM'infection pnrulente " s Several surgeons who have treated of the condition cf invalids after the late Franco-Prussian War seem inclined to think that the results, as regards the conservation of the motion of the arm, are more favorable in cases treated on the expectant plan, than in those dealt with by excision. MOSSAKOWSKY (P.) (Statistischer Bericht fiber 1415, franzosische Invaliden, in Deutsche Zeitsehrift fiir Chir., 1872, B.I, S. 333) observes: "As a general thing, it is my impression, that tbe cases of wounds of the shoulder joint that were conservatively treated, and healed with anchylosis * showed better functional results than the cases treated by resection.'' Bertiiold (Statistilc der durch den Feldzug 1870-71, invalide gewordenen £ Munnschaften, u. s. w., in Deutsche Militdrarzt. Zeitschrift,1872, B. I, S. 4G9) remarks: " Comparing the preliminary results of the healing process of the five cases of resection with the four cases conservatively treated for shot wounds of the shoulder joint, the results of the latter have been more favorable as regards the ability to use the arm for occupations at the present date," although he adds : "The examination of the invalids took place about seven months after the injur)-, a period too early to allow conclusions regarding the end-results of the case.'- But there was much diversity of opinion. BILLROTH (Til.) (Chir. Brirfe aus den Kriegslazarethen in Weissenbergund Mannheim, 1870, Berlin, 1872. p. 210) declares: "As, in cases of resections, you can have no control as regards the prospective functions cf the arm, especially when a large portion of bone is to be excised, it is always better for the patient to escape with an anchylosed joint, without resection, than to have a dangling joint after resection." Langexueck (B.) (t.'hir. Beuhiichtungen aus dem Kriege, Berlin, 1874, S. lit!) contends : '" if it be true that anchylosis of the shoulder joint enhances the usefulness of the rest of the extremity, and especially of the hand, we would be obliged, in shot injuries of the shoulder joint, to constantly strive for the accomplishment of anchylosis.'' But he adds: "The presumption that anchylosis * * would bring about greater usefulness of the arm than could bo had with a shoulder joint, even with limited motion, rests upon a fallacy, occasioned by a neglect to take into consideration the various degrees of severity of shot wounds ofthe shoulder joint. * The shot injuries of this articulation that heal with anchylosis are, in all respects, injuries of a minor degree." The same author, at another page (op. cit, S. 113), cites nine successful eases of shot wounds of the shoulder joint treated on the expectant plan, the patients recovering ■'completely with conservation of good motion ofthe arm," and remarks: "Whether, with the adoption of the conservative treatment of shot wounds of the shoulder joint during the last war (Franco-German, 1870-71) more special attention was paid to the preservation or re-establishment of good motion < f the joint, I do not know, but doubt very much, as I several times noticed that surgeons, content to have saved the patient's life and arm, feared the methodical institution of passive motion. It is certain that the results of the cases of conservative treatment of shot wounds of the shoulder joint above cited challenge greater attention to the side of conservative surgery." But Professor Langexdi.CK concludes (loc. cit, p. 154) that ""the expectant treatment in eases of severe shot fractures, such as those in which I performed resection, can never be carried out successfully; sooner or later, during the pericd cf infiltration or suppuration, unless you allow the patient to perish, you will see before you the alternative of either resection ..i- amputation." LOII.MKYEU (C F.) (Die Schusswunden und Hire Behandlung, 1859, S. 192) argues that "the attempt to leave the healing of such wounds to Nature only, is always very hazardous, as most of the patients, if they do not perish of pyaamia, become so debilitated, by continued sup- puration aud repeated formation of abscesses, as to be brought to the verge of the grave." FISCHER (H.) (Kriegschi. Erf., 1872, p. 147) observes: ' The perforating shot injuries of the shoulder joint were, at first, all conservatively treated. In two eases, we were compelled to adhere to thfi .con- servative treatment, while, in the meantime, the patients fared so badly that operative interference did not appear justifiable. Both died." SECT. III.| WOUNDS OF THE SHOULDER JOINT. 517 Some of the precautions to be observed in attempting an expectant treatment, alter these injuries, such as absolute rest, a restricted diet, and the other requirements of an antiphlogistic regimen, have already been incidentally adverted to, in commenting on the cases selected for detail, of the five hundred and five, returned on the reports of the War. If these prophylactic measures were not enjoined, the patients fared badly, as attested by numerous clinical histories. In addition, the necessity of scrupulous attention to the removal of all foreign bodies, including projectiles, fragments of clothing and of bone, and blood-clots also, was largely exemplified. Moreover, there were frequent illustrations of the importance of early free incisions, for the relief of pus-formations in and about the joint; and, in some cases, the utility of drainage was much insisted on. Mr. MacCormac, in his notes1 on the surgery of the French-German campaign of 1870, does good service in giving prominence to the utility of an axillary pad or cushion in shot fractures of the upper extremity of the humerus. I take the liberty of copying his illustrations (Figs. ,°>94, 395) of the dressings used by that "veteran authority in military surgery," the renowned Dr. Stromeyer. A similar dressing, rendered familiar to our surgeons by Dr. Fox's apparatus for fractured clavicle,2 was much employed, not only in the cases treated on the expect- ant plan, but in those in which recourse was had to There can be no FIG. 31)5.—STROMEYBlt's cushion as applied fur shut fracture of the upper extremity of the humerus. [After MacCormac.1 excision. kig. m-sriiOMEYER's axiiiary question of the utility of pad. [AfterMacCormac.] -1 . J some appliance of this de- scription, judiciously adjusted. Surgeon Gr. C. Harlan indicated, in the apparatus figured on page 509. how it was possible to avoid the dangers of tight bandaging of the upper arm in these shot fractures, and yet to secure the advantages of extension and counter extension,3 by means of a bracketed splint with vertical adhesive strips; and the practical value of this suggestion will not fail to be appreciated. If immobility of the limb can thus be provided for, and the displacement inward of the upper part of the humerus, ■MacCormac (W.) (Notes and Recollections of an Ambulance Surgeon, etc., 1671, p. 97) says: "He [Stromeyer] has himself told me, so highly did he estimate the value of this cushion, that he considered it the most valuable appliance he had invented during his life, which is very strong language from a man who, like him, has done so much for surgical science." And Mr. MacCormac adds: " I have tried this mode of treatment myself, and found it to answer every purpose. The cushions are very readily made, and can he manufactured of different sizes. A very good size is one in which the sides measure about fourteen or fifteen inches in length." There must be a misprint or mistake here, since the distance from the axillary fold to the inner condyle rarely exceeds, even in tall persons, ten inches, and a pad of fifteen inches would be inconveniently long. MACLEOD (G. H. B.) (Notes, etc., 1858, p. 304), commenting on Dr. iStromei'KU'S recommendation to make the trunk the splint in fractures high up in the humerus, declares : "As pus commonly burrows, and has to be evacuated on the inner aspect of the arm, it is difficult to carry such an idea into practice.'' The validity ofthe objection is not apparent. Ballingall ((}.) (Outlines of Mil. Surg., 5th ed., 1855, p. 37G) dwells on the importance of a pad in the axilla. Passayant (6.) (Bemerkungen aus dem Gebiete der Kriegschirurgie, Berlin, 1871, S. 30), remarking on the inutility of bandaging in shot fractures of the upper extremity of the humerus, states that: "I know of no better treatment than by STROMEYER's pad, upon which the fractured arm rests without any bandaging. * * * This pillow does, according to my view, better service than any bandaging, either in the sitting or prone posture." And this author cites a number of cases in support of his opinion. 2NORR18 (G.) (Practical Surgery, by ROBERT LISTOX, with Notes and Additional Illustrations, Philadelphia, 1838) gives the earliest description I have seen of this apparatus, which "was introduced into the practice of the Pennsylvania Hospital in 18-.&, by Dr. Fox" (loc. cit, p. 47), and is now so generally employed. (See SMITH (H. H.) Minor Surgery, 1859, p. 217, and SARGENT (P. W.) On Bandaging, etc., 1862, p. 129.) The axillary pad, it is hardly necessary to remark, was used at least as early as the seventh century by Paulus iEGlXETA. (See Book VI, Syd. Soc, ed. 1846, Vol. II, p. 480.) Yet "the ball of soft wool placed in the arm-pit, and secured with a bandage and sling," was but a rudimentary notion, imperfectly fulfilling the indications so well met by the cuneiform pillows of Fox and Dr. STROMEYER. 3Unless Dr. Harlan's suggestion meets the difficulty, the remarks of THILLAYE (Traiti des Bandages et Appareils, 3eme . 577, by Dr. KOREltT ADAMS, on Abnormal Conditions of the Shoulder Joint, and the fourth chapter of Dr. 11. W. Smith's well-known Treatise on Fractures in the Vicinity of Joints, 1847, p. 176. BlE*KL (R.) (Kriegschir. Aphorismen von 1866, in Arch, fiir klin. Chir., Berlin, 1809, Band XI. S. 426) has some remarks on the subject; and in the classical works of Boyer, COOPER, DurUYTRKN, and Nelaton, compound fractures involving the .-boulder are discussed. Professor Esmakch, of Kiel, in his celebrated work Uber Resectionen, u. s. w., 1851, S. 51, has some observations on the expectant treatment of shot fractures at the shoulder; and Professor Hannover, of Copenhagen, in his valued treatise Das Endresullat der an Ddnischen Verwundeten, u. s. w., in Med. Jahrbiicher des Oesterreich. Staates, B. 18, 1869, S. 109-137, also adverts to this subject. SKCT. III.] EXCISIONS AT THE SHOULDER. 519 of the subject has been somewhat fully referred to in the preceding and subjoined foot- notes. The question of the safety and comparative advantages of attempting expectant treatment, after shot fractures of the articular extremities of the humerus and scapula, requires further investigation. It is proved that under judicious management the results of expectant measures as to life and limb may be most satisfactory. It remains to be shown that, under the ordinary conditions of war-surgery, immediate operative interference mav not be the safest plan. While the opinion offered in my preliminary report1 of 1865 may have been expressed too emphatically, as deduced from insufficient data, it may still be held that the proportion of cases of shot fracture at the shoulder in which an expectant treatment is expedient is comparatively small, and that recourse should generally be had to excision, unless concomitant injuries of the blood-vessels or nerves, or extended lesions of the soft parts, or of the shaft of the humerus, render amputation imperative, EXCISIONS AT THE SHOULDER.-The cases of excision at the shoulder for shot injury reported during the War were so numerous that, if their discussion does not definitively settle the questions regarding operative interference in such cases, they furnish, at least, a mass of evidence unprecedentedly large2 toward the solution of the problems presented by this interesting subject. The histories of no less than eight hundred and eighty-five cases were reported, and the results, as to fatality, have been ascertained in all save nine.3 It would appear that six hundred and seventy of these operations were for direct shot injury of the articulation,4 two hundred and fifteen either for shot fracture in near proximity to the joint, or for consecutive caries or necrosis.5 It was thought inex- 1 Circular 6, S. G. O., 1865, p. 55. It is there stated that: " Of 36 cases of gunshot fracture ofthe head ofthe humerus, selected as favorable cases for the expectant plan, and treated without excision or amputation, 16 died, or 44.4 per cent., a ratio in favor of excision of 11.96 per cent." Evidently this is a flagrant instance of generalization from insufficient data, inasmuch as 505 cases were reported of shot fractures at the shoulder treated expectantly, with a fatality of 27.5 per centum only; and with every allowance for erroneous diagnoses, the expectant plan makes a better numerical showing than I formerly believed possible. I am the more penitent for the hasty conclusion in the preliminary report, because it has misled several trusted surgical authorities. Among others, Dr. Ashhurst (Princ. and Pract. of Surgery, 1871, p. 16.">), relying on these statistics, states that "expectant treatment gave worse results than either [excision or amputation], the mortality, even in selected cases, being as high as 44.4 per cent." 2 Prom all the sources of information I have been enabled to consult, printed, manuscript, aud verbal, including the doubtful cases of Percy, Larrey, and Guthrie, the cases reported from the Paris revolutions of 1830 and 1848, and the Antwerp siege of 1831, from the French campaigns in Algiers, from the hostilities in Schleswig-Holstein, from the war in Lombardy in 1848-49, from the Crimean war, from the Italian campaign of 1859, from the New Zealand war of 1863-5, from the Danish war of 1864, from the Austro-Prussian " six weeks' war " of 1866, from the returns of the French- fierman war of 1870-71 that had reached this country at the close of the year 1874, and, finally, from nearly a hundred cases communicated in writing or verbally, I have succeeded in collating less than five hundred and fifty examples of excision at the shoulder from shot injury, apart from those here* tabulated, or less than two-thirds of the aggregate here recorded. 3 A citation from an article in iheAmerican Journal of Medical Sciences, 1868, Vol. LVI, p. 128, may he permitted here: " The report on the nature and extent ofthe materials available for a surgical history ofthe war, included in Circular No. 6, .S. G. O., 1865, was published in October of that year, a few months after hostilities had closed, and was professedly a preliminary and prefatory report, in which all pretension to completeness was repeatedly disclaimed. * * And, on every page, [it] endeavors to show the impracticability of gratifying the natural desire ofthe public for immediate information as to the results of the surgery of the War, without the greatest sacrifices of accuracy or completeness. In relation to a few ofthe surgicaj questions of especial interest * * an attempt was made to satisfy professional impatience, by giving tabular statements of all the facts on these subjects then in the possession of the Bureau, so far as was consistent with the space and time to which the compiler was restricted. But these were supplied with the reiterated caution that the results were incomplete, and that deductions from them were premature." That the preliminary report has been mistaken in Europe, as well as in this country, for the official surgical history, is a fact of which I am often reminded. Dr. P. Lcil•TLER (Generalbericht, a. s. w., 1867, S. ~88), citing Circular 6, emphasizes a criticism on the statistics of shoulder joint excisions: " Five hundred and seventy-five resections of the shoulder joint! That is undoubtedly quite a number, such as would admit of generalization. It is the number to be found in the official report ofthe American War ofthe Union. But in sixty-seven cases the result was not ascertained." [The last italics are the editor's.] 4 Six of these remain undetermined. Two hundred and twenty-three, or 33.58 per cent., terminated fatally. 6 The result of three cases is unknown. In two hundred and twelve determined cases, there were eighty-three deaths, a mortality of 39.15 per centum, more than five per centum greater than in those cases in which the joint was directly injured. 520 INJURIES OF THE UPPER EXTREMITIES. iciiap. ix. pedient to segregate these groups; but more desirable to classify the cases according to the portions of bone removed, as in Table XXI, and in relation to the primary, intermediary, or secondary dates of the operations: Table XXI. Numerical Statement of Eight Hundred and Eighty-five Cases of Excisions at the Shoulder Joint after Shot Injury. PARTS EXCISED. OPERATION. Total. Primary. Intermediary. Secondary. Undetermined date. The upper extremity of the humerus, with parts of either clavicle or scapula, or of both. 20 3 175 293 27 11 3 55 155 10 6 26 50 1 o 17 19 12 42 14 273 517 39 Head of the humerus........................... Excision at shoulder; parts not definitely distinguished........ 518 224 92 51 885 The different groups will be further analyzed, with details and figured illustrations of the more important cases in which such data were available, and tabular statements of the remainder. Excisions of the Head of the Humerus with Portions of the Clavicle or Scapula.— The forty-two reported cases of this group, enumerated just above, will be more fully tabulated further on, in Table XXII. In three cases, the operations consisted in decap- itations of the humerus with removal of the outer portion of the clavicle; in thirty-six, of excision of the upper extremity of the humerus and of portions of the processes of the scapula; in three, of excisions of the extremities of the three bones next the joint. Of the thirty-six cases in which the head of the humerus together with portions of the shoulder blade were removed, the parts of the scapula excised are specified with precision in thirty-three. -The acromion, and sometimes portions of the spine, were exsected in seventeen cases; the head or neck, in eleven cases; the coracoid, in two cases; while, in three instances, coracoid, acromion, head of scapula,1 as well as head of humerus were excised, these latter, in reality, being entitled to be styled excisions of the shoulder joint. It is remarkable that the mortality, in the reported cases of this group, is less than that returned for simple decapitations of the humerus after shot fracture, scarcely a fourth terminating fatally. There were twenty primary, eleven intermediary, and ten secondary operations, and one successful instance of unspecified date. The appearance of the limb in one of the successful intermediary cases is represented by Figure 2 of Plate XIII, opposite, and wood-cuts showing the results of several of the primary and secondary operations are intercalated in the text further on. Detailed abstracts of six cases that furnished illustrations to the Museum may precede, in inverse order, the tabular summary. One was a secondary, two were inter- 'LOJFFLEB (F.) (Generalbericht, u. s. w., Berlin. 1867, S. 290) remarks: "Fracture of the head of the humerus with injury ofthe articular portion ofthe scapula was comparatively frequent in .shot wounds of the shoulder joint. This complication makes the prognosis of excision of the joint more serious, but is not a counter indication, in case of comminution, the surgeon is compelled to remove, after the resection ofthe head of the humerus, the fragments of tbe glenoid process. If there are only fissures, the question arises, whether it be advisable to excise the head or processes surrounding the glenoid cavity of the scapula. In our three cases, which recovered, this was not considered advisable. The progress of these cases, it must be admitted, was hindered by tedious burrowing of pus." *■& 111.' the i ,■•■' " lp,' r '■'■O.- : II.!'. .•cisians cf tii" ri To "/ ;.v.-o v- : ■•i author ' . r.igk't. ■/?:•■:■ y^,»/ / in rcaiit' <>urth i;irv v!' r: "• ' j i'r:,rturc ot .1,1. This • .■' "ipelW ; \ ..!'..-r t -. lurgicu Histor\- of theW.ir uf the Rebellion Vol II Chap IX Opposite pa ye 520. ■k;.II Fig III. Fie-..TV. K.M.Wells del J.T$Teii I iffi. PLATE XIII. RESULTS OF EXCISIONS OF THE HEAD OF THE HUMERUS Fro.I. Private Martin Kellv P'ig.HI. Sergeant .Jacob Yakey. Fir.. II. h-ivate H. .Ioiips.Spkc. 2479 A.M. M. Ym.W. Private .1. K. Clark. Spec. 633 A.M M / SECT. 111.] EXCISIONS AT THE SHOULDER. 521 FIG. 396.—Cicatrices after an ex- cision of the head of the humerus and portion of the clavicle for shot fracture. Fio. 397. —Head of left humerus excised for shot fracture. Spec. 3047. mediary, and three primary operations. A secondary case, where the patient survived an excision involving a large portion of the clavicle as well as the head of the humerus, was carefully illustrated by Surgeon R. B. Bontecou; U. S. V., and detailed as follows: Cask 1492.—Private John Harvey, Co. F, 29th Massachusetts, aged 21 years, was wounded at Petersburg, June 17, Hilt, treated in a Ninth Corps hospital, and thence sent to Washington, and admitted into Harewood Hospital June 21st, suffering from a shot wound of the left arm. The ball entered at the upper third of the arm, passing upward, grooving the head of the humerus, and fracturing the left clavicle. On admission, the injured parts were in good condition, but the patient was very weak from excessive suppuration. On the 28th, the ball was extracted from under the fractured clavicle. On July 17th, the patient was etherized, and Surgeon E. B. Hontecou, U. S. V., excised the head of the humerus and about three inches of the left clavicle, which was denuded and protruding. The patient did well under supporting treatment. He was discharged from service February IS, l.silj, on certificate of discharge for dis- ability from " resection of the humerus and three inches of the sternal end of the clavicle." The foregoing notes, with two photographs, taken at Harewood Hospital, representing the appearances of the shoulder after recovery, together with the portion of the humerus removed, were contributed to the Museum by Dr. Bontecou. The photographs give a tolerably good idea of tlie form of the cicatrices (FlG. 396) and of the extent of the incisions. The pathological specimen (Fig. 397) consists of the shattered head of the humerus. "A line of demarcation, crossing the epiphyseal line, encircles a necrosed portion of the specimen."—Cat. Surg. Sect, 1865, p. 100. Examiner T. Hooper, of Fall River, Massachusetts, reported in Sep- tember, 1866, that the arm was anchylosed and useless, could not be moved in any direction, was still painful, and the patient thought it would have been better had it been amputated. This pensioner died on December 29, 1869. If the foregoing case be reckoned successful, and, unquestionably, the patient's life was prolonged for several years by the operation, the ten secondary operations give the favorable showing of a mortality rate of only twenty per cent. In the two fatal cases,1 the patients succumbed after several months of profuse suppurative inflammation. Of the eleven intermediary cases, the results were far less favorable, inasmuch as six patients died. Several of the survivors enjoyed comparatively good use of their limbs: Case 1493.—Private E. Jones, Co. D, 67th New York, aged 22 years, was wounded, May 12, 1864, at the battle of Spottsylvania, and sent to a Sixth Corps hospital, in charge of Surgeon E. F. Taylor, 1st New Jersey. He had been struck by a conoidal musket ball, which comminuted the surgical neck ofthe humerus and the coracoid process ofthe scapula, and lodged just below the clavicle. He was removed to Fredericksburg, and thence to Washington, and was admitted to Carver Hospital May 16th. At that date, the shoulder was highly inflamed and the arm greatly swollen. On May 17th, the patient was placed under the influence of ether, and the head and two inches of the shaft of the humerus, and the fragments of the coracoid process (Fig. 398) were removed, through a U-shaped incision, by Surgeon O. A. Judson, U. S. V. The case pro- gressed rapidly toward recovery, and without any unfavorable complications. Attention was paid to supporting the elbow in order to approximate the upper extremity of the humerus to the glenoid cavity, and the wound was kept open for a time by dossils of lint. The coraco- brachialis and the 6hort head of the biceps doubtless formed new attachments at the base of the coracoid process. A photograph of the patient was taken December 1, 1864 (Surg. Ser. Phot, A. M. M., Vol. I, p. 17), at which date the cicatrix was perfectly sound, and the patient's control over the movements of the limb eminently satisfactory. Jones was dis- charged December 12, 1854, and pensioned. Drs. A. Parr and W. Bell, of New Brighton, England, reported, October 20, 1868: "Excision of the shoulder joint on the left side, and consequently he has lost the use of the left arm, and will never regain it." This pensioner was paid December 4, 1873. The shattered excised portions of bone are represented in the annexed wood-cut (Fig. 398), and the appearance of the limb is represented in Plate XIII, Fig. 2 (opposite page 520), by a drawing reduced from a photograph prepared at the Army Medical Museum in 1854. In a brief history, found after the compilation of the foregoing statement of the case, Dr. Judson says that: "Treatment consisted in introducing a siphon of lint into the wound to promote drainage. The end of the humerus was brought up as near to the glenoid cavity as possible by adhesive straps and bandage." The case is No. 25 in Table XXII. 1 Harris and Jenkins, Nos. 15 and 23 of TABLE XXII p. 524. The immediate causes of death are not reported. Both patients were in crowded hospitals in unhealthy climates. 66 Fig. 398.—Excised head of humerus and coracoid process after shot frac- ture at the left shoulder. Spec. 2479. 522 INJURIES OF THE UPPER EXTREMITIES [CHA1\ IX. Fig. 399.—Head of left humerus and portion of thencromion excised af- ter shot fracture. Spec. 24G6. An abstract of another successful intermediary operation has been published by the lamented Surgeon George Derby, 23d Massachusetts,1 and is noted as the ninth case in the tabular statement on page 524. In four of the six fatal intermediary operations the unfavorable termination was ascribed to pyaemia. The most detailed example is the following: Casio 1494.—Private B. M------, Co. H, 99th Pennsylvania, aged 23 years, was wounded at the Wilderness, Mav 6, 1864. He was sent from a Second Corps hospital to Washington, to Finley Hospital, and arrived May 11, 1S54, with a "gun- shot wound of the right shoulder, fracturing the acromion and coracoid processes and injuring the head of the humerus and spine of the scapula." "On May 24th." Surgeon G. L. Pancoast, U. S. V., reported, "he had a chill of an hour's duration. On the 25th, chloroform was administered and resection of the head of the humerus and excision of the fractured processes and fragments of the spine of the scapula were performed. At the time ofthe operation the condition ofthe injured parts was very unfavorable; the shoulder very much swollen, though not very painful; the patient's pulse was small and quick. Copious suppuration followed, together with frequent and watery stools, uncontrollable by opiates or astringents. Stimulants and nutritious diet were given. Death, June 3, 1S54." Dr. Pancoast forwarded to the Museum the head of the humerus and portion of the acromion, which are represented in the adjoining wood-cut (Fig. 399), and are described (Cat. Surg. Sect., A. M. M., 1366, p. 90) as consisting of the "head of the left humerus obliquely excised through the surgical neck. The extremity of the acromion is mounted with the specimen. Pieces of the scapular spine were also removed, but are not preserved. The head is grooved transversely across its anterior face." The case is numbered 30 in the tabular statement. If an autopsy was had in the case, no report was communicated to the Surgeon General's office. In the other two intermediary operations that terminated fatally, and which are enumerated as Cases 12 and 33 in Table XXII, gangrene and recurrent consecutive haemorrhage were assigned as the cause of death. Among the twenty primary operations in this category, two terminated fatally, and, in a third case, the result could not be ascertained—a very favorable exhibit. In two of the seventeen successful instances, detailed clinical reports were transmitted, and photo- graphs of the patients were forwarded to the Museum: Case 1493.—Brigadier General E. B. Brown, U. S. V., was wounded at Springfield, Missouri, January 8, 1863, by a musket ball at short range. Surgeon S. H. Melcher, Missouri S. M., reported: "The ball entered the left arm four inches below the apex of the shoulder, striking the humerus at the surgical neck, severing the long head of the biceps, passing upward and backward, splintering the shaft and fracturing the head of the humerus, striking the lower edge of the glenoid cavity, which it also fractured, and lodging just back of the neck of the scapula. I performed the operation for excision forty-four hours after tlie injury The incision was V-shaped, and the head of the humerus and shaft of the bone, measuring five inches in all, and a small portion of the articular surface of the scapula, were removed. The wound healed by granulation, and, by January 31, 1863, was closed, except a small opening which discharged a moderate amount of pus. The limb was gradually shortening, and was, at that date, two inches shorter than the other. By a sling supporting the elbow, he used the forearm readily, and was daily walking about town. In five weeks after the battle he made the journey from Springfield to Sedalia, riding daily five to ten miles on horse- back, holding the reins in his left hand. In the fall of 1864 he was continually in the saddle, and commanded, his brigade in the famous pursuit of Price by Pleasonton." This officer resigned his command November 10, 1865, and was pensioned from that date. On November 21, 1870, Dr. Melcher forwarded the photograph copied in the cut (Fig. 400). showing the condition of the arm and shoulder at that time, nearly seven years after the operation. He stated that this officer "had wonderful use of the entire arm; being able to chop wood, to play billiards, to support his fowling piece at the shoulder while shooting, and to be constantly engaged in active out-door employment." As is usual in these cases, the pension examining surgeons' reports conflict with that of the operator. Examiner J. Bates, of St. Louis, reported, January 9, 1866: "Arm almost entirely useless;" and in September, 1873, a Board, consisting of Examiners Fir. 400.—Appearance of a rase of excision ofthe Porter, Hill, and Whitehill, reported "want of power in the'arm, and deformity." shoulderjomt seven years after the operation.—Phot. . n ■>• ii, i i -»r 1 i"-i 301, Surg. Sect., A. M. M. A pension of thirty dollars a month was paid this officer as late as March, l>ii4. 1 DF.nilY (ft.), Case of Resection of the upper third of the Humerus, in the Boston Med. and Surg. Jour., 1863, Vol. LXVIII, p. 358. A photo- graph of this pensioner is preserved at the Museum (Card. Phot. Surg. Sect, Vol. II, p. G), and au attempt was made to get a drawing from it; but the illustration was too unsatisfactory to warrant the insertion of a wood-cut, SECT. III.] EXCISIONS AT THE SHOULDER. FlG. 401.—Cicatrix in a case of excision of the head of the humerus. Another strictlv primary case suggests the fallacy of the dictum that operations of this class should not be performed on the battle-field,1 and illustrates also the utility of a suspensory apparatus, when judiciously applied and intelligently worn: Case 1496.—Lieutenant I. N. Hawkins, Co. C, 73d Ohio, aged 22 years, was wounded at Atlanta, August !">, 1804. Surgeon W. C. Bennett, U. S. V., reported: "A minie' ball fractured the right humerus, passed through the glenoid cavity, and was lost beneath the scapula. Resection was performed by Surgeon II. II. Lampion, 79th Ohio." This officer was sent to Nashville, and, on November 10th, came under the care of Surgeon J. E. Herbst, U. S. V., who noted: "Gunshot fracture of the right humerus in the upper third, penetrating tlie shoulder joint. On August 5th, the head and two inches ofthe shaft ofthe humerus were excised through a linear incision five inches in length. The patient states that he was in good condition at the time of the operation. The after-treatment consisted of simple dressings and supporting splints, aud the patient did well." On November 27lh, Lieutenant Hawkins was transferred to Cincinnati, and was treated in Grant Hospital until February 8, 1865, when he was returned to duty. On May 15, 1805, he was discharged the service and pensioned. In his declaration, the pensioner states that he was also wounded at Bull Run, August 30, 1802, in the right arm above the elbow, slightly fracturing the humerus, and on October 29, 1833, at Lookout Valley, was wounded in the left ankle, causing a severe flesh wound. For Commissioner of Pensions, J. A. Morgan, Chief Clerk, April 28, 18ti8, sent to the Surgeon General's Office, at the request of Mr. Hawkins, a photo- graph, copied in the wood-cut (FlG. 401). In the accompanying memorandum it is stated that: "He had good use of the arm from the elbow down. He writes legibly. Pr. Waddle, of Chillicothe, Ohio, had examined him some two weeks before, and said that there was no union of bone, or cartilage formed in place of that removed." Dr. E. D. Hudson, who furnished this pensioner with a suspensory apparatus, stated that the arm was shortened half an inch; that the wound was soundly healed, with a deep sulcus underneath the acromion. The arm was useless for lack of leverage; the functions of the hand and forearm were, however, normal. This pensioner was paid March 4. 1874, at his home at Austin, Minnesota. Tliere are several other reports of the case, the latest by Pension Examiner R. A. Barnes, of Austin. They substantially confirm and reiterate the foregoing facts. The next primary case exemplifies a removal of the acromial process, and, as well, an excision of a portion only of the head of the humerus, a group of rare operations, of which fourteen instances will be enumerated in Table XXIII, on page 528. Case 1497.—Private P. Hogan, Co. K, 4th Infantry, aged 23 years, was wounded at Gettysburg, July 2,1863. Assistant Surgeon B. Howard, U. S. A., reported, from a Fifth Corps hospital: "A mini6 ball entered at the outer border of the deltoid, striking the head ofthe left humerus, and fracturing its upper third, and also the adjacent part of the acromion process, the ball lodging iu the glenoid cavity. I made an incision parallel with the posterior border of the deltoid down to the joint, turned out the head of the humerus, and, instead of removing it entire, made a clean section both of it and ofthe acromion process, leaving the inner two-thirds ofthe head ofthe humerus and the corresponding portion ofthe acromion." On July 25th, the patient was transferred to the Cotton Factory Hospital at Harrisburg, and, on September 1st, to Fort Columbus, New York, where he was discharged October 10. 1864. Assistant Surgeon P. S. Connor, U. S. A., noted upon the certificate of disability: "Physically not suitable for the Veteran Reserve Corps." He was pensioned. Examiners G. C. Ashmun and T. C. Miller, of Cleveland, reported, September 8, 1873: "There has been a gunshot wound of the left shoulder, the ball entering on the outer aspect, passing inward, and lodging in the joint, whence it was removed. There is loss of the acromion process of the left scapula to the extent of one and a half inches, and loss of a portion of the head of the humerus and glenoid fossa of the scapula. Disa- bility arises from the partial anchylosis of the left shoulder joint, which is such as to prevent full extension of the arm and rotation. Disability rated total." The specimen (No. 1377), contributed by Dr. Howard, is described at page 85 of the Catalogue of the Surgical Section of the Museum, of 1866, as: "A section one-third of an inch in thickness, excised from the outer portion of the head of the left humerus for fracture. A portion of the conoidal ball is attached. A section of the acromion, which was made at the same time, has not been preserved." It is impracticable to take space to detail the remaining thirty-six cases of excisions involving the different bones of the shoulder; but the more important particulars regard- ing them are set forth in the descriptive numerical statement on the following page. 1 In a Report of the Associate Medical Members of the Sanitary Commission on the Excision of Joints for Traumatic Cause, Cambridge, 1862, "respectfully recommended by the Commission to the medical officers of our army now in the field," it is stated, at page 22, that: " Excisions of large joints arc never to be practised on the battlefield, or under conditions that will require the immediate transportation of the wounded." The motives that led the eminent gentlemen who signed this report to volunteer advice to the field surgeons are worthy of aU praise; but their judgment, on this point, has not been confirmed by those who had improved the best opportunities for observation. 521 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. Sit, Table XXII. miary of Forty-two Coses of Excisions of the Upper Extremity of the Humerus, together loith Pa/ts of either Clavicle or Scapula. Name, Age, and Military Description. Date of Injury Nature of Injury. Datk of Oimcra- tton. Operation and Operator. Result. 12 15 17 Benson, XV. H., Pt., K, 45th Pennsylvania, age 26. Boynton, O. F., Pt., C, 14th Wisconsin. Brown, E. B., Brigadier General, U. S. V. Burgdorff. A., Pt., K, 149th New York, age 35. Carter, It., Pt.,K,2dGeorgia, age 34. Chamberlain, T., Pt., G, 30th Ohio, age 21. Coy, G. W., Sergeant, D, 56th Massachusetts, age 28. Creighton, J. D., Pt., F, 12th Massachusetts. Dunham, J., Pt., 3d New York Cavalry. Durning, J., Pt. 1,12th New York, age 33. Fulton, H. D., Pt., E, 30th Indiana. May 6, 1864. Mar. 27, 1865. Jan. 8, 1863. July 20, 1864. May 3, 1863. Sept. 14, 1862. June 17, 1864. Aug. 29, 1862. Aug. 20, 1862. April 16. 1865. Sept. 19. 1863. Garland, A. M., Pt., H, 5th June 1, New Hampshire. 1862. Goodwin, Tt. S., Pt., A, 11th Massachusetts, age 25. Halford, H., Pt., A, 8th Michigan, age 39. Harris, S. S., Pt., G, 70th Indiana, age 26. Hartman, J. C, Pt., C, 4th Iowa Cavalry, age 45. Harvey. J., Pt., F, 29th Massachusetts, age 21. Hawkins, I. N.. Lieutenant, C, 73d Ohio, age 22. 19 Hayes. E., Lieuten.-mt-col- nnel. S.'tli Ohio, age 34. Mav 3, 1863. Sept. 1, 1862. May 15, 1864 June 10, 1864. June 17. 1864. Aug. 5, 1864. Mav leii-J Gunshot fracture of the left scapula and the head of the humerus. Comminution of the right scap- ula, involving the head of the humerus, by a shell fragment. Musket ball fractured the left shoulder joint and the shaft of the humerus and severed the long head of the biceps. Lacerated wound of left shoul- der joint by shell fragment; bones considerably fractured. Gunshotfracture of the clavicle and the head, neck, and shaft of the humerus. Conoidal ball fractured tbe right shoulder joint. Compound fracture of the left shoulder joint by a shell frag- ment. Gunshot fracture of the right shoulder joint. Head of left humerus and the glenoid cavity comminuted by a conoidal ball. Shot fracture of right shoulder joint; necrosis of the head of the humerus. Canister shot comminuted the head of the left humerus, the glenoid cavity, and the acro- mion process of the scapula. Ball comminuted right clavicle at its outer third, grazed the head of the humerus, and was lost in the tissue of the arm. Compound fracture of the right shoulder joint by grapeshot. Shot fracture of the head and neck of the left humerus; fragments of bone embedded deep in the joint. Musket ball fractured the spine of the left scapula, the glen- oid cavity, and the head of the humerus. Gunshot fracture of the left shoulder joint. Musket ball destroyed about one-third of the inner side of the articular surface of the left humerus and the extrem- ity of the clavicle. Gunshot fracture of the right shoulder joint. Conoidal ball fractured the head of the right humerus and perforated the shoulder joint. Mav 27 1864. Mar. 27, 1865. Jan. 10, 1863. Julv 21 1864. Mav 4, 1863. June 17 1864. Oct. 16, 1662. Sept. 18 1862. Mav 12, 1865. Nov. 1, 1863. June 26 1862. May 3, 1863. Dec. 14, 1862. June 22, 1864. June 17, 1864. July 17, 1864. Aug. 5, 1864. Mav 8, ISol. Excision of the head of the humerus and a portion of the scapula, by Surgeon A. F. Sheldon, U. S. V. Excision of the head of the humerus and the acromion process of the scapula, by Surg. E. Powell, 72d Illinois. Excision of the head and a portion of the shaft of the humerus, and a small piece of the glenoid cavity ofthe scap- ula, by Surgeon S. H. Mel- cher, Missouri S. M. Removal of the head of the humerus and portions of the clavicle and scapula. Excision of one and a half inches of the sternal end of clavicle, and the head, neck, and two and a half inches of the shaft of the humerus. Excision of the head of the humerus and the spine of the scapula. Resection of the head of the humerus and superior portion of the scapula. April 15,1865, superior epiphysis and dya- physis removed piece-meal with pliers, by Ass't Surgeon G. M. McGill, U. S. A. Head and two and a half inches of the humerus and a portion ofthe acromion removed, by A. A. Surgeon J. M. McCalla. Removal of neck of the scapula and head and shaft of the humerus to the junction of the middle and upper third, by Surgeon G. Derby, 23d Mass. Excision of the head of the humerus and a portion of the scapula, by A. A. Surgeon G. VV. Van Voast. Excision of the head of the humerus, the glenoid, and the acromion, through a linear incision, by Ass't Surgeon C. F. Haynes, U. S. V. Excision of the head of the humerus and the acromial end of the clavicle, by Ass't Surg. H. L. Sheldon, U. S. A. Excision of end of the clavicle, the superior process of the scapula and the head andpart of the shaft of the humerus. Removal of extremity of the acromion and portions of the head of the humerus, by Ass't Surg. XV. A. Conover, U. S.V. Removal of three inches of the upper end of the humerus, the acromial process, and part of the spine, and also of the body of the scapula, through a straight incision, by Ass't Surg. 11. T. Legler, U. S. V. Excision of the head and neck of the humerus and portions of the scapula forming the glenoid cavity, by A. A. Surgeon W. I). Hall. Removal of three inches ofthe clavicle and the head of the humerus through the surgical neck, by Surgeon R. B. Bon- tecou, U. S. V. Excision of the acromion pro- cess of the scapula and the head and three inches of the shaft of the humerus, bv Surg. H. A. Langdon, 79th Ohio. Excision of a portion of the glenoid cavity and the head of the humerus, by .Surgeon A. K. Fifield, 29th Ohio. Disch'd September 11, 1864, and pensioned. In October, 1873, diseased bone was discharging; arm useless. Died April 9,1865, of erysipelas. Disch'd November 10, 1865, and pensioned. November, 1870, '' wonderful use of the entire arm." See Case 1495. Disch'd May 30, 1866, and pen- sioned ; arm nearly immovable at shoulder joint. Died June 19, 1863, from exhaus- tion following hsemorrhage. Discharged January 9, 1863, and pensioned; arm shortened one and a half inches. Disch'd June 5, 1865, and pen- sioned ; arm useless. Disch'd June 11, 1863. and pen- sioned. November, 1870, wound frequently breaks out. Discharged September "28, 1863, and pensioned; limb shortened three inches; union wholly muscular. Died May 25, 18G5, of pyaemia. Disch'd April 22,1864. October, 1868, useful arm. Died June 28, 1862. Spec. 4932, A. M. M. Disch'd November 10, 1864, and pensioned. September, 1873, arm useless. Disch'd April 6, 1863, and pen- sioned ; arm emaciated and use- less. Spec. 1023, A. M. M. Died August 14, 1864, at the field hospital at Bridgeport, Alabama. Died June 24, 1864, of pyaemia. Discharged February 18, 1865, and pensioned; arm useless. Spec. 3047, A. M. M. See Case 1492. Disch'd June 2, 1865, and pen- sioned; disability total and permanent. See Case 1496. Disch'd November 4, 1864, and pensioned; muscular atrophy; arm and hand entirely disabled. SECT. III.J EXCISIONS AT THE SHOULDKR. Name, Age, ano Military description. Hogan, P., Tt., K, 4th Infan- try, age \!6. Horton. R. E., Sergeant, E, Oih N. Y. Cavalry, age 30. Inge, R-, Pt., B, 1st Tennes- see, age 23. Jenkins, L., Pt., H, 24th Col ored Troops. Jones, J., Pt., A, 11th Con- necticut, age 2.">. Jones, R.. Pt., I), G7th Now York, age 22. Lyon, R., Sergeant, E, 49th Virginia, age "23. Marsh, N. P., Pt., C, 39th New Jersey, age 34. Mead, J., Pt., K, 12th Wis- consin, age 23. Miller, M.. Pt., K, 119th New York, age 28. M-----, B., Pt.. H, 99th Pennsylvania, age 23. Raymond. W. B., Corporal, K, 7th Wisconsin, age 17. sampson, I., Pt., I, Illinois. Sanford, J. E., Pt., D, 7th Massachusetts, age 24. Shamville, V., Pt., K, 14th Louisiana, age 27. Shreeve, D. H., Pt., F, 88th Illinois, age 43. Stcekel, J. F., Pt., E, 6th New Jersey, age 22. Sullivan, E., Pt., F, 20th Massachusetts, age 18. July 2, 1863. Sept. 19, 1864. Aug. 8, 1863. July 10. 1803. June 11 1864. Mav 12, 1864. Oct. 19, 1864. Dec. 19, 18G4. June 24 1803. June 15 1864. Mav 5, 1Sj4.' Feb. 7, 1865. Mav 6, 1864. Aug. 2 1804. Nov. 25 1863. May 6, 1864. Mav 12, 1864. natiuik ok Injury. Conoidal ball fractured tho July 5, head of the left humerus anil 1803. the acromion process of the scapula, and lodged in the cavity of the joint. Musket ball passed through the Sept 1! right glenoid cavity and frac- 1864. tared the head of the humerus, Gunshot fracture of the right Aug. 8, shoulder joint. 1803. Contused wound of the shoul- der joint, with partial fracture of tlie head of the humerus, caused by a piece of plank, which was struck by a shell. Minie ball fractured the head Juno 23, ofthe left humerus, the cora- 1661 coid process, and the body of the scapula. Comminuted fracture of the May 17, surgical neck of the left hu- 18GL merits and the coracoid pro cess of the scapula by n musket ball. Gunshot fracture of the left Oct, 19, shoulder. 1804. Fracture of the right humerus, Dec. 19, scapula, and clavicle by frag- 1804 ment of shell. Minie ball passed through the shoulder joint, destroying it. Musket ball comminuted the Sept. 10, upper third of right humerus 1864 and injured the scapula. Gunshot fracture of the aero- May 25 mion and coracoid processes 1804. of the right shoulder, with injury of the head of the hu- merus and the spine of the scapula. Gunshot wound of the right Feb. shoulder, involving the joint. 1865. Conoidal ball passed through Jan. 7, the left shoulder joint, shat- 1865. tered the head and neck of the humerus, and fractured the head of the scapula. Gunshot fracture of the right May 30, humerus, extending into the 1864. shoulder joint. Shell fragment fractured the Aug. 25 left shoulder. 1864 Acromion process of the left Nov. 26, scapula and the head and 1863. shaft of the left humerus shat- tered by a musket ball. Mini6 ball passed directly July 12 through left shoulder joint, 1864 fracturing the articular sur- face of the head of the hu- merus and the acromion of the scapula, and dividing the long tendon of tho biceps. Conoidal ball fractured the left May 1 shoulder joint. 1804 Opera- tion. Operation and Operator. Excision of the outer third of the head and the correspond- ing part of the acromion pro- cess, liv Assistant Surgeon B. Howard, I'. S. A. Removal ofthe head and three inches of the shaft uf the hu- merus, with the articulating surface of the scapula, by Surgeon A. P. Clark, 6th New York Cavalry. liescntion of the head and two inches of the shaft of the hu- merus, the coracoid and acro- mion processes, a portion of the sjline, anteriorand inferior bonier uf the scapula, and a portion of tlie glenoid cavity, by A. A. Surgeon A. Sterling. Secondary excision of the head and two'inches of the shaft of the humerus, and the head and neck of the scapula. Excision ofthe head ofthe hu- merus, the coracoid process, and p'irtioii of the articulating end of the scapula, hy A. A. Surgeon R. Ottman. Head and two inches of the shaft and fragments of the coracoid removed, through a V-shaped incision, by Surg. O. A. Judson, U. S. V. Removal of the acromion pro- cess and the head of the hu- merus, hv Surgeons Morfitt and C. H.'Todd, 13th Virginia. Removal of the head and one and a half inches ofthe shaft of the humerus, the coracoid process of the scapula, and the head of the clavicle, by Surg. L. W. Bliss, 51st New York. Excision of part ofthe glenoid cavity and the head of the humerus. Head and portion of the shaft of the humerus, four inches in all. and the acromion pro- cess of the scapula, removed through a linear incision, bv Surg. M. Goldsmith, U. S. V. Excision of the head of the humerus through the surgical neck, and the fractured pro- cesses and fragments of the spine of the scapula, bv Surg. G. L. Pancoast, U. S.'V. Excision of the head of the humerus and the acromion process of the scapula, thro' a V-shaped incision, by A. A. Surgeon XV. XV. Bidlack. Removal of the head and dis- eased portions of the scapula and the head of the humerus, by Surgeon J. 11. Ludlow, U. S. V. Removal ofthe head and three inches ofthe shaft and a por- tion ofthe acromion, through a straight incision, by A. A. Surgeon F. XV. Kelly. Removal of the head ofthe hu- merus and the acromion pro- cess of the scapula, by Surg. Dickson, 4th Louisiana. Excision of the head and four inches of the shaft of the hu- merus, and a portion of the scapula, bv Surgeon F. XV. Lytic. 36tli Illinois. The head of the humerus and three-fourths of an inch of the acromion removed, through a straight incision, by Assistant Surgeon G. A. Mursick, U. S. V. Removal of the head of the humerus, the acromion pro- cess, a portion of the spine of the scapula, and the missile, by Surg. N. Hayward, 20th Massachusetts. Disch'd October 10, 1864. and pensioned; arm nearly useless. Spec. 1377, A. M. M. See Cask 1497. Disch'd August 22, 1865, and pensioned; useful arm. Escaped February 18, 1864. Spec. 2090, A. M. M. Died April 25, 1864. Spec. 2724, A. M. M. Died June 26, 1864. Spec. 3265, A. M. M. Disch'd Dec. 12, 1864. and pen- sioned; ann useless for manual labor. Spec. 2479, A. M. M., and Fig. 2, Plate XIII. Transferred, for exchange, Feb- ruary 16, 1805. Discharged July 8, 1865, and pensioned; arm powerless. Disch'd Aug. 21, 18C3, and pen- sioned. March, 1870. arm use- ful from the elbow down. Disch'd July 23, 1863. and pen- sioned. April. 1869, arm short- ened nearly four inches, and useless. Died June 3. 1864. Spec. 2466 A. M. M. See Case 1494. Disch'd June 27, 1P0.5. and pen- sioned: muscular atrophy: mo- tion at the elbow joint is nearly perfect. Disch'd March 14, 1865, and pen- sioned ; perfect use of haud and forearm. June 7th, secondary haemorrhage; ligation of circumflex artery. Dicil June 16, 1864, from recur- rent hsemorrhage. Retired March 13, 1865, for dis- ability, by Retiring Board. Disch'd February 24, 1865, and pensioned. Disch'd October 6,1864, and pen- sioned; "shoulder joint de- stroyed." Disch'd January 17, 1865, and pensioned: arm powerless and nearly useless. ■~)2i\ INJURIES OF THE UPPER EXTREMITIES. [chaimx. Namk, Aoe. anp Military DPmRIPTION. Datk. OI" Injury. Nature of Injury. Date of Opera-tion. Operation and Operator. Result. Thomas. E. M. D., Pt., G, 8th Louisiana, age 30. Unknown. Pt., 6th New York Cavalry. Way, J., Pt., G, 9th Colored Troops, age 19. Webster. A. G., Pt., II, 7th .Maine, age DO. Weller, I, l't., G, 12th Vir-ginia, age 21. Aug. 25, 1864. June 11, 1864. Sept. 29, 1864. June 10, 1864. June 11, 1864. Gunshot fracture of the left shoulder joint. Conoidal ball fractured the head of the left humerus and the scapula. Gunshot wound of the left shoulder joint. Musket ball crushed tbe head ofthe left humerus and passed through the glenoid cavity, shattering the head of the scapula. Gunshot fracture of the head ofthe left humerus, the glen-oid cavity, and the neck of the scapula. Aug. 25, 1864. June 11, 1864. Jan. 9, 1865. June 10, 1864. June 29, 1864. Excision of the head of the humerus and the acromion process of the scapula, by Surgeon J. N. K. Monmonier, 8th Louisiana. Removal of the head of the humerus, fragments of the scapula, and ball, through a straight incision, by Ass't Surg. J. XV. Williams/U.S.A. Head of the humerus and a portion of the acromion pro-cess of the scapula removed, through a straight incision, by A. A. Surg. F. E. Martin-dale. Excision of the head and neck of the humerus and t wo-thirds of the bead of the scapula, by Surgeon G. T. Stevens, 77th New York. Excision of the head, one inch of the shaft of the humerus, with a portion of the scapula, through a straight incision. Transferred, for exchange, Feb-ruary 16, 1865. The patient fell into the hands of theenemy. Spec.2933,A.M.M. Disch'd July 3, 1865, and pen-sioned ; arm useless for labor. Disch'd December 2, 1864. and pensioned; cannot extend hand to mouth. August 30, 1864, condition favor-able; furloughed; recovered. It will be observed that there were ten fatal, and one undecided case, and that there was an excessive fatality in the eleven intermediary operations. The ten deaths were ascribed to consecutive hsemorrhage in two instances, to pysemia in five, to erysipelas in one; in the two remaining cases the proximate causes of death can only be surmised. Thirty-six of the patients were Union, and six Confederate soldiers, and five of the latter1 recovered and were sent home, faring even better than their opponents. Partial Excisions of the Head of the Humerus.—While the extraction of fragments of the shattered head of the humerus was common, formal excisions of portions of the head were seldom attempted. Such operations were approved by Baudens,2 whose services in promoting the employment of excisions of joints in military surgery have been insuf- ficiently appreciated. Few other authors have even mentioned this particular group. There were fourteen examples reported, of which two will be detailed: Case 1498.—Pi-ivate Robert Wilson, Co. D, 6th Connecticut, aged 24 years, was wounded at Pocotaligo, October 22, 1832, and was admitted into hospital Xo. 1, Beaufort, on the 24th. Surgeon E. B. Bontecou, U. S. V., furnished the following special report of the case : "This patient was admitted with a gunshot wound of the left shoulder, the ball entering anteriorly, midway between the acromion and coracoid processes, and grazing the internal aspect of the head of the humerus deeply at its junction with the neck of that bone. No otlier wound was made, and the ball was not discernible through the wound. A considerable swelling under the pectoralis, near the clavicle, with tenderness and green discoloration, indicated the possibility that the ball was lodged there. Motion of the arm was painful; no crepitus, however. The swelling extended to the shoulder and arm, with some oedema of the forearm; radial pulse good. Wet dressings were kept applied until October 28th, when ice- bag and cerate dressings were substituted. On November 11th, the swelling having considerably subsided, I resected the head of the humerus bya transverse incision ofthe deltoid, and a perpendicular one from it down the posterior part of the arm. The chain saw was applied, after dissecting back the soft parts to a very small extent, and without dividing the attachment of any other muscle, the long head of the biceps having been shot away. Ice and cerate were continued, with oiled lint in the wound. When the joint was laid open, pus in considerable quantity came away. A track was discovered leading inward under the clavicle, but the ball could not be found. The swelling soon very much diminished, and the patient expressed himself as very well. On November 6th, there was increase of pain, and evidently more swelling in the infra- and supra-scapular regions, with tenderness and well-marked fluctuation, but no discoloration. The clavicle is difficult to recognize, the parts are so tense and swollen. A poultice to cover the whole shoulder and neck was ordered, and a laxative of castor oil, and half-diet. On November ?th, the patient was doing well; the discharge of pus was copious; full diet, with a half-pint of beer at noon and night, was directed. On November 8th, the patient was doing well, but as he had not slept well the previous night, ten grains of Dover's powder was ordered. On the 10th, the abscesses in the neck and underneath the pectoral muscle having discharged 1 In a letter dated Williston, Fayette County, Tennessee, March 25, 1874, to Surgeon General Barnes, .Mr. Richard Inge remarks that the opera- tion at the Overton Hospital was '"A complete success. I am writing with the arm, a masterpiece of surgical skill." He fears that the case may have been lost sight of, after his escape from prison. He announces that he is on his way to his native city of London, but is willing to visit Washington (asking only that (lovernment, against which this foreigner had fought for several years, should supply transportation). His chirography is so good as to be almost as remarkable as his impudence. 2 Baudkxs. Mimoire sur la Risection de la tete de Vhumirus, dans le Recueil de Mem. de Mid. de Chir. et de Phar. Militaires, 1855, 2eme serie, FXtTSTOXS AT TIIR SHOT LI HIP. lit FlG. 403.— Portion of the head of the left humerus ex- cised for shot- fracture. Spec. 2029. I'li. 402.—Result of excision ofthe head of the left humer- us for shot-fracture. [From a photograph.] through the shoulder wound, tlie poultices wore discontinued; and the surfaces of tlie deltoid, which had torn from the sutures and were {raping, were approximated with straps, and tlie whole limb was enveloped in lint and dry tow. On November 18th, the abscess of the neck and breast suppurated less. On November 26th, suppuration was again quite copious, and there was indistinct fluctuation above the clavicle, and also in the pectoral region, midway between the nipple and the left clavicle. Some wads of clothing were this day removed bv the dresser, as they were projecting from the wound. The lips of the wound were drawn together gently by straps, and charpie was applied. The patient was permitted to dress and to walk about, and felt better than • when in bed. On December 1st, the abscess over the clavicle was opened and a considerable quantity of pus escaped. I was unable to discover the ball, as I had hoped. A poultice was applied to this abscess. On Decem- ber 10th, the abscess midway between the nipple and clavicle was opened and there was a free discharge of pus. A probe could be passed under the clavicle and all through the axilla, which was one vast pus- bag. I could not discover the ball. The patient walked about, and was off the bed the greater part of every day. On December 29th, this man had gained llesh ; bis wounds were nearly closed, and there was but little discharge. He was sent northward on the steamer Star of tho South." lie entered hospital at Port Wood, December IU, l-\>2, and was thence sent to New Haven, and transferred to the Veteran Reserves, September 30, 1833, and subsequently discharged and pensioned, September 4,1834. At Fort Wood Dr. Bon- tecou saw this soldier, in July, 1833, "'quite well, and with a useful arm." (See Fig. 402.) Examiner \V. H. Trowbridge, of Stamford, July 8, 1837, reported: "Applicant is so crip- pled as to be unable to use his left shoulder. He suffers much pain, and his general health is permanently affected." On February 17, 1874, Mr. Wilson visited the Army Medical Museum, and stated that in October, 1834, while leaping to the ground from a fence, the ball became dislodged, and was removed by Dr. Hulburt, of Stamford. The excised portion of the humerus from this case was contributed to the Museum by the operator, Dr. Bontecou, and is represented in the adjacent wood-cut (FlG. 403). The line of section is oblique, crossing the anatomical neck. This pensioner was paid March 4, 1874. Dr. Bontecou reported the following case also; and appears to have earnestly con- curred in the sound doctrine of MaWisme and of Baudens, that the surgeon is not at liberty to sacrifice the smallest portion of tissue which it may be practicable to save: Case 1499.—Corporal H. Hatfield, Co. 13,14th New York Heavy Artillery, aged 23 years, was wounded at Fort Steadman, March 25,1835. and was received into the Ninth Corps hospital at City Point; thence transferred to Washington, and admitted into Harewood Hospital on April 2d. Surgeon E. B. Bontecou, U. S. V., reported: '"Gunshot wound of the right shoulder, the ball entering near the distal extremity of the clavicle and passing out below the acromion process of the scapula, injuring the head of the humerus. The wound was somewhat inflamed and discharging freely. On May 6th, the patient was placed under the influence of ether, and a small portion of the head of the humerus was resected. Simple dressings were applied and supporting treatment ordered, with favorable result." The patient was doing well when discharged from service, July 28, 1835. He was pensioned from this date, and was paid to March 4, 1874; but there are no records of the biennial examinations on file in the Pension Office. The photograph represented in the wood-cut (FlG. 405), together with the specimen (IlG. 404), preserved in the Army Medical Museum, was contributed by the operator, Dr. Bontecou. The specimen is described by Dr. Woodhull as "a portion of the head of the right humerus excised for gunshot, and consists of a section one-half inch in its greatest thickness, completely carious, and retaining tion'of headofSi-'l.t but a sma11 Part of the articular surface."—Cat. Surg. Sect, humerus excised 1833, p. 97. A further search of the record of this pensioner, after shot injury. i ■ ■, . „ „,., ,,,,,.,. , , Spec. 4:>AJ wno resides at Perry City, New \ork, indicates that the result „ , . Fig. 40j.—Cicatrices after an excision at the shoul- ot the operation must have been tolerably satisfactory, since, der. [From a photograph.1 September 4, 1-71, a reduction was made in his pension. Examiner M. M. Brown, of Ithaca, reported, December 23, 1873, that there was "complete anchylosis" [at the shoulder]; that the arm was "shortened one and a half inches, and the muscles of the arm are much atrophied, and the movements of the arm very limited." The pensioner's request for increased assistance was accorded, "to date from Marcli 4. 1874." In May, 1874, Examiner M. L. Bennett, of Watkins, reported the disability as verv serious. ;)i'S INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. There is an interesting specimen in the Museum, contributed by Dr. B. Howard, U. S. A., that illustrates this special operation,1 although, as complicated by an excision of the clavicle, the case is classified elsewhere. It is one of the few osteological preparations in the collection, from cases of primary excisions limited to the epiphysis. The results in this series attest, at least, the comparative safety of free openings into the shoulder joint after shot injury, but do not prove that, when the head of the humerus is grazed or grooved by a ball, it is safer to slice off the injured portion rather than to decapitate the bone. Anchylosis was too frequent to permit much to be said in favor of partial excisions in this region: Table XXIII. Summary of Fourteen Cases of Partial Excisions of Head, of the Humerus after Shot Injury. Name, Age. and Military Description. Date of Injury. Nature of Injury. Date of Opera- tion. Operation and Operator. Result. 1 Caldwell, J., Lieut., F, 61st Pennsylvania. Dennison, W. J., Corporal, Thompson's Independent Battery. Fulton, W. J., Pt,, A, 1st Pennsylvania Cavalry, age 22. Gissel, W. S., Pt., E, 5th Maryland. Harrington, M., Pt., B, 11th Infantry, age 23. Hatfield, H., Corp'l, B, 14th New York Heavy Artillery, age 23. Jones, S. XV., Pt., M, 12th Pennsylvania Cavalry, age 18. Jones, W., Corp'l, K, 100th New York, age 22. Mahon, D., Pt., D, 57th New York. McCulley, T., Corporal, B, 63d Pennsylvania. Robbins, S., Pt., D, 42d Illinois. Sargent, A. H., Pt., F, 4th Texas, age 25. Wilson, R., Pt., D, Gtli Con- necticut, age 24. Yeazell, S., Pt., B, 06th Ohio, age 19. Aug. 21, 1864. Sept. 17, 1862. July 10, 1863. Sept. 17, 1862. July 2, 1863. Mar. 25, 1865. July 25, 1864. April 2, 1865. Sept. 17, 1862. May 3, 1863. Nov. 25, 1863. July 3, 1S63. Oct. 22, 1862. June 15, 1864. Ball shattered about one-half of the head of the humerus. Head of the right humerus deeply notched. Fracture of head of left hu- merus. Shot \found of right shoulder. Conical ball passed through head of left humerus; also, wound of right arm. Head of right humerus frac- tured. Inner half of the head of the left humerus much shattered. Aug. 21 1864. Oct. 4, 1862. July 11 1863. Nov. 20, 1863. May 8, 1865. Aug. 15, 1864. Right shoulder joint fractured Sept. 15, by a conoidal ball. 1865. Shot wound of left shoulder... Fracture of head of right hu- merus; loose fragments of bone became necrosed. The same ball destroyed the left eye and fractured the superior maxilla. Head of the left humerus frac- tured; parts indurated; fistu- lous openings. Ball split the head ofthe right humerus longitudinally and from right to left. Ball entered between acromion and coracoid processes and lodged in the head of the left humerus. Conical ball passed through the right shoulder joint and scapula. Oct. 1, 1862. July29, 1863. Aug. 16, 1864. Nov. 1, 1862. June 16 1864. Shattered portion of head re- moved with gouge, by Surg. O. T. Stevens, 77th N. York. Head partially resected, by Surg. II. S. liewit, U. S. V. Excision of sharp points and removal of fragments from head. Wound enlarged and shattered fragments excised. Posterior half of head excised, by A. A. Surg. A. D. Hall. Portion of the head of the hu- merus excised, by Surgeon It. B. Bontecou, U. S. V. Excision of inner half of the head, by A. A. Surgeon J. Dickson. Two-thirds of the head of the humerus excised, by Ass't Surg. J. H. Armsby, U. S. V. Partial resection of head of humerus Half of the head excised by straight incision through del- toid, by Ass't Surgeon W. Thomson, U. S. A. A large portion of the head excised, by A. A. Surgeon J. Sloan. Anterior portion of the head of the humerus removed. Superior and greater portion of head excised, by Surgeon It. B. Bontecou, U. S. V. One-half inch of the head re- moved with the chain saw, by Surg. J. W. Brock, 66th Ohio. Disch'd September 3, 1864. Not a pensioner December 4, 1874. Disch'd November 24, 1862, and pensioned. Sept, 1874, unable to elevate arm beyond level; arm useless for manual labor. Disch'd Sept, !), 1864, and pen- sioned. April, 1873, arm use- less for manual labor. Died November 10, 1862. Disch'd April 5,1864; pensioned. March, 1874, both arms much weakened in use of muscles. Disch'd July 25,1865; pensioned. May, 1874, muscular atrophy ; has very little motion of arm or forearm. Spec. 4143, A. M. M. Disch'd June 30.1865; pensioned. September, 1873, complete an- chylosis of left shoulder joint and muscular atrophy. Disch'd January 15, 1866, and pensioned. Sept., 1873, anchy- losis of shoulder joint and mus- cular atrophy ; can use hand for writimr. Spec. 588, A. M. M. Duty, January 21, 1863. Not a pensioner in December, 1874. Disch'd July 13, 1864, and pen- sioned. May, 1873, unfitted for all manual labor. Spec. 1683, A. M. M. Disch'd December 23, 1864, and pensioned. April. 1872, com- plete and permanent anchylosis at shoulder joint Furloughed October 14, 1863. Disch'd September 4, 1834, and pensioned. Sept., 1873, loss of use of arm. Spec. 2029, A. M. M. Mustered out March 3, 1865, and pensioned. Sept., 1873, partial stiffness of tbe joint, and pain upon motion. An analysis of this brief tabular statement is almost superfluous. It will not escape the reader's attention that but one of the cases terminated fatally, that three were primary, three intermediary, and six secondary operations, and that in two cases the date of operation was undetermined, and that one of these was the single fatal case. Of the nine pensioners in this category, it is reported that two preserved serviceable arms, while anchylosis or "a useless arm" is recorded in seven instances. 1 Specimen 1377, Sect. I, A. M. M. The details of the case are given on p. 523 (Cash 1497), and the operation is tabulated as No. 20 in Taislk XXII. Fie II Fig 111, he. IV. Wai .1 phot IJ.eu l,tl PLATE XIV. RESULTS OF EXCISIONS OF THE HEAD OF THE HUMERUS Kie.l I/ipuI Jacobs Spec 1787 A.MM Fk; II. Private VV A. Herdersofi r'u; III. Private Reardon Sn-x m« A M >•' Km. IV. Lieut. ('. T. Rand. mm v.. • '.-A-' H,-:' A "''.r; ' * :?fc .--a PLAT' XiV RESU-TS Or EXCISIONS HEAD OF THE HUMERUS >■.- 'A SECT. III.] EXCISIONS AT THE SHOULDEU. 529 Decapitation of the Humerus for Shot Injury.—There were two hundred and seventy-three of this category. Primary Decapitations of the Humerus for Shot Injury.—One hundred and seventy- five operations were referred to this group. A few will be detailed, and all tabulated. ^Successful Cases.—There were one hundred and nineteen survivors, of whom a large proportion retained a useful hand and forearm and several a serviceable upper arm: Case 1500.—Sergeant C. F. Rand, Co. K, 12th Now York, aged 24 years, was wounded at Gaines's Mill, June 27, 1862. Tliere is no hospital record of the case until the patient's arrival at Philadelphia; but, twelve years subsequently, the injured man stated that "he laid on the field all that night, and was carried to the general field hospital at Savage's Station the next morning. There was free bleeding from the wound. At Savage's Station the head of the humerus was excised, either by Surgeon E. Bentley, 12th New York, or by Acting Assistant Surgeon J. Swinburne. From this station he was sent to Rich- mond." He complained of the road and river transportation. After discharge from the prison hospital he stated that he was exposed at the dock until the arrival ofthe transport Daniel Webster, on which he was conveyed to Philadelphia. He entered Satterlee Hospital on July 30, 1862, and was discharged a month subsequently and pensioned, Surgeon I. I. Hayes certifying: "Resection of shoulder, necessitated by shot wound." This pensioner re-enlisted in the Veteran Reserves, and was appointed in November, 1863, a second lieutenant, and assigned, in May, 18(14, to duty at Douglas Hospital. Assistant Surgeon W. Thomson, U. S. A., had prepared a photograph, which is copied in Figure 4 of Plate XIV, opposite page 529, and furnished a copy to the Museum with the following memorandum: "This officer can use his arm at table, and plays well on the banjo." On January 1, 1868, Lieutenant Rand was discharged. Examiner John Root, of Batavia, New York, in June. 1869, reported: "The arm hangs by the muscles and ligaments, and for manual labor is of no use;" and, in September, 1873, Examiner J. O. Stanton reported: "About three inches of shortening of the limb. Cannot raise the arm. Has little use of the hand." This pensioner was paid in September, 1874. Another case, represented on Plate XIV, was reported by the operator as simply a primary decapitation of the humerus, though subsequent reports would indicate that several inches of the shaft were removed. It is probable that consecutive necrosis and the elimination of tubular sequestra may account for the discrepancies in the report: Case 1501.—Corporal W. A. Henderson, Co. K, 1st U. S. Sharpshooters, aged 21 years, was wounded at Kelly's Ford, November 7, 1863. Surgeon J. W. Lyman, 57th Pennsylvania, reported, from a Third Corps hospital: "A gunshot fracture of the head of the right humerus, with resection of three inches." This patient was sent to Washington, and entered Douglas Hospital November 9th. Assistant Surgeon W. Thomson, U. S. A., reported: "Resection of right shoulder joint. This man was discharged May 3, 1864." Dr. Thomson sent to the Museum a photograph, which is represented in Figure 2 of Plate XIV, opposite page 529, with a statement that the "arm is useful; the patient can feed himself and take his hat off." This corporal was pensioned. Examiner W. A. Jackson, of Lapeer, Michigan, November 26,1866, reported: " The ball entered at the tuberosity ofthe right humerus and came out one inch below the coracoid process of the right scapula, completely comminuting the upper portion ofthe humerus. Four inches ofthe bone is lacking. The muscles ofthe right side of the chest both front and back are shrunk, leaving the right side of the thorax looking like a skeleton. The lung on the right side, below the clavicle, gives a dull sound on percussion, and the right side of the chest does not fill well in the act of respiration, and he is not able to make use of the right arm and hand." This pensioner was paid September 4, 1874. Case 1502.—Sergeant C. A. Winser, Co. A, 6th Wisconsin, aged 22 years, was wounded at Gravelly Run, March 31, 1865. Surgeon A. S. Coe, 147th New York, reported, from a Fifth Corps hospital: "A wound of the right shoulder by a mini6 ball." On the same day the head of the humerus was excised by Surgeon John C. Hall, 6th Wisconsin, through a straight incision parallel to the axis of the arm. On April 3d, the patient was sent to Washington, and entered Columbian Hospital, and, May 4th, was transferred to Judiciary Square Hospital. Surgeon E. Griswold, U. S. V., reported: " * * Admitted with resection of right shoulder, performed on the field. * * On May 14th, the wound was attacked with erysipelas, which in a few days subsided." On June 13, 1865, this soldier came to the Army Medical Museum, and a photograph was made, which is copied in Figure 2 of Plate XVIII, opposite page 544. There was "nearly complete cicatrization, and promise of a com- paratively useful arm." He was discharged July 16,1865, and pensioned. Examiner J. Nichols, of Washington, July 20,1865, reported: "Had resection ofthe head and two and a half inches ofthe shaft ofthe right humerus, with margin of glenoid cavity. Arm useless for labor." Examiner H. C. Taylor, of Chautauqua, New York, November 10, 1863, reported: "The wound not soundly healed; occasionally suppurates; is very painful. Arm nearly useless. I think amputation would be preferable under the circumstances." The "biennial" pension report of 1873, made by Examiner C. Hard, of Ottawa, Illinois, elicited no new facts. This pensioner was paid June 4, 1874. Case 1503.—Private J. M. Davis, Co. C, 10th Georgia, aged 19 years, was wounded at Gettysburg, July 3, 1863. He Btated that, at a field hospital for Confederate prisoners, resection ofthe head ofthe left humerus had been performed by Surgeon J. J. Knott, P. A. C. S. On July 25th, the patient entered Camp Letterman Hospital. Acting Assistant Surgeon H. H. Sutton noted: "A mini<5 ball fractured the left humerus two inches below the shoulder joint. Resection of the head of the humerus was performed. When admitted the patient was very feeble; wound suppurating very freely; arm much swollen; had trouble- some diarrhoea. August 15th, diarrhoea checked. August 20th, erysipelas. September 2d, erysipelas disappeared; health 67 530 INJURIES OF THE UPPER EXTREMITIES. ICHAP. IX. improving; discharge from wound diminished. September 15th, arm still swollen. October 15th, transferred, convalescent." This soldier was sent to West's Buildings Hospital, Baltimore, on October 15th, and paroled November 12, 1863. In 1869. the operator, Dr. Knott, forwarded to the Army Medical Museum a photograph ofthe patient (Card Photographs, Surg. Sect., A. M. M., Vol. I, p. 7) with a copy of a letter received from him, stating: * * "In the first place, the part of Nature to form a bone was nothing more nor less than a mere gristle attaching itself to the shoulder and to the end of the bone, which is about five inches down the arm. The end of the bone feels somewhat ragged, as though it never had been sawn off, though I think that roughness was caused by a decaying of the bone during my long sickness at Gettysburg. My arm is as limber as a rag, and as sound as any flesh. When I think of the strength and use of my arm, I feel under many obligations to you; for I have been told that you contended for the operation, while the others opposed it and were in favor of cutting the arm off at the shoulder. I use it to a good advantage in ploughing, hoeing, and cutting with an axe. I have never tried particularly to see how much I could raise from the ground, but to show some gentlemen, one day, that I had strength in it, I raised a coil of rope from the floor of a grocery store, which (the merchant said) weighed about one hundred and twenty-five pounds; it didn't feel very heavy. I find a greater difficulty in striking or nailing overhead than anything that I have ever tried." Preparations of primary decapitations of the humerus after shot injury were rarely preserved. The Museum has but five from the one hundred and seventy-five operations.1 Case 1504.—Lieutenant-Colonel W. M. L------, 89th New York, aged 23 years, was wounded at Fair Oaks, October 27 18(54. He was sent from an Eighteenth Corps hospital to Hampton Hospital. Surgeon D. G. Rush, 101st Pennsylvania, con- tributed the specimen (Fig. 406) with the following history: "Wounded by a musket ball, which entered immediately outside of the right coracoid process and passed backward and outward, making its exit through the back part of the deltoid muscle. below the posterior border of the acromion, and involved the head of the bone by passing directly through the top of it. He was admitted to hospital at Fort Monroe, October 29th, and I removed the head of the bone on the same date by making a V-shaped flap incision. The head was enucleated, and sawed off through the surgical neck by a chain saw. This operation was followed by perfect recovery. The treatment consisted in cold-water irrigation, nourishing diet, tonics, stimulants, etc." This patient was discharged May 15, 1865, and pensioned. Examiner W. H. Johnson, of Johnstown, New York, January 23, 1866, reported: "He has not the use ofthe arm, although he has the use in part of his fingers." In September, 1867, Examiner C. C. P. Clark, of Oswego, reported "the humerus badly diseased and the arm entirely useless." In September, 1869, Acting Assistant Surgeon W. P. Buel, Petersburg, Virginia, certified : "I find that the wound is still open and discharging purulent matter, proving that the bone is still exposed." This pensioner died May 9, 1874. Dr. J. H. Claiborne, of Petersburg, states that: "His death was caused directly by haemorrhage from the lungs, indirectly by pulmonary abscesses, the result of a protracted drain upon hissystem by the wound in his shoulder, which wound had never healed, but required dressing daily, and discharged more or less pus, sanious matter, and necrosed bone," and that "there were some three or more openings upon the surface ofthe shoulder anteriorly," and " thatthe distal end ofthe clavicle had also the appearance of having been involved, either in the primary or secondary accidents of the wound." * * "Had frequent attacks of inflammation of the lung, abscesses, and haemoptysis, often endangering his life." * * "The lung in the wounded side was almost exclusively affected," etc. The wound ofthe shoulder was recognized hy the Pension Bureau as the remote cause of death. Case 1505.—Private T. Donohue, Co. K, 123d New York, aged 19 years, was wounded at Peach Tree Creek, July 20, 18li4. Surgeon C. N. Campbell, 150th New York, reported, from a Twentieth Corps hospital: " Gunshot wound of left shoulder, resection of head and neck of humerus," and a further report states: "Surgeon J. Chap- man, 123d New York, excised the head of the humerus." Four days subsequently the patient was transferred to Nashville, where he remained till the end of August, and then went to Louisville, and entered Brown Hospital, where Dr. B. E. Fryer, U. S. A., recorded: "A shot fracture of the head and neck of the left humerus. Excision was made through a straight anterior incision of about four inches, on the field, and the wound was nearly healed when the patient was admitted here." After a few days this soldier was sent to Albany, and entered the Ira Harris Hospital May 3, 1865. Pro- fessor J. H. Armsby reported the excision as heretofore narrated, and contributed to the Museum a plaster cast of the mutilated limb, which is represented in the adjacent wood-cut (Fig. 407). It is described (Cat. Surg. Sect., 1866, p. 538) as a cast of the left shoulder [taken] about one year after a primary excision ofthe head of the humerus. There are two large circular cicatrices on the anterior face of the upper portion of the arm, which is somewhat flattened but not otherwise deformed." Examiner J. S. Delavan, Albany, July 12,1865, reported: * * "The upper part of the limb is, of course, entirely useless. The operation is the most successful I have ever seen." Examiner W. S. Searle, of Troy, in 1866, reported the limb as "of no service in manual labor." In September, 1873, Examiner W. S. Austin, of Oxford, Kansas, reported that: "The deltoid muscle and those adjacent are atrophied, and the arm is useless for the purposes of manual labor." This pensioner was paid June 4, 1874. Three of the recovered cases are illustrated in the lithographic plates.2 Fir,. 406.—Head of the right humerus primarily excised for shot fracture. Spec. 3802. Fig. 407.—Copy of excision at the Spec. 4203. of a plaster cast in a case shoulder after shot injury. KCat. Surg. Sect, 1866, Specimens 380;?, 5749, of cases of recovery, and 2838, 1062, and 4023, ef fatal cases. *See Figures 2 and 4, of Plate XIV, opposite page 529, and Figure 2, Plate XVIII, opposite page 544. SECT. III.] EXCISIONS AT THE SHOULDER. Table XXIV. 531 Summary of One Hundred and Nineteen Cases of Recovery after Primary Decapitation of the Humerus for Shot Injury. Name, Age, and Military Description. Natl" «k of Injur v. Opera- tion. Operation and Operator. Result and Remarks. Adams, T., Corp'l, I, 80th Illinois, age 20. Agnus, F., Lieut., 5th New York. Armstrong. W. M., Serg't, D, 20th Mississippi, age y4. Baker, W. H, Lieut., C, "th Tennessee, age 2-'. Balcom, H. A., Serg't, D, 6th MaiDe, age 25. Bancroft, P. S._, Lieut., E, 111th Pennsylvania, age 32. Barkley, A. J., Pt., D, 32d Iowa, age 22. Barnes. J. H., Pt., K, 4th Michigan. Barrett, G., Pt., Pumell Le- gion, age 37. Bell, H. W., Corp'l, A, 14th Virginia, age 33. Bevard, H., .Serg't, E, 61st Ohio, age 23. BiUmire, C. XV.. Pt., G, G3d Ohio, age 20. Bofo, A. G.. Pt., H, 8th Georgia, age 26. Booker, D., Pt.. K, 4th Ohio Cavalry, age 23. Bowen, G. IF., Serg't, B, 1st Georgia, age 24. Brogan, P., Pt.. I, 69th Penn- sylvania. Brown, B. F.. Pt., F, 38th Georgia, age 21. Bryan. P., Corp'l, A, 93d Illinois, age 33. Bosh. X., Pt., C, 60th New York, age 25. Campbell, T. .)/., Pt.,C,17th Mississippi, age 27. Colburn, T., Pt, M, 2d Con- necticut Artillery, age 28. Cray, L., Corp'l, D, 9th Minnesota, age 21. Davis, J. M., Pt., C, 10th Georgia, age 19. Dibble, A. H., Pt., F, 33d New York. Dicker son, A., Serg't, D,25th Georgia. Dixon, H. W., Capt., 6th S. Carolina Cavalry, age 34. Donohue, T., Pt., K, 123d New York, age 19. Downs, J. E., Pt., E, 9th U. S. C. Troops, age 24. Dustin, S. B., Pt., K, 117th New York, age 34. Ellison, R., Serg't, E, 3d Georgia, age 23. Emery, W. H., Lieut., C, 19th Maine, age 24. Eve, L. H., Corp'l, A, 6th Missouri, age 24. Everett, J., Pt., F, 55th Pennsylvania, age 32. July 4, 1864. June 27, 1862. Nov. 30, 1864. June 3, 1864. Mav 10, 1864. Sept. 17, 1862. April 9, 1864. Sept. 30, 1864. Aug. 18, 1864. Julv 3, 1863. Julv 26, 1864. July 27, 1864. July 2, 1863. June 3, 1864. Nov. 30, 1864. Mav 12. 1864. Dec. 13, 1862. Nov. 25, 1863. May £6, 1864, Dec. 11, 1862. June 22, 1864. Dec. 15, 1864. July 3, 1863. Mav 3, 1863. Dec. 7, 1864. Oct. 7, 1864. July 20, 1864. Sept. 29, 1864. June 27, 1864. Aug. 21, 1864. Mav 6, 1864. Dec. 28, 1864. June 18, 1864. Head of right humerus shat- tered Right humerus comminuted .. Head of right humerus frac- tured. Comminuted fracture of head of right humerus. Ball passed through neck of right humerus. Right humerus fractured near the shoulder joint. Right humerus fractured...... Wound of right shoulder joint by a mini6 ball. Fracture of upper portion of left humerus. Fracture of head of humerus.. Fracture of left humerus ; the ball emerged through the scapula. Comminution of right shoulder. Wound of right shoulder joint. Fracture of right shoulder joint. Gunshot wound of shoulder... Fracture of head of right hu- merus. Comminuted fracture of head of humerus. Fracture of left shoulder...... Shot fracture of the upper third of right humerus. Wound of right shoulder joint. Fracture of right humerus___ Conoidal ball lodged in head of left humerus, shattering the bone. Head of the left humerus com- minuted. Fracture of upper fifth of right humerus, and injury of right wrist joint. Fracture of head of the right humerus. Ball passed through anatom- ical neck. Head and neck of left humerus fractured. Fracture of the neck of right humerus; capsule slightly opened on outer side. Upper part of left humerus com- minuted ; joint involved. Fracture of upper third of hu- merus. Fracture of the left shoulder.. Wound of left shoulder joint. Fracture of left shoulder joint. July 4, 1864. June 27, 1862. Nov. 30, 1864. June 3, 1864. May 10, 1864. Sept. 17, 1862. April 9, 1864. Sept. 30, 1864. Aug 18, 1864. July 3, 1863. July 26, 1864. July 27, 1864. July 3, 1863. June 3, 1864. Dec. 1, 1864. May 12, 1864. Dec. 14, 1862. Nov. 25, 1863. May 26, 1864. Dec. 11, 1862. June 22, 1864. Dec. 15, 1864. July 4, 1863. May 4, 1863. Dec. 8, 1864. Oct. 8, 1864. July 21, 1864. Sept. 29, 1864. June 27, 1864. Aug. 21, 1864. May 6, 1864. Dec. 28, 1864. June 18, 1864. Head, through straight incis- ion, by Surg. S. H. Kersey, 36th Indiana. Head excised, by A. A. Surg. J. Swinburne. Head excised............... Head excised through a horse- shoe incision in deltoid. Head excised, by Surg. Dick- son, 14th Louisiana. Excision of head and neck... Head excised. Head excised, bv Surg. W. R. DeWitt, U. S. Y. Head excised, through straight incision, by Surgeon A. A. White. 8th Maryland. Head excised, bv Surgeon C. J. Bellows, 7th'Ohio. Head excised................ Head, through a three-inch incision, by Surgeon A. B. Monahan, 6:id Ohio. Head of humerus excised..... Head excised, by Surgeon A. Satterthwaite, 12th N. Jersey. Head excised over anterior aspect. Head excised, by Surgeon M. Rizer, 72d Pennsylvania. Head excised................ Upper portion of humerus ex- cised, by Surg. R. J. Mohr, 10th Iowa. Head excised, by Surgeon H. B. Whiton, 60th New York. Head excised through anterior longitudinal incision. Excision of head, by Surgeon G. L. Potter, 145th Pennsyl- vania. Head excised, through perpen- dicular excision in front, by Surg. A. T. Bartlett. 33d Mo. Head excised at surgical neck. Excision of head of humerus; gangrene and sloughing. July 22,1863, arm amputated at shoulder joint. Excision of head through in- cision over anterior aspect. Head excised through straight incision. Head and neck excised, thro' straight incision, by Surg. J. Chapman, 123d New York. Head and neck of humerus, by Surg. J. R. Weist, 1st U. S. Colored Troops. Head excised through linear incision. Head and neck of bone excised. Head excised, through a verti- cal incision, by Surgeon G. Chaddock, 7th Michigan. Head removed by flap opera- tion, by Surg. D. W. Harts- horne, U. S. V. Head excised, by Surg. G. T. Stevens, 77th New York. Disch'd Jan. 26, 1865; pensioned. Sept., 1673, arm hangs power- less ; has some use of the hand. Resigned July 26,1865. Good use of forearm. Not a pensioner. Transferred to Provost Marshal March 27, 1865. Furloughed July 26, 1864. Disch'd Sept. 27,1864; pensioned. Some use of arm; can flex el- bow and bring hand to chest. Resigned March 30, 1863; pen- sioned. Sept., 1873, arm use- less for manual labor. Disch'd Dec. 16,1864; pensioned. Sept., 1K73, atrophy of muscles of upper part of arm. Disch'd May 17,1865: pensioned. August, 1874, movements of shoulder greatly impeded. Disch'd May 31.1865; pensioned. September, 1873, use of arm totally destroyed. Exchanged November 12, 1863. Disch'd April 4,18C5; pensioned. September, 1873, total loss of use of left arm. Disch'd June 15,1865; pensioned. Sept., 1874, arm hangs helpless. Retired February 4, 1865. Disch'd Jane 21,1864; pensioned. September, 1873, the whole arm is nearly useless. To Provost Marshal January 27. 1865. Disch'd Dec. 12,1864; pensioned. February, 1871, cannot elevate arm; motions of hand good. Recovery. Disch'd Dec. 10,1864; pensioned. January, 1872. arm useless for manual labor. Disch'd May 4, 1865; pensioned. Sept., 1873, no use of arm, and but little of forearm and hand. Recovered, with good motion and partial use of arm. Disch'd Dec.24,1864; pensioned. Sept., 1873, very little motion at tbe shoulder joint. Disch'd Aug. 25,1865; pensioned. May, 1867, cannot extend arm; limb useless for manual labor. Paroled November 12, 1863. Disch'd Nov. 16,1863; pensioned. Disability total, third grade. Transferred for exchange, Feb- ruary 24. 1865. Furloughed October 31, 1864. Disch'd July 12,1865; pensioned. Sept., 1873, arm useless for man- ual labor. Spec. 4203, A. M. M. Disch'd Jan. 10,1866; pensioned. Disability total, third grade. Disch'd Dec. 29,1864; pensioned. Sept., 1873, loss of use of arm. Transferred for exchange. Disch'd Oct. 13,18H4 ; pensioned. Sept., 1873, partial muscular atrophy of arm and forearm. Disch'd June 6, 1865; pensioned. Sept.. 1873, muscles of arm atro- phied ; but little use of arm. Disch'd Jan. 2, 1865; pensioned. Sept., 1873, is unable to raise the hand; the arm hangs helpless. 532 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. Name, Age, and Military description. Farmer, W. M.. Pt., F, 82d Indiana, age 21. Fellhager, J., Pt, C, 27th Pennsylvania, age 47. Foot. A., Lieut., B, 14th Infantry. Foster, S. C., Pt., D, 5Gth Massachusetts, age 21. Fredenburg, G. W., Pt., B, 11th Connecticut, age 27. Gibson, W. A., Pt., B, 16th Alabama, age 2ti. Godfrey, P., Pt,, E, ICth N. Carolina Artillery, age 20. Grijjis, J. F., Pt., F, 9th Alabama, age 21. Ham, J., Pt., A, 1st North Carolina Cavalry. Hanniski, G., Pt., I, 46th New York, age 29. Hays, M., Pt., C, 151st New York, age 33. Haywood, M. H., Pt., C, 125th New York, age 44. Henderson, W. A., Pt, K, 1st Sharpshooters. Hendrickson, W., Pt, C, 143d New York, age 39. Hiser, W., Pt., K, 1st Ohio Cavalry, age 21. Houston, J. P., Capt, K, 5th Minnesota. Hyde, R., Pt, B, 3d Maine, age 28. Jackson, J. A., Pt, B, 28th Alabama, age 18. Jackson, R., Pt, B, 42d Virginia. Jackson, S. R., Lieut., G, 1st Maine Cavalry. Kauth, F., Pt., H, 9th New York, age 20. Kidder, J. E., Pt., C, 75th Indiana, age 30. Kingsley, G. "YV., Pt., 4th An; Massachusetts Battery. 18 Kirk, C, Corp'l, D, 1st Maine Nov. 4, Artillery, age 29. 1864. Datk OF Injury, Feb. 25, 1864. Nov. 25, 1863. Aug. 18, 1864. Mav 24. 1864. May 16, 1864. Nov. 29, 1864. May 29, 1864. July 3, 1863. June 9, 1863. Sept. 30, 1864. May 12, 1864. Oct. 7, 1864. Nov. 7, 1863. Sept. 14, 1863. Aug. 20, 1864. Dec. 15, 1864. May 31, 1862. Sept. 19, 1863. Mar. 25. 1865. Oct. 27, 1864. Sept. 17 1862. Sept. 19 1863. Lewis, XX'. M., Lieut.-Colonel, 89th New York, age 23. Liebman, L., Pt., I, 7th Wis- consin, age 17. Lipscomb, W. A., Serg't, C, 5th South Carolina, age 30. Little, T., Lieut., 1st Maine Cavalry, age 20. Livingston, R. N., Capt., F, 118th New York, age 19. Lynn, J. W., Pt., C, 52d Ohio. McClellan, J. F., Pt, B, 122d Ohio, age 23. Maher, W., Pt., D, 67th Ohio, age 30. Oct. 27, 1864. Feb. 7, 1865. Sept. 12, 1864. April 6, 1865. May 16, 1864. June 27, 1864. Nov. 27, 1863. Aug. 14, 1864. Nature of Injury. Fracture of upper portion of left humerus. Fracture of head of left hu- merus. Fracture of shoulder joint___ Fracture of upper third of left humerus. Head of right humerus frac- tured. Fracture of the head of the left humerus. Fracture of head of humerus.. Shell fracture of right humerus near surgical neck. Wound of right shoulder joint. Shot wound of right shoulder. Upper portion of right humerus fractured. Fracture of right humerus___ Fracture of right humerus___ Fracture of head of left hu- merus. Comminuted fracture of head of left humerus. Head of right humerus com- minuted. Fracture of head of humerus. Fracture of head of humerus. Fracture of left shoulder...... Fracture of left shoulder joint Ball passed through head of left humerus. Wound of left humerus. Ball burrowed itself in the upper part of the humerus. Comminuted fracture of the head of the left humerus by a conoidal ball. Gunshot fracture of the head of the riffht humerus. Minie ball fractured the head of the right humerus. Shot fracture of the head of the left humerus. Gunshot wound of the right shoulder joint, ball lodging in the head of the humerus. Shot injury of the left shoulder joint. Shot wound of the left humerus at about the insertion of the deltoid. Miniej ball perforated the right shoulder, fracturing the head of the humerus. Conoidal ball passed trans- versely through the head of the left humerus, opening the joint. Date of Opera- tion. Feb. 25, 1864. Nov. 26, 1863. Aug. 18, 1864. May 25, 1864. May 18, 18*64. Nov. 29, 1864. May 29, 1864. July 4, 1863. June 10, 1863. Sept. 30, 1864. Mav 12, 1864. Oct. 7, 1864. Nov. 7, 1863. Aug. 23, 1864. Dec. 16, 1864. On field. Sept. 19, 1863. Mar. 25, 1865. Oct, 27, 1864. Sept. 20, 1862. Sept. 19 1863. Aug. 7, 1862. Nov. 4, 1864. Oct. 29, 1864. Feb. 7, 1865. Sept. 13, 1864. April 6, 1865. May 16, 1864. June 27, 1864. Nov. 28, 1863. Aug. 14, 1864. Operation and Operator. Head excised, by Surgeon W II. Lemon, 82d Indiana. Head excised............... Head excised, by Surg. T. M. Flandrau, 146th New York. Head and neck excised...... Head, at anatomical neck, thro' straight incis'n, by Ass't Surg. D. Satterlee, 11 th Conn. Head excised, by Surg. D. S. S. McMuhon, 7th Texas. Head and neck of humerus excised. Head excised, by Surg. H. A. Minor, P. A. C. S. Headandneck excised through straight incision. Head excised, by Acting Staff Surgeon A. T. Fitch. Head excised, by Surg. J. R. Cotes, 151st New York. Head excised, by Surg. J. W. Wishart, 140th Pennsylvania. Excision of head of humerus. See Case 1501, p. 529. Excision of head. Head and neck of humerus excised. Head excised, by Surg. V. B. Kennedy, 5th Minnesota. Head and portion of surgical neck.through vertical incision down the deltoid, by Surgeon D. Prince. U. S. V. Head excised at the surgical neck. Excision of head of humerus.. Head of humerus excised. Head excised, through a V- shaped incision, by Surg. G. C. Humphreys, 9th N. Y. Head excised, by Surg. J. A. Stillwell, 22d Indiana. Excision of head, by Surgeon W. R. Brownell, 12th Conn. Removal of head of humerus at surgical neck, by Surg. W. B. Reynolds. 2d Sharpshooters. Excision of the head through the surgical neck, through a V-shaped incision, by Surg. D. G. Rush, 101st Pa. Resection of the head of the humerus, by Surgeon D. C. Ayres, 7th Wisconsin. Resection of the head of the humerus. Excision of the head of the humerus, through a straight incision, by Surgeon G. W. Colby, 1st Maine Cavalry. Excision of the head of the humerus. Removal of the head of the humerus. Excision of the head of the humerus through a straight incision four inches in length. Head of the humerus excised, through a longitudinal incis- ion, by Surgeon C. M. Clark, 39th Illinois. Result and Remarks. Disch'd Nov. 9, 1864 ; pensiotied. Sept, 1S73, unable to perform long-continued labor. Disch'd June 11,1864; pensioned. Sept., 1873, the arm is of no use to the pensioner. Returned'to duty; promoted Cap- tain January 18,1865. Retired from service Nov. 5, 1866. Disch'd June 19,1865; pensioned. Sept., 1873, disability equal to loss of hand for purposes of manual labor. Disch'd Mar. 23,1865; pensioned. Ap 1,1874, can extend arm from body to an angle of about 35°. Transferred for exchange Feb- ruary 24, 1865. Escaped October 23, 1864. Paroled November 12, 1863. Retired February 14, 1865. Disch'd Mar. 22,1865; pensioned. Sept., 1873, non-union of bone; arm useless. Disch'd July 28,1865; pensioned. Sept., 1873, the extremity dan- gles by his side. Disch'd Mar. 28,1865; pensioned. Sept., 1873, arm useless for all purposes of manual labor. Disch'd May 8,1864 ; arm useful, can take off his hat November, 1866, arm useless for purposes of manual labor; pensioned. Disch'd Feb. 13, 1864. Not a pensioner in June, 1874. Disch'd Ap'l 17,1865; pensioned. Died Aug. 17, 1866, "from the effects of a gunshot wound of left lung." (?) Disch'd Sept. 26,1865; pensioned. Has not been heard from since 1865. Disch'd Feb. 15,1863. Not a pen- sioner in November, 1874. Recovered. Paroled May 6, 1865. Disch'd Mar. 15,1865; pensioned. Limb useless. Died February 11, 1873. Disch'd May 5, 1863. Consider- able motion at joint, forearm as useful as ever. Died May 6, 1864. Disch'd Jan. 19,1864; pensioned. Sept., 1873, unable to move arm outward from body on account of union of scapula and humerus. Disch'd Oct. 16,1862; pensioned. Died November 9, 1870. Disch'd Ap'l 27,1865; pensioned. Sept., 1873, arm weak and of but little use. Disch'd May 15,1865; pensioned. Died May 9, 1874, of harnior- rliafre from lungs. Spec. 3802, A. M. M. Disch'd July 3.1865; pensioned. Sept., 1873, disability total. Furloughed; doing well. Disch'd Aug. 1,1865; pensioned. Sept, 1873, forearm and hand seriously atrophied and weak. Returned to duty June 17, 1865. July 1, 1866, arm and hand atrophied and useless; pens'd. Disch'd May 1,1865; pensioned. Sept, 1873, disability total, third grade. Disch'd May 2, 1864; pensioned. Hand and arm permanently useless for labor. Disch'd May 25,1865; pensioned. Sept., 1873, arm hangs useless by his side. SECT. III.] EXCISIONS AT THE SHOULDER. 533 Name, Age, and Military Description. May, S. H., Lieut., D, 10th Louisiana, age 23. Mealus, W. H., Pt., F, 186th New York. Meek, T. J., l't.. M, Phillips's (Jeorgia Lesion, age "JO. Merry', K. 11., l't., F, Uth Merryman, J. R., Pt., D, 1st Maryland Cavalry, age 21. Mesley, 0. L., l't'., Ii, 18th Infantry. Miller, H. J., Pt., C, 74th Illinois, age 19. Miller, J. S„ Corp'l, D, 79th Pcnnsylrnnin, age 21. Miller, T. B., Pt., I, 116th Pennsylvania, age 19. Mitchell. H. II., Pt., D, 25th Iowa, age 24. Moore. W. A., Corp'l, E, 18th North Carolina, age 21. Morell, W. J., PL, H, 15th South Carolina, aye 37. Morris, T. J., Pt.," F, 15th Iowa, age 30. Murray, C, Pt., I, 15th Mas- sachusetts, age 20. Myers,J.B.,Pt., F,1st South Carolina, age 28. Myers, J. C, Pt., D, 61st Pennsylvania, age 21. Neale, F. R., Serg't, D, 1st Cavalry, age 29. Norton, G. D., Pt., K, 5th Connecticut, age 23. Nott. P. R.. Pt., K, 89th Illinois, age 20. Palfrey, F. W., Colonel, 20th Massachusetts. Parcher, F. M., Pt, E, 8th Minnesota, age 22. Perkins, H. C, Pt, D, 49th Georgia, age 20. Peters, J., Pt., K, 42d New York. Presley, J. G., Lieut-Col., 25th South Carolina, age31. Punch, M., Pt, C, 29th Penn- sylvania, age 23. Rand, C. F., Serg't, K, 12th New York, age 24. Rector, T. S., Serg't, A, 11th Virginia, age 22. Reed, J., Corp'l, F, 6th Mary- land, age 22. Reeder, W. H., Corp'l, I, 3d Delaware, age 24. Reynolds, J. P., Pt, 2d Ken- tucky Cavalry. Rhines, J., Lieut., E, Illinois, age 23. Riley, J., age 18. Pt, E, 2d Ohio, July 1, 1863. April 2, 1865. Nov. 29, 1863. May 19, 1863. July 22, 1864. July 4, 1864. Juno 27, 1864. July 21, 1864. June 2, 1864. Jan. 11, 1863. .Vug. 16, 1864. June 24, 1864. July 22, 1864. July 3, 1863. Dec. 13, 1862. June 1, 1862. April 1, 1865. May 15, 1864. June 21, 1864. Sept 17, 1862. Dec. 7, 1664. July 2, 1863. May 12, 1864. May 7, 1864. Oct. 27, 1863. June 22 1862. July 2, 1863. Nov. 27, 1863. June 19, 1864. Aug. 2, 1862. June 27 1864. Oct. 8, 1862. Nature of Injury. A mini6 ball passed directly through right shoulder joint Gunshot fracture of the right shoulder joint. Gunshot wound of right shoul- der joint, fracturing humerus. Gunshot wound of the left shoulder. Shot fracturo of tho left hu- merus. Gunshot fracture of the right shoulder and wound of breast. Mini6 ball fractured the head of the left humerus. Gunshot wound of the left shoulder joint. Minie1 ball passed through the right shoulder joint Gunshot wound of the left shoulder. Conoidal ball passed through the head ofthe right humerus. Gunshot fracture of the left humerus Gunshot fracture of the head of the left humerus. Shot fracture of the head of the right humerus. Gunshot wound of the right humerus. Gunshot fracture of the head of the right humerus and of the scapula. Gunshot fracture of the head of the left humerus. Minie' ball fractured the head of the left humerus. Shot fracture of the head of the left humerus. Canister shot fractured the left shoulder joint, Conoidal ball fractured the head of the right humerus. Comp'd fracture of upper third of right humerus by shot. Shot fracture of upper third of the left humerus. Comp'd comminuted fracture of upper third of left humerus. Compound fracture of neck of right humerus, extending into the joint. Gunshot fracture of the head of the right humerus. Gunshot wound through the right shoulder joint. Conoidal ball fractured right lower jaw and the head of the right humerus. Comminuted shot fracture of the upper portion of the hu- merus. Mini6 ball fractured the head of the left humerus and the spine of the scapula. Shot fracture of left shoulder.. Conoidal ball fractured head of right humerus; also wound in right lung. Opera- tion. Operation and Operator. July 1, 1863. April 2, 1865. Nov. 29, 1863. May 19, 1863. July 22, 1864. July 4, 1864. June 27, 1864. July 21,| 1864. June 2, 1864. Jan. 11, 1863. Aug. 16, 1864. June 24. 1864. Julv 23, 1864. July 4, 1863. Dec. 13, 1862. June 1, 1862. April 1, 1865. May 15, 1864. June 22, 1864. Sept 18, 1862. Dec. 8, 1864. Julv 3, 1863. May 12, 1864. May 8, 1864. Oct. 29, 1863. July 3, 1863. Nov. 28, 1863. June 19. 1864. Aug. 3, 1862. June 27 1864. Oct. 8 1862. Removal of tho head of the humerus. Excision of the head of the humerus, by Surgeon J. A. Hayes, 11th New Hampshire. Resection of the head of the humerus. Removal of bone, including the head of humerus, by Surg. M. W. Robbins, 4th Iowa. Head of the humerus excised. Excision of head of humerus. Aug. 7th,ciicularamputation nt the shoulder joint, by Ass't Surg. T. A. McGraw, U. 8. V. Head of humerus excised, by Surgeons H. E. Hasse, 24th Wisconsin, and W. P. Pierce, 88th Illinois. Removal of head of humerus.. Head of humerus removed. thro' longitudinal incision, by Surg. P. E. Hubon, 28th Mass. Excision of head of humerus.. Excision of head of humerus, hy Surg.W.S.Love, P. A.C.S. Excision of head of humerus. Excision of head of humerus. Excision of head of humerus, by Surg. H. E. Goodman, 28th Pennsylvania. Resection of head of humerus.. Head of humerus excised, by Surg. It. M. Tindle. 61st Penn. June 17, 1862, amputation at should, joint.by Dr. W.Parker. Excision of head of humerus.. Excision of head of humerus, hy Surg. A. K. Fifield, 29th Ohio. Head of left humerus removed, thro' a straight incision, by Surg. H. B. Tuttle. 89th 111. Resection of head of humerus, by Surg. N. Hayward, 20th Massachusetts. Head of humerus remov'd, thro1 a slightly curved incision, by Surg. S. D. Turney, U. S. V. Excision of head and part of the neck ofthe humerus. Excision of head of the bone, by Surg. S. H. Plumb, 82dN.Y. Excision of head of humerus.. The severed head of humerus dissected and twisted from its socket, and sharp points of the lower fragm'ts removed with a chain saw, by Surg. J. A. Wolfe, 29th Pennsylvania. Head of humerus excised, by A. A. Surg. J. Swinburne. See Case 1500, p. 529. Resection of head of humerus.. Excision of head of the right humerus. Wound enlarged and head of humerus excised, by Surg. J. H. Beech, 24th Michigan. Removal of head of humerus, thro' a single vertical incision, by Surg. F. H. Gross, U. S.V. Excis'n of head of humerus, bv Surg's H. E. Hasse, 24th Wis!, and W.P.Pierce, 88th Illinois. Excision of head of humerus.. Result and Remarks. Transferred for exchange Octo- ber 27, 1-863. Disch'd June 12,1865; pensioned. Sept., 1873, disability equal to loss of limb for purposes of man- ual labor. Furloughed Sept. 23, 1864. Disch'd July27,1863; pensioned. Sept, 1873, has no control over the arm. Transferred for exchange Sept. 21, 1864. Disch'd December 31, 1864, and pensioned. Disch'd Feb. 27.1865; pensioned. Sept., 1873, has but very little use of the shoulder joint. Disch'dMay22,1865; pensioned. Sept., 1873, arm hangs power- less at side. Disch'd Jan. 17,1865; pensioned. Sept., 1873, arm hangs dangling at side. Disch'd Ap'l 10,1863; pensioned. Sept, 1873, arm atroph'd, weak, of little use for manual labor. Retired March 1, 1865. Furloughed July 25, 1864. Disch'd July 24,1865; pensioned. Apr'l, 1868. impairedstrength of arm unfits him for active labor. Disch'd Feb. 20,1864; pensioned. Oct., 1873, shortenedtwoinches; motions of shoulder limited. March, 1863, doing well. Disch'd Nov. 25,1862; pensioned. Died December 31, 1863. Disch'dJuly20,1865; pensioned. Oct., 1872, has considerable use ofthe arm. Disch'd Sept. 23,1864; pensioned. Sept., 1873, unable to raise the arm from the side. Disch'd Mar. 22,1865; pensioned. April, 1873, can use his hand; arm useless for manual labor. Disch'd Ap'l 13,1863; pensioned. Sept., 1873, limb useless for heavy manual labor. Disch'd May 23,1865; pensioned. Sept., 1873, the arm is useless. Recovered, with perfect use of the forearm. Disch'd February 24, 1865, and pensioned. May 31st, transferred to State; doing well. Disch'd July 16, 1864, and pen- sioned. Sept., 1873, muscular atrophy: has good use of hand. Spec. 5749, A. M. M. Disch'd Aug. 30,1862. Appointed lieutenant in Vet. Res. Corps in Nov., 1863, and discharged Jan. 1, 1868 ; arm useless for labor. See Fig. 4, Plate XIV. Recovered, and paroled Novem- ber 12, 1863. Disch'd Oct. 28, 1864; pensioned. Oct., 1873, arm perfectly useless. Disch'd Feb. 3, 1865; pensioned. January, 1872, cannot raise arm from side. Disch'd Oct 28,1862; pensioned. Feb., 1874, disability equal to loss of one hand for purposes of manual labor. Disch'd Oct. 27,1864; pensioned. Sept., 1873, arm useless. Disch'd Feb. 15,1863; pensioned. Died December 16,1871; cause of death unknown. 534 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. N, Name, Agk, and Military DEbCllirTION. Date OF INJURY. Nature of Injury. Date of Opera TION. Operation and Operator. Result and Remarks. 98 Robinson, A., Pt., E, 10th New Jersey. 99 Robinson, P.., Pt, D, 39th Colored Troops. » Rutherford. G., Serg't, F, 2d Minnesota, age 25. 101 | Scott, J., Pt, E, 29th Col- ored Infantry, age 27. Scullion, H., Corp'l, K, 99th Pennsylvania, age 22. Shafer, J. W., Pt., F, 33d Virginia, age 21. Shannon, J., Pt, I, 29th Ohio. Shelby, W., Pt., E, 8th Mis- souri. Sherman, E., Pt,, G, 55th Ohio, age 19. Slayton, E. B., Pt, D, 112th New York, age 26. Smith, C, Pt., G, 42d Ohio, age 22. Smith, J. S., Corp'l, K, 14th New Hampshire, age 32. Stack, R., Pt., D, 6thInf try, age 30. Steel, S. S. W., Serg't, C, 139th Pennsylvania, age 36. Stewart, W. F., Corp'l, G, 127th Illinois. Taylor, G. W., Major, 14th Alabama, age 27. Ustick, A., Sergeant, K, 4th Ohio, age 27. Wedgewood, G. R. S., Pt, E, 8th Minnesota, age 25. Weldon, J. J. C, Corporal, E, 4th West Virginia. White, W., Corp'l, K, 59th Illinois, age 27. Wilson, W. L., Pt, E, 104th Illinois, age 21. Winser, C. A., Sergeant, A, 6th Wisconsin, age 22. May 19, 1865. July 30, 1864. June 19, 1864. July 30, 1864. June 6, 1864. Sept. 17, 1862. < May 8, 1864. May 17, 1862. July 3, 1863. June 1, 1864. Dec. 29, 1862. Sept. 19, 1864. July 2, 1863. Sept. 21, 1864. Dec. 28, 1862. May 12, 1864. May 25, 1864. Dec. 7, 1864. May 19, 1863. Dec. 15 1864. July 20, 1864. Mar. 31. 1865. MiniS ball fractured the head of the humerus. Shell fragment fractured the head of the left humerus. Conoidal ball fractured the up- per third ofthe left humerus. Shot fracture of the head of the left humerus; also wound of right arm and hand. Gunshot fracture of the left shoulder. Shot perforation of the right shoulder joint. Right humerus fractured by a minie ball. Compound shot fracture of the head of right humerus; also fracture of lower jaw. Conoidal ball fractured the right humerus in its upper third. Gunshot wound of the left shoulder joint. Compound shot fracture of the head of the right humerus. Gunshot fracture of the head of the left humerus. Shot fracture of the head of the humerus. Shot fracture of the head of the right humerus. Ball and buckshot fractured the head of the left humerus. Shot wound of right shoulder joint: missile passed through head of humerus. Shot fracture of left shoulder joint. Compound comminuted shot fracture of the head of the right humerus. Gunshot fracture of the left humerus. Conoidal ball fractured the head of the right humerus. Shot fracture of tbe left hu- merus, involving the shoulder joint. Head of the right humerus shattered by a conoidal ball. May 19, 1865. July 31, 1864. June 19, 1864. July 30, 1864. June 7, 1864. Sept. 17, 1862. May 8, 1864. May 47, 1862. July 4, 1863. June 3, 1864. Dec. 29, 1862. Sept. 19, 1864. July 3, 1863. Sept. 22, 1864. Dec. 28, 1862. May 12, 1864. May 25, 1864. Dec. 9, 1864. May 19, 1863. Dec. 15, 1864. Julv 21, 1864. Mar. 31, 1865. Removal of the head of the humerus on the field. Resection of the head of the humerus, by Surg D. Mac- Kay, 29th Colored Troops. Resection of the head of the humerus, by Surgeon C. N. Fowler, 105th Ohio. Resection of head of humerus and amputation of right index finger, by Surg. D. MacKay, 29th Colored Troops. Dec. 3, 1866, amputation of left arm. Removal of the head of the humerus through an incision posteriorly. Excision of the head of the humerus, by Surg. — Smith, 33d Virginia. Head of the humerus excised, by Surgeon A. K. Fifield, 29th Ohio. Head of the humerus removed, by Surgeon J. R. Bailey, 8th Missouri. Excision of the head and neck of the humerus. Removal of the head of the humerus. Head of the humerus excised, by Surg. J. Pomerene, 42d Ohio. Removal of the head of the humerus through a straight incision. Excision of the head of the humerus. Resection of head of humerus, by Surg. S. F. Chapin, 139th Pennsylvania. Head of humerus excised, by Surg. E. Andrews, 1st Illinois Artillery. Excision of head of humerus through a V-shaped incision. Removal of head of humerus, by Surg. S. H. Plumb, 82d New York. Excision of head of humerus through a slightly curved in- cision. Excision of the head of the humerus. Head of the humerus removed thro' a longitudinal incision. Resection of the head of the humerus, bv Sargeon R. F. Dyer, 104th Illinois. Removal of head of humerus, through a straight incision, by Surgeon J. C. Hall, 6th Wis- consin. Disch'd July 19,1865. Does not appear upon Pension Rolls. Undetermined. Does not appear upon Pension Rolls. Disch'd June 21,1865: pensioned. Oct., 1873, use of arm greatly impaired. Disch'd June26,1865; pensioned. October, 1873, disability total. second grade. Disch'd June21,1865; pensioned. Feb., 1873, arm useless for man- ual labor; able to grasp and lift small objects with hand. Transferred for exchange A ugust 19, 1864. Disch'd May 4, 1865; pensioned. Sept, 1873, arm useless for pur- poses of manual labor. Disch'd Dec. 20,1864; pensioned. August, 1873, arm useless for manual labor. Disch'd Jan. 22,1864; pensioned. Oct., 1873, has use of arm only from the elbow down. Cannot elevate arm. Disch'd Dec. 28,1664 ; pensioned. Sept., 1873, arm useless for pur- poses of manual labor. Disch'd Ap'l 22,1863: pensioned. January, 1874, no fulcrum for movements of ann. Disch'dMay31,1865; pensioned. Sept., 1873, disability rated to- tal, third grade. Disch'd Sept. 11,1865; pensioned. He died November 3, 1867. Disch'd Ap'l 20,1865; pensioned. Sept., 1873, there is crepitation at the shoulder joint when the humerus is moved. Disch'd April 2,1863; pensioned. Sept., 1874, disability rated to- tal, third grade. Recovered, and retired in Nov., 1864. Disch'd June 21,1864; pensioned. Sept., 1873, has not much use of arm; can partially flex and extend same. Disch'd June 14,1865; pensioned. March, 1867, arm useless for all practical purposes. Disch'd July 29,1864; arm near- ly useless for manual labor in February, 1874; pensioned. Discb'dSept 14,1865; pensioned. Oct.,1873,handandarm useless. Disch'd Feb. 28.1865; pensioned. Sept., 1873, disability equiva- lent to loss of arm. Disch'd July 16,1865; pensioned. September, 1873, arm nearly useless. It is probable that among the one hundred and nineteen reported examples of primary- decapitation of the humerus for shot injury, there may have been instances in which portions of the shaft were removed; but it has been deemed proper to accept the statements of the operators. Fifty-six operations were on the right, and fifty on the left side; and, in thirteen instances, this point could not be determined. An endeavor has been made to include in this group only such excisions as were practised, so far as could be ascertained from the reported evidence, within seventy-two hours from the date of injury. The method of operation was reported in only about a fourth of the cases.. A straight anterior incision vas practised in twenty-three instances; in five cases the joint was exposed by raising -.'ither an oval or V-^baped flap; in two cases curved incisions at the outer margin of the leltoid were employed. In eighty-nine operations the mode of incision is not specified. SECT. III.J EXCISIONS AT THE SHOULDER. 535 § Unsuccessful Operations.—Fifty-six primary decapitations of the head of the humerus for shot injury were reported that had a fatal termination. Abstracts of three are given, and all of the cases are enumerated in the subjoined Table XXV, on the succeeding pages: Case 1506.—Private G. H. Fiske, Co. H, 81st New York, was wounded at Fair Oaks, May 31, 1862, and was sent to Washington and admitted to Judiciary Square Hospital. Acting Assistant Surgeon D. W. Cheever forwarded, together with the pathological specimen, the following description and abstract ofthe case, by Acting Assistant Surgeon Calvin G. Page: "Speci- men of humerus after exsection of portion of the head of tbe humerus for gunshot wound, the missile entering over tho sternum, and passing under the pectoralis major and through the humerus near the head of tbe bone, shattering the head, and passing out on the external side of tlie arm. The patient was wounded May 31, 1862; the operation was on the day ofthe injury. The man entered hospital June 4th; did well till August 5th, when bleeding commenced at the interior wound. August 7th, profuse haemorrhage. On attempting to reach the artery by laying open the track of the original wound, and finding the vessel, the bleeding was so profuse that the patient died while operating. An ulcerated opening was found in the artery near the junction of the axillary and brachial. It appears to have occurred the sixty-sixth day after the accident. The exfoliated portions ofthe upper end of the lower extremity of the humerus and the processes of absorption of the glenoid cavity are well shown by a section thereof; at the point of ulceration the artery was adherent to the muscular tissues." Acting Medical Cadet Burt G. Wilder reported: "In searching for the artery, after death, it was cut so as to remove the upper border ofthe ulcerated opening, but the lower border is entire; a part of the deltoid is removed to show the cavity from which the bone was excised." The specimen (No. 1062, Cat. Surg. Sect., 1866, p. 97) consists of "a wet preparation of the upper fourth ofthe left humerus. The head has been broken into several fragments, which have retained their vitality and become consolidated in new positions, with new muscular attachments. One of these consolidated fragments has been again fractured, possibly in the removal of the speci- men. A formation, as if of a cyst surrounding a lodged bullet, appears in the outer and anterior region. The axillary artery presents a large opening from ulceratiou, indicating death from secondary hemorrhage." The catalogue refers to the preparation as received without a history; but the foregoing notes ofthe case were subsequently identified. Fractures at the shoulder by shell fragments, grapeshot, or other large projectiles, inflicting such limited injury as to permit excision, were uncommon. The following is an instance, which has furnished to the Museum one of the few specimens of primary decapitations of the humerus for shot injury: Case 1507.—Private J. A. F----, Co. M, 21st North Carolina, was wounded at the assault on Fort Steadman, March 25, 1865, and was admitted to a Ninth Corps field hospital on the same day. Surgeon G. W. Snow, 35th Massachusetts, reported: "A grapeshot wound ofthe left shoulder, fracturing the head of the humerus. Resection of humerus and removal of grapeshot by Surgeon J. A. Hayes, 11th New Hampshire. Died March 31, 1865." The specimen, represented in the adjacent wood-cut (Fig. 408), is described (Cat. Surg. Sect, 1866, p. 99) as: "The head of the left humerus, excised through the surgical Fig. 408.—Head of neck. A bullet has grooved the external portion of the head, and two fissures extend in the inner articular excise™ for%ho™fra<> surface. The bone bruised by the ball is carious. Eeceived from a Ninth Corps hospital."1 ture- sl>ec- 4023. Case 1508.—Corporal H. Darragh, Co. K, 106th Pennsylvania, aged 40 years, was wounded at Petersburg, June 18, 1864, and, after treatment in the base hospital at City Point, was sent to Washington and admitted to Lincoln Hospital. Acting Assistant Surgeon J. F. Burdick reported: "The above soldier had undergone resection of the head of the humerus, and I saw him but once, and that was just previous to his death. The resection was performed prior to his admission to this hospital. He was very much emaciated; respiration was difficult; the arm was gangrenous. Death occurred July 14th. There is no record of treatment or diet. Medical Cadet Strickler informs me that he has had fifteen drops of tincture of chloride of iron three times a day, and simple water-dressing to the wound. Brandy was daily administered, at frequent intervals." The autopsy was made, on the day of the patient's death, by Acting Assistant Surgeon H. M. Dean, who contributed a pathological preparation from the case, with the following history: "Body is very much emaciated; post-mortem rigidity not very well marked; height five feet seven inches. The external surface of the right arm is gangrenous for a distance of six inches above the elbow. He * has had a wound in the right shoulder, for which the head of the humerus has been resected. The upper extremity of the humerus, which was denuded for about half an inch, was drawn up by the muscles in contact with the glenoid cavity. The coracoid process of right scapula was also fractured. Wound slightly gangrenous. Eight lung firmly adherent to the walls of the thorax and to the diaphragm. On section ofthe upper and lower lobes a large amount of a frothy fluid exuded. The lining membrane of the bronchi was very much congested. Left lung healthy. Right lung weighed twenty-one ounces; left, eleven and a half ounces. Spleen very much enlarged, firm, not pulpy, weighed nine ounces. Pericardium healthy. Heart: both ventricles contained a fibrinous clot; heart weighed nine ounces. Liver weighed fifty-one ounces, small and contracted; measured seven and a half by six and a quarter and three and a half inches; mottled and convoluted, more resembling the brain than the liver." The specimen consists8 of "portions of right scapula and humerus, from a subject on whom excision of the head of the humerus had been performed in the field. The wound was gangrenous at the time of death, and the specimen shows no reparative effort." 'In regard to this and other primary operations done on March 25, 1865, Dr. Samuel Adams, U. S. A., wrote: "I regret exceedingly that, owing to the confusion caused hy the whole army being then on the move, it was impossible to keep a record of these cases, and it is beyond my power to furnish the particulars now required. These men were all sent to the Depot Field Hospital at City Point, when the Corps moved to Burksville Junction on the 3d of April.'' "Specimen 2838, Catalogue of tlie Surgical Section, Army Medical Museum, 1866, p. 85. 536 INJURIES OF THE UPPER EXTREMITIES. ICHAP. IX. Table XXV. Summary of Fifty-six Cases of Heaths after Primary Decapitations of the Humerus fc Shot Injury. or Name, Age, and Military Description. Date OF Injury. Nature of Injury. Date of Opera- tion. Operation and Operator. Result and Remarks. Anguish, H., Corp'l, 1,157th New York. Black, F. G., Pt., D, 125th Illinois, age 24. Blancliard, L. N., Pt., K, 8th N. York Artillery, age 26. Boothby, S., Lieut.-Col., 1st Maine Cavalry, age :10. Bowen, J. A., Pt., G, 59th Virginia, age 35. Burke, A., Pt, 18th N. York Battery. Bnrkhardt, G., Pt., H, 7th Illinois, age 26. Choate, S. H., Pt., H, 6lst Illinois, age 27. Darragh.H., Corp'l, K, 106th Pennsylvania, age 40. Davis, N. E., Lieut., F, 39th Illinois, age 21. Douglas, A. P., Pt., K, 111th Pennsylvania, age 24. Erwin, B. H., Pt., I, 70th Indiana. Fee, J. A., Captain, I, 48th New York, age 27. Fiske, G. H., Pt., H, 81st New York. Fox, E., Pt., C, 8th Tennes- see, age 37. Friar, J. A., Pt., M, 21st North Carolina. Fulton, J., Corp'l, F, 14th Ohio, age 22. Gillam, W., Pt., D, 184th Pennsylvania, age 46. Gillespie, M., Pt., C, 6th North Carolina, age 39. Glass, M., Corp'l, C, 2d Penn- sylvania Artillery, age 22. Green, J., Private, E, 59th Illinois. Green, N. S.. Pt., A, 56th Massachusetts, age 28. Habicht, L., Pt., C, 55th Virginia, age 24. Hamilton, XV., Pt., I, 23d Ohio, age 22. Handy, C, Sergeant, F, 79th Illinois, age 19. Hardengorf, R. D., Pt., E, 109th New Y'ork, age 21. Harrill, J. W., Sergeant, B, 26th Alabama, age 25. Henderson, C, Pt,, C. 158th New York, age 21. Hocb, T., Sergeant, H, 17th Pennsylvania. Hopkins, E. N., Pt., H, 17th Pennsylvania. Humphrey, J-, Pt., G, 1st Wisconsin, age 23. James, G., Pt., G, 75th New York. July 1, 1863. June 27, 1864. June 3, 1864. May 10, 1864. Nov. 14, 1864. July 1, 1863. Mar. 24, 1865. Dec. 14, 1864. June 18, 1864. Oct. 13, 1864. July 20, 1864. July 2, 1864. June 28, 1864. May 31, 1862. July 21, 1864. Mar. 25, 1865. June 14, 1864. June 3. 1864.' June 3, 1864. July 30. 1864. June 20, 1864. May 6, 1864. Oct, 1, 1864. Sept. 3, 1864. June 1, 1864. July 30, 1864. July 3, 1863. Mar. 31 1865. June 11 1864. J une 24, 1863. May 30, 1864. June 14 1863. Gunshot fracture of the right shoulder. Compound shot fracture of the left humerus. Gunshot wound of right shoul- der joint ; also wound of hand. Shot fracture of right humerus. Compound shot fracture of the right humerus. Shot fracture of the head and neck of the right humerus. Wound of left shoulder joint, fracturing head of humerus. Gunshot fracture of head of right humerus, tbe inner edge of the glenoid cavity, and the coracoid process. Missile lodged in chest cavity. Shot fracture of upper third of right humerus. Conoidal ball comminuted up- per portion of right humerus. Minifi ball fractured the right humerus. Fracture of the head of right humerus by conoidal ball. Gunshot fracture of the right shoulder. Musket ball fractured head of lefthumerus and wounded the median vein. Fracture of scapula and head of humerus by a conoidal ball. Grapeshot fractured the head of left humerus. Ball passed through the head of left humerus. Shot fracture of head of left humerus. Comminuted shot fracture of head of left humerus. Shot fracture of left humerus, upper third. Gunshot fracture of shoulder .. Conoidal ball wounded the left shoulder joint. Gunshot wound of right shoul- der joint. Shot wound of right shoulder with great comminution of bone. Shot fracture of head of right humerus. Gunshot fracture of the right shoulder joint; also wound of breast. Fracture of right humerus by shot. Shot fracture of right humerus. Shot fracture of left shoulder joint, Minie' ball fractured the right humerus. Gunshot fracture of the right shoulder. Shot wound of right shoulder.. July 1, 1863. June 27, 1864. June 3, 1864. May 10, 1864. Nov. 14, 1864. July], 1863. Mar..24, 1865. Dec. 16, 1864. June 18, 1864. Oct. 13, 1864. July 20, 1864. July 2, 1864. June 28, 1864. May 31, 1862. July 21, 1864. Mar. 25. 1865. June 14, 1864. June 3, 1864. June 3, 1864. July CO, 1864. June 20 1864. May 6, 1864. Oct. 1, 1864. Sept. 5, 1864. June 1, 1864. July 30. 1864. July 3, 1863. April 1, 1865. On field, June 27, 1863. May 30, 1864. June 14 1863. Excision of head of humerus .. Removal of head of humerus .. Excision of head of humerus on the field. Head of humerus excised, by A. A. Surgeon T. Liebold. Excision of head of humerus .. Removal of head and neck of the humerus. • Resection of head of humerus, by Surgeon J. Pogue, 66th Illinois. Head of the humerus removed at the surgical neck, by Sur- geon S. D. Turney, U. S. V. Excision of head of humerus.. Removal of head of humerus, by Su»ge3, and pensioned; has very free use of forearm and hand. Disch'd Feb. 8,1865; pensioned. Sept., 1873, "arm almost pow- erless in some directions." Disch'd Nov. 5, 1863; pensioned. Sept., 1873, disability total. 3d grade, and permanent. Spec. 2590, A. M. M. Disch'd Aug. 21, 1865. and pen- sioned. Sept., 1865, has no use of his left arm. Disch'd Sept.21,1864; pensioned. Died Jan. 13, 1867, of phthisis. Spec. 2592, A. M. M. Disch'd Feb. 22,1864; pensioned. Sept., 1869, strength of arm greatly impaired. Spec. 19G9, A. M. M., and Photo. 100. Recovered, and transferred, for exchange, Nov. 1, 1864. Disch'd Sept. 26, 1864, and pen- sioned. Sept, 1873, disability total, 3d grade. Spec. 2595, A. M. M. Disch'd Jan. 24,1865; pensioned. Sept., 1873, disability total, 3d grade. Spec. 2435, A. M. M. Disch'd Oct. 28, 1863; pensioned. Dec, 1873, shoulder joint an- chylosed ; the elbow joint and forearm are free in their mo- tions. Spec. 1912, A. M. M. Disch'd June 17,1864; pensioned. Dec., 1871, the arm is useless from injury to the muscles and nerves. Disoh'd July 27,1864 ; pensioned. March, 1874, " elbow and wrist are not affected, and the power of grasp is good.'" 541 INJUEIES OF THE UPPEE EXTREMITIES. [CHAP. IX. It will be remembered that four of the operations were on the right, and nine on the left side. In seven instances, the excised portions of bone were sent to the Museum. See Figures 412 supra and 415 infra. In an eighth case, photographs of the part excised, and of the patient after recovery, were transmitted: Case 1514.—Lieutenant C. A. Waldron, Co. B, 2d Rhode Island, age 24 years, was wounded iu the left shoulder at the Wilderness, May 6,1864. This officer was treated in the Seminary Hospital, Georgetown, and subsequently in private quarters in Washington, and received a leave of absence, at the termination of which he was mustered out, June 17, 1864. Examiner C. G. McKnight, of Providence, reported, November 4, 1864: "Wounded in the left shoulder, the bone being shattered badly. The wound is still open and discharging; the arm is entirely useless." On April 1, 1868, Dr. H. W. Rivers, late surgeon 4th Rhode Island, who treated this officer after his discharge, reported. "From the time of his being wounded he had very little treatment until he came under my charge. Pieces of bones continued to come away from time to time; several sinuses formed about the shoulder, and a constant fetid discharge was kept up. Mr. Waldron came under my notice about the first of September, 1867, and, after a careful examination of the parts, I advised him to have the head of the humerus excised. At this time, he was very much emaciated and run down. On September 27th, his general health having been improved by tonics and good diet, he presented himself for the operation. Assisted by Surgeons G. W. Carr, late ofthe 2d Rhode Island, and R. Millar, late of the 4th Rhode Island, and in presence of Dr. W. H. Hazard, of Wakefield, the patient being thoroughly under the influence of sulphuric ether, a V-shaped incision was made including the whole of the deltoid muscle. The flap thus made being dissected up, showed the head and upper portion of the humerus in a very carious condition. Several pieces, including the portion of the head not destroyed by caries, were detached and removed. The shaft was then sawn through and detached. A few pieces of carious bone were then removed by the gouge, and the parts brought together with six points of interrupted sutures. The wound was dressed with compresses wet with water, half a grain of morphia administered, and the patient put to bed. On September 28th, a solution of permanganate of potash was substituted for the water dressing. On October 3d the patient was doing well, and from this date he continued to improve, the wound uniting almost by the first intention in three weeks from the date of operation. On March 20, 1868, he came to Providence to be photographed. His arm was found to be in a very useful condition, the wound having been long since healed. He was able to carry his hand to his mouth, tie his cravat, and to grasp with considerable power. His general health had improved, and he had gained fifteen pounds in weight since last October. The accompanying photo- graphs show the result of the operation and the pieces of bone removed." The photographs are copied in the annexed wood- cuts (FiGS. 413 and 414). In December, 1871, Mr. Waldron was examined by a Board, who reported that his arm was useless from injuries to the muscles and nerves. His pension was paid March 4, 1874. One of the patients in this series1 survived an amputation above the knee, in addition to the excision of the shoulder; his case will be detailed in the account of thigh amputa- tions. Another succumbed from phthisis, although not until more than three years after the operation. The following is a good example of secondary excision of the head of the humerus with a ball embedded in it: Case 1515.—Corporal R. McCIain, Co. C, 1st U. S. Sharpshooters, aged 31 years, was wounded at Mine Run, November 27, 1863, and was admitted to Fairfax Seminary Hospital, from a Third Corps field hospital, on December 4th. Surgeon D. P. Smith, U. S. V., contributed the specimen (FlG. 415) with the following notes: "Gunshot fracture of the head of the humerus. The patient being able to use the arm in writing, the severity of the injury was not suspected until December 20th, when resection was performed by Surgeon D. P. Smith, U. S. V. No bad symptoms supervened." In the Catalogue of the Surgical Section, of 1866, the preparation is described: The specimen consists of '"'the head of the right humerus, excised through the surgical neck for a partial fracture at the posterior portion of the anatomical neck by a conoidal ball, which lodged." The patient was discharged February 22, 1834, and pensioned. Examiner G. K. Johnson, of Grand Rapids, reported, September 7, 1869: " A musket ball struck the right humerus about two inches below the shoulder joint, passed upward and buried itself in the head of the bone. In consequence ofthe injury to the bone, find of the resulting inflammation, the head of the bone and about one or one and a half • Fi!G'j41'*-15;1!1 JmPacted inches of the shaft were excised. The result is that the movements and strength of the arm are greatly in head of right humerus. . ° ° J Spec. 1999. impaired." The pensioner was paid September 4, 1874. FIG. 413.—Cicatrices after a secondary decapi- tation of the humerus for shot injury. [From a photograph.] Fig. 414.-Frag- ments of left humerus. ' Case of Lieut. C. A. Fuller, 61st New York. This officer was wounded on the second day of the battle of Gettysburg, and underwent primary amputation at the lower part of the left thigh, by Surgeon C. S. Wood, 66th New York, at a Second Corps hospital. If..- !•!.■ . t, x-74 ■;.'!.lie.''! ■> ;,y „ >n'i- >, "villi* G. • jlj, .1 v,\ <. m ;, ■ ■ i I: r,e i: f/ Lho urgical Historvot the W«»r of the Rfbe!!mn Vol II ("i\j.y K. Kit:. I Fit;. III. Fn;. IV \C.Bell phot J.Bum Ivth PLATE XVIII. RESULTS OF EXCISIONS OF THE HEAD OF THE HUMERUS Furl. Major T G. Morrison I'll'..II. Sere'eant ('.A Wiiuser Fui. Ill Private D. Sinelelon. Fig. I\'. Private (". Ross Spec, win A.M.M. EXOTSTONS AT THE SHOULDER. 545 § Unsuccessful Cases.—>-An equal number of cases terminated fatally. But in one of these there was a fracture of the first rib, and possibly the chest cavity was interested directly, or by extension of inflammatory action; and, in three instances, diarrhoea or dysentery existing antecedently to the injuries or operations, wore assigned as tho causes of death. Eleven operations were on the right and one on the left side, the thirteenth case being undeter- mined, a result added to the evidence adduced on pages 537 and 514, as to the relative fatality of the operations on the right and left sides, that fails to confirm the surmise of Professor Esmarch (tfber Resect., u. s. w., op. cit. s. 49) that the operation on the left side has a higher mortality rate than on the right; a suggestion, it is proper to add, very carefully qualified by that eminent surgeon: Case 1516.—Private W. S------, 3d New York Independent Battery, aged 20 years, was wounded at Petersburg, March 23, I860, and was admitted to Harewood Hospital, Wash- ington, on April 2d. Surgeon R. B. Bontecou, U. S. V., reported: "Admitted April 2, M>5, suffering from a gunshot wound over the right scapula, the ball entering the deltoid muscle, injuring the head of the humerus, and making its exit near the spine. Resection of head of right humerus was performed, April"26th, through an incision about four inches long, over the deltoid muscle. At the time of the operation, the patient was very weak, and suffering from diarrhoea. An abscess had collected in the upper part of the arm, near the head of the humerus, and the parts were infiltrated with pus. The result was unfavorable, and the patient gradually sank, and died from exhaustion May 10, 1865." The operator, Dr. Bontecou, forwarded to the Museum a photograph of the patient ( Card Photographs, Vol. II, p. 10), which is copied in the adjacent wood-cut (FlG. 416). It was taken soon after the operation, when a happier result was anticipated. Table XXIX. Summary of Thirteen Fatal Cases of Secondary Excisions of the Head of the Uumerus for Shot Injury. ncision and exit wound in a secondary decapitation of the humerus. [From a photograph.] Name, Age, and Military Description. Naturk of Injury. Opera- tion. Operation and Operator. Result and Remarks. Beckwith, R. J., Pt., B, 12th N. York Cavalrv, age 28. Br'ooker, J. R., Pt., E, 11th South Carolina, age 39. Bryant, D. H., Pt., C, 7th Wisconsin, age 35. Burkhardt, H., Pt., E, 16th Louisiana. Fitzgerald, B., Corporal, G, 73d Ohio, age 23. May, Jacob,Pt.,B, 37thOhio, age 18. Miller, G. A., Pt., E, 33d Indiana, age 21. Scale, J. P.. Pt.. D, 31st Mississippi, age 33. Stewart, W., Pt., 3d New York Battery, age 2J. Stilwell, J., Pt., I, 1st Mary- land Cavalry, age 21. West, J., l't., I, 37th New York, age 18. Wilson, M. L., Lieut., A, 122d New York, age 28. Ziemer, W., Pt., 11, 9th Wis- consin. Mar. 9, 1865. June 20, ieo4. Mav 8, 1864. Sept. 20, 1863. Sept. 19, 1863. June 4, 1863. May 15, 1804. Nov. 30, 1804. Mar. 25, 1865. Aug. 16, 1804. June 30, 1862. Mav 6, 1804. Sept. 30, 1862. Gunshot wound of the right shoulder. Minie ball pierced the right hu- merus just below anatomical neck, making a round hole without fissure. Gunshot wound of right shoul- der joint; ball injured the head of humerus. Musket ball fractured the head of the right humerus. Shot fracture of the right hu- merus, involving tho shoulder joint. Conoidal hall passed through the head of right humerus. Musket ball fractured the head of right humerus. Head of right humerus frac- tured by conoidal ball. Mini6 ball entered the deltoid muscle, injured tbe head cf right humerus, and emerged near the spine. Shot fracture cf head of left humerus; much disorganiza- tion cf muscular tissues. Round ball and buckshot grooved and fractured the head of the right humerus. Gunshot wound of right shoul- der and fracture of first rib. Minie ball fracturedandlodged in head of humerus. May 5, 1805. Aug. 3, 1864. June 30, 1864. Nov. 16, 1803. Nov. 13, 1863. July 12, 1863. July 2, 1804. Jan. 14, 1805. Ap'l 26, 1865. Sept. 21 1804. June 10, 1864. Nov. 1, 1802. Excision of the head of the humerus. Excisiou of the head of the hu- merus through a V-incision, by Ass't Surgeon E. Curtis, U. S. A. Head of humerus removed at the surgical neck, by A. A. Surg. (J. F. Trautvnan. Excision of head of humerus, by Surg. A. M. McMahon, C4th Ohio. Head of humerus excised at surg. neck, by A. A. Surg. (1. P. Ilachenberg. Removal of head of humerus at the surgical neck, by Surg, .I.G. Keenon, U.S. V. Excision of head (if humerus at surgical neck, bv Ass't Surg. II. T I,ogler, U*. S. V. Head of humerus removed, by A. A. Surg. !.. Sinclair. Head i t"tin- humerus removed tliraugh incision over deltoid, by •Surgejn R. B. Bontecou. U. S. V. Head ofthe humerus removed through astraight incision, by A. A. Surg. J. (!. Morton. Excision cf the head cf the humerus at the surgical neck, by A. A. Surg. S. I). Gross. Removal of head of humerus, by Surgeon 11. W. Ducachet, U. S. V". Excision of head of humerus.. Died May 12, 1865, of pyaemia. Died Aug. 11, 1864, from irrita- tive fever. Died July 4, 1864. from exhaus- tion after haemorrhage. Spec. 3048, A. M. M. Died November 23, 1863, from diarrhoea. Died November 21, 1863, of py- aemia. Spec. 1925, A. M. M. Died July 23, 1863, of pyaemia. Spec. 1703, A. M. M. See CASE 1517. Died August 8, 1864, of exhaus- tion. Died March 3,1805, of dysentery. Died Mu v 10.1865,from diarrhoea. See Case 1516. Secondary haemorrhage Sept. 21; ligation of subclavian artery. Died September 23, 1804. Died A ug ust 20, 1862, of pyaemia. Spec. 3b8, A. M. M. Died June 19, 1804, of pyaemia. Died Nov. 6, 18G2, of pyaemia. 69 516 INJURIES OF THE UPPER EXTREMITIES. [chap. ix. Eleven of the operations were on the right side. Tlie joint was exposed by raisin^ a flap, in one instance, and by linear incisions anteriorly, and parallel with the fibres of the deltoid, in seven cases; "in five cases, this point is not noted. The following is a fatal case of that remarkable group of shot penetrations of the epiphysis without splintering, which appear to occur only in young subjects, and are very rare: Case 1517.—Private Jacob M- -, Co. B, 37th Ohio, aged 18 years, -\vas wounded at Vicksburg, June 4,1833, and was Fig. 417.—Head of the right humerus excised for shot in- jury. Spec. 1703. treated in the regimental hospital until July 4th, when he was sent, on the hospital steamer D. A. January, to Memphis, and admitted to Adams Hospital. Acting Assistant Surgeon J. Thompson reported: "Gunshot fracture of the head of the right humerus. On examination, it was found that the ball had entered at the posterior portion of the deltoid muscle, passed directly through the head of the humerus, and came out at the anterior edge of the deltoid; wound suppu- rating very much; the patient is unable to move his arm; he has quite a yellow appearance of the skin and sclerotic coat of the eye; pulse 110. Excision of the head of the humerus was decided upon, and was performed July 12, 18 J3, by Surgeon J. G. Keenon, U. S. V., by making a semilunar incision, dissecting up the deltoid, disarticulating the head of the bone, and sawing off the same at the anatomical neck with a chain saw. The bone was then placed in position, the flap retained by a few interrupted sutures, and dressed with cold water until suppuration was again established. Half a grain of morphia was then administered and the patient put to bed. July 13th, patient rested well last night; no treatment constitutionally. July 14th, wound looks well; pulse 112; bowels constipated; administered half an ounce of salts, which operated mildly. Evening, patient rather restless; pulse 118; half a grain of morphia ordered at bedtime. July lGth, patient rested very poorly last night; had violent rigors; pulse 110; mouth dry this morning; wound looks very well; suppurating; quinia ordered; discontinued cold water to wound and substituted simple dress- ings. July lGth, patient rested well last night; says he feels well; pulse now 100; wound suppurating nicely; ordered citrate of quinia, five grains three times a day, and beef tea, four ounces every three hours. July 17th, patient rested well last night; says he feels very well this morning; bowels rather constipated; ordered sulphate of magnesia, which operated about noon, and also tincture of chloride of iron, beef tea, and ale. July 20th, patient has had some severe rigors; pulse 103; tongue a little coated; skin moist; wound suppurating; continue iron, ale, quinine, and beef tea. July'21st, patient rested well last night; bowels moved this morning; continue treatment. July 22d, patient had severe rigors; quinine and Dover's powders ordered. July 23d, patient rested poorly last night; had severe rigors this morning; countenance quite dull; skin and eyes very yellow; wound still suppurating. Treatment, iron, beef tea, and ale, ad libitum^ Progress unfavoi-able." Death resulted from pysomia, July 23, 1863. The specimen (FlG. 417) was contributed to the Museum by Dr. Keenon, and consists of "the head of the right humerus excised at the surgical neck. The external portion of the head and anatomical neck on both sides of the epiphyseal line are occupied by a cavity the size of a walnut, with spongy and carious walls. There are no fissures in the head of shaft."—Catalogue, Surgical Section, 18G6, p. 100. The statistics of the twenty-six secondary decapitations of the humerus for shot injury, unless accompanied by qualifying comments, would represent the operation too unfavor- ably;1 since several of the cases proved fatal from causes foreign to the injury or operation. Decapitations ofthe Humerus for Shot Injury of Uncertain Date.—Seventeen excisions at the shoulder, belonging to this subdivision, were reported without indication of the length of the period between the reception of the injury and the date of operation. The twelve successful, four unsuccessful, and one undetermined case are tabulated below, and a fatal case and one of the successful cases are detailed at some length: Case 1518.—Private J. If. AT------, Co. F, 11th Georgia, was Avounded at Gettysburg, July 3. 1863. He was sent to a field hospital for Confederates; but no account of the case is found recorded other than a memorandum by Surgeon H. Janes, U. S. V., giving the dates of injury and of transfer, and the note: "Ball in shoulder joint." The patient was transferred to David's Island, Xew York, on July 18th. Surgeon J. Simons, U. S. A., reported that he entered the DeCamp Hospital July 22d, and died of pysemia August 8,1883. Dr. A. N. Brockway, of Harlem, Xew York, formerly Acting Assistant Surgeon at DeCamp Hospital, on September 10, 1868, transmitted to the Museum the excised .head of the humerus from this case (FlG. 418), stating that: "The only history that I was able to obtain was that it belonged to a member of a Georgia regiment, and that the head of the bone was extracted by Acting Assistant Surgeon J. W. Dickie, in August 1863, at the DeCamp Hospital, and that the patient shortly afterward died. I made diligent inquiry of the wardmaster, but could obtain no further history." This was probably an intermediary operation. The ball entering laterally has comminuted the head of the humerus and is impacted in its cancel- lous ti.-sue. The specimen affords quite a typical example of those cases imperatively demanding excision. 1 It is well known that many eminent surgeons have advocated secondary excisions at the shoulder as less hazardous than early operations ; the data collected en the subject will be analyzed at the close of the .Section. Fig. 418.—Ball impacted in the head of the right humerus. Spec. ihJd'J. SECT. III.] EXCISIONS AT THE SHOULDER. 547 but the reported details arc other- A successful case was illustrated by a photograph wise, unfortunately, very imperfect: Case lfil'.l.—Corporal B. E. Rice, Co. H, 7th Wisconsin, aged 19 years, was wounded at Cnincsville, August 28, 1862, and was treated in the regimental hospital until August 30th, when lie was transferred to Washington, and admitted to Colum- bian College Hospital, and discliargod the service December 22, 1862, Surgeon T. R. Crosby, U. >S. V., certifying to: " Gunshot wound, requiring resection ofthe head of the left humerus." On March 28, 1870, Dr. S. G. Armstrong, of Boscoliel, Wisconsin. reported: " Gunshot wound, ball entering the shoulder joint from the front. Removed to Wash- ington, D. C, Columbian College Hospital. Head of humerus exsected after a number of days; secondary operation. Wound entirely healed in six months. Bones anchylosed, yet the arm cannot be raised from the side, admitting only of moderate forward and backward motion. The wound is healed soundly, yet large loss of tissue occurred. The humerus is two inches shortened. Arm can be used only from the elbow downward. Amount of neuralgic pain only trifling. Gen- eral health but little influenced by the operation." Dr. Armstrong also forwarded a daguerreotype, of Mr. Riee. taken March 21, 1870, which is copied in the wood-cut (FlG. 41'J). Examiner J. M. Jenkins, of Sibley, Iowa, reported, May 20, 1S74: "Cunshot wound of left shoulder. Head and neck of humerus resected. Very large cicatrix; the deltoid, long head of biceps, infra- spinatus, aud pectoral muscles were, apparently, severed, and the nerves injured. The arm is shortened one and a half inches. The shoulder is very much atrophied, and the arm and forearm are somewhat smaller, and are easily chilled; he has but little use ofthe limb. Disability increas- ing, aud may become total. The arm has but little motion, and the forearm and hand are very weak." Upon searching the case, it has been impracticable to obtain any important particulars of its earlier history. Surgeon D. Cooper Ayres, 7th Wisconsin, reported the admission of the patient to regimental hospital with a " serious gunshot wound of the shoulder." Dr. Crosby does not describe the operation or mention the name of the operator. All of the reporters agree that the operation was on the left side. The position of the cicatrix is reversed in the daguerreotype, as copied in the wood-cut, and appears as of the right side. This is an error very liable to remain undetected in illustrations prepared by photography, even after careful scrutiny. Fig. 419. — Cicatrices eight years after an excision of the head of the humerus. Table XXX. Tabular Statement of Seventeen Decapitations of the Humerus for Shot Injury, in which the Intervals between the Dates of Injury and of Operation were not ascertained. Name, Age, and Militart Descrhtiox. Nature of Injury. Opera- tion. Operation and Operator. Result and Remarks. Black, J.,Pt., E, 51st Illinois, age 18. Cloud, W. W., Pt., I, 4th Georgia. Coggens, J., Pt., F, 5th Xew York Cavalrv, age 21. Gozer, .T., Pt.' F, 89th Illi- nois, age 33. Hayward, S. P., Pt., B, 6th Missouri, age 23. May, R., Pt.,D, 19th Indiana, age 19. Mulqueen, D., Pt., G, 6th Kentucky Cavalry, age 32. Prosser, 0., Pt., A, lGth Louisiana. Rice. B. E., Corpoial, H, 7th Wisconsin, age 19. Smith, \V., Pt., H, 173d New York. Torbet, J. P., Pt., F, 3d Ohio, age 23. Van Scoter, A. B., Sergeant. H, 4th Michigan, age 31. Clapson, C, Corporal, A, 110th New York. Clark, W., Pt., K, 1st Massa- chusetts, age 34. Roberts, L., Pt., H, 35th South Carolina. J. M. M-----, Pt., F, 11th Georgia. Gilhurley, M., Pt., C, 14th Alabama. June 27, 1864. May 10, 1864. May 25, 1862. Dec. 31, 1862. Aug. 31, 1864. Aug. 28, 186-2. April 6, 1865. Nov. 25, 1863. Aug. 28, 1862. June 14, 1863. Dec. 31 1862. July 1, 1862. June 30, 1862. Julv 3, 1863. Sept. 7, 1862. Comminuted shot fracture of left humerus. Gunshot wound of right shoul- der. Shot fracture of upper third of right humerus. Compound comminuted shot fracture of humerus. Fracture of head of left hu- merus by fragment of shell. Shot fracture of head of left humerus. Conoidal ball fractured the left humerus. Gunshot wound of shoulder. Conoidal hall penetrated the left shoulder joint. Gunshot wound of right shoul- der joint. Mini6 ball perforated the right shoulder, shattering the head of the humerus. Shot fracture of upper third of left humerus. Shot fracture of upper third of left humerus, involving joint. Shot perforation of left shoul- der joint; head of humerus badly fractured. Gunshot wound of shoulder... Minie ball embedded itself in the cancellous structure. Gunshot fracture of the right humerus at shoulder joint. Mav 27, 18*63. Aug.- 1863. Excision of head of humerus.. Excision of the head of the right humerus. Excision of head of humerus.. Removal of head and portion of the neck of the humerus. Head of humerus excised..... Excision of head of humerus.. Resection of head of humerus, by a Confederate surgeon. Excision of head of humerus.. Excision of head of humerus. See Case 1519. Excision of the head and neck of tho humerus. Excision of head of humerus. Head of humerus excised, by Ass't Surgeon J. R. Smith, U. S. A. Excision of head of humerus.. Excision of head of humerus, by Surg. T. M. Getty, U.S.A. Excision of head of humerus.. Vet. Res. Corps, Sept. 4, 1864; not a pensioner in July, 1874. Furloughed September 20, 1864. Disch'd September 17, 1862; not a pensioner in December, 1874. Disch'd Apr. 29,1863; pensioned. March,1872, arm nearly useless. Disch'd May 19, 1865; pensioned. Kept.. 187:1, anchylosis of shoul- der joint: loss of power of arm. Disch'd November 23, 1862; not a pensioner. Discharged September 8, 1865, and pensioned : not heard from since March, 1866. Transferred to Provost Marshal February 20, 1864 ; recovered. Disch'd I lee. 22,1862; pensioned. May, 1874, very little motion in arm; forearm and hand very weak. Photograph S. S., 267. Disch'd Mar. 7, 1864; pensioned. Sept., 1873, the limb is useless for manual labor. Disch'd Apr. 29.1863 ; pensioned. Sept.,. 1813, result of operation excellent. Disch'd Dec. 19,1862; pensioned. March, 1872, anchylosis of the shoulder joint. Died June 16, 1863, of pyaemia. Died July 21, 1862. Died October 26, 1864. Removal of head of humerus, | Died. Spec. 5599, A. M. M. See by A. A. Surg. J. XV. Dickie. Case 1518. Excision of head of humerus. r8 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. Excisions of the Head and Portions of the Shaft of the Humerus.—Five hundred and seventeen case.s were referred to this category, and are classified in four divisions. Two hundred and ninety-three were primary operations, one hundred and fifty- five intermediary, fifty secondary, and in nineteen cases the interval between the date of the injury and the date of the operation was undetermined. Primary Excisions of the TJppsr Estremity of the Humerus for Shot Injury.—This large subdivision, when portions of the shaft as well as the head were removed, includes two hundred and ninety-three cases, with a mortality rate of only 27.3 per cent. ^Successful Operations.—In a large proportion of the two hundred and thirteen successful operations the progress and details of the cases have been traced: Case 1520.—Private S. B. Crane, Co. H, 13th Infantry, was wounded at Chickasaw Bayou, near Vicksburg, December 29, 1832, and was operated on in a Thirteenth Corps hospital, and thence sent on a transport to St. Louis, entering Lawson Hospital January 17, 1833. Surgeon C. T. Alexander, U. S. A., reported: "Gunshot fracture of the neck ofthe right humerus by a conoidal ball, which lodged at the superior angle of the scapula. Excision of the upper third, including the head, four inches in all, was performed on the field, Decem- ber 29th, by Surgeon George S. Walker, 6th Missouri, through a linear incision, splitting the deltoid muscle." The patient recovered, and was discharged the service April 27,1863. On September 5,1834, Examiner John H. House, Independence, Iowa, reported: "The applicant received a ball through the right shoulder, shattering the head of the humerus and scapula, which required resection of three inches of the humerus. The vacancy is not replaced by new bone. He has no use of the arm, but can hold or carry any article in the hand; disability total." In September, 1838, the pensioner was sent to New York by order of Surgeon M. Mills, U. S. A., and was furnished by Dr. E. D. Hudson with an apparatus which greatly facilitated the movements of the arm. Prior to this he had full control over the forearm and hand, but the ligamentous attachments ofthe upper extremity of the humerfls to the scapula were so long that the movements of the arm were very imperfect. The arm was shortened only one and a half inches, and its size was nearly normal, except that the deltoid was wasted from disuse. After the application of the apparatus, there Avas satisfactory power over the motions of the arm. The photograph, copied by the wood-cut (Fig. 420), was taken at this time, and contributed to the Museum by Dr. Hudson. The pensioner was paid March 4, 18T4. flattening below the acromion, and atrophy of the brachial muscles, so common in these cases, is well exemplified in the following instance: Case 1521.—Private C. S. Wilson, Co. D, 3d Wisconsin, aged 21 years, was wounded at Averysboro', March 10, 1855, and was admitted into a Twentieth Corps hospital, where excision ofthe head ofthe right humerus was performed, through a straight anterior incision. The patient was subsequently treated ia Foster Hospital, New Berne, and McDougal Hospital, New York, and was discharged from the latter May 29, 1835, and pensioned. Examiner H. O. Hitchcock, of Kalamazoo, on February 7, 1837, forwarded the photograph of this soldier, as copied in the wood- cut (FlG. 421), with the following particulars: "The man was wounded by a mini6 ball, which passed through the right shoulder joint, shattering the upper part of the humerus. The operation was performed six hours after the infliction of the injury. The wound was not healed until October, 1863. The head and about three inches of the shaft, in all about four and a half inches of the humerus, had been removed. There has been no restoration of bone. Motion at the shoulder is lost, but motion at the elbow is good, and the grasp of the hand is good. He can write quite well by moving the hand with the left one. He can chop wood pretty well; can drive horses with the hand, and can do any kind of work in which the shoulder is not required as a pivot or fulcrum." Examiner H. Neill, of St. James, Minnesota, reported, September 6, 1873: "Adduction and abduc- tion, and the power of extending the arm at a right angle from the trunk, are wholly lost. The arm is shortened about three inches, and there is a partial atrophy of the arm." This pensioner was paid March 4, 1874. The following is one of the seven cases1 of this category illus- trated by the lithographs on excision at the shoulder : Case 1522.—Sergeant Jacob P. Yakey, Co. D, 125th New York, aged 21 years, was wounded at Petersburg, June 22, 1834, and sent to a Second Corps hospital, where Surgeon D. Houston, 2d Delaware, reported that "he was struck by a conoidal ball, which entered the left Fir,. 420.—Cicatrix after excision of the head of the humerus. Th< FIG. 431.— Appearance of cicatrix and limb two years after excision at the shoulder. H. 1 Casi> of Ft. Yakey (Fig. 3, Plate XIII, op. p. 520). Lieut. Jacobs and Ft. Reardon (Figs. 1 and 2, PLATE XIV, op. p. 529), Captain Quindlen, •rsr't Fratt, and l't. Ewing (Figs. 1, 3, and 4, PLATE XVIII, op. p. 544). SECT. III.] EXCISIONS AT THE SHOULDER. 5-t9 shoulder at the anterior edge ofthe deltoid muscle, and fractured the humerus." On the same day Surgeon William S. Cooper, 125th Xew York, excised the head and three inches of the shaft of the left humerus through a V-shaped incision, the patient bein"' under chloroform. The ease progressed well. On June 2-^th, the patient was sent to Lincoln Hospital, and furloughed on September 17th, and discharged November ID. 1 - il. In January, 133.3, he was admitted to a hospital at Troy as contract nurse. He had an abscess of the left arm, which was incised by Surgeon G. II. Hubbard, U. S. V., and a small fragment of necrosed bone was removid. After this the wound healed firmly. Sergeant Yakey was pensioned. Examiner W. S. Searle reported, July (i. 1803, "the arm is useless at present." Examiner A. Churchill, of Utica, reported, September 29, 1833, the injury and operation, and added: " There is still a running sore near tho shoulder joint, and another near the elbow joint. The bone removed has not been reproduced; he has little control of the muscles of the arm, and the limb is of slight service for manual labor." Examiner C. 13. Coventry, of Utica, reported, September 4, 1M73, "almost total loss of use ofthe arm. Disability total." A photograph ofthe patient was made at Lincoln Hospital (Contributed Surg. I'/mt, A. M M., Vol. II, p. 13), which is copied in Figure 3, Plate XIH, opposite page 5.20. Tliere has been no application for a supporting apparatus in this case. Cask 1523.—Serjeant B. Wilsey, Co. D, 4th Xew Jersey, aged '.50 years, was wounded at Petersburg, April 2, 183,"). On the 11th, he was sent to Washing- ton, to Harewood Hospital. Surgeon 11. B. Bontecou, U. S. V., noted: "Gunshot wound of left shoulder, the ball fracturing the head of the humerus. Pesection of the head of the humerus was performed on the field on April 2d, through a straight incision in the long diameter of the deltoid muscle, about four inches of the shaft being also removed. The case progressed favorably under simple dress- ings, splints, and supporting treatment, and was doing well up to the end of June, 1833; but no osseous formation had taken place up to that date." On July 23th, he was sent to Ward Hospital, Newark, and thence discharged the service, August 30, 1833. Examiuer E. A. Smith, of Philadelphia, S.-ptember 4, 1833, reported that: " The wound of operation was then unhealed; there was ligamentous union, and he had all the motions of the forearm and hand." The pensioner was paid March 4, 1874. The wood-cut (ElG. 422) was taken from a photograph in the Museum (Card Photographs, Vol. II, p. 6). A letter from this pensioner, dated August 8, 1^74, Berlin, Pennsylvania, states that the operation in this case "was performed by Surgeon E. Sharpe, loth New Jersey, assisted by Surgeon B. A. Watson, 4th Xew Jersey. As to usefulness, it is of very little usa. It has gathered and discharged several times. * * I can use the hand some. * * Several pieces of bone have lately come from it. It always has gathered about once a year until last winter, and since then, nearly every month." Case 1524.—Private S. C. Allen, Co. A, 93d Xew York, aged 21 years, was wounded in the right shoulder by a piece of shell, at Spottsylvania, May 10, 1.-' il. Primary excision of the upper extremity of the humerus was done at the hospital ofthe 3d division of the Second Corps, in charge of Surgeon O. Everts, 20th Indiana. The name of the operator was not reported or remembered by the patient, who was sent to Washington, aud received at Campbell Hospital on May 14th. Surgeon A. F. Sheldon, U. S. V., noted: " Gunshot fracture of the right humerus at the upper third. The head and five inches of the shaft of the humerus excised through an incision five inches in length. The operation was performed in a field hospital; operator unknown. The patient says he was in good health at the time, and that simple dressings were applied, and that the wound did well." A year subsequently, May 23, 1835, this soldier was transferred, convalescent, to hospital at Albany, and was discharged November 30, 1835, and pensioned. Assistant Surgeon J. H. Armsby, U. S. V., forwarded a picture ofthe pensioner, taken at the time of his discharge (Contributed Surgical Photographs, A. M. M., Vol. V, p. 10), and an excellent plaster-cast showing the cicatrices of the mutilated shoulder (Spec. 2845, A. M. M.), which As-istant Surgeon Woodhull has described1 as : "A cast ofthe right arm, showing the results of primary excision. The head and about four inches of the shaft appear to have been removed. A broad, nearly straight cicatrix on the posterior surface of the arm embraces the wound of exit. A small cicatrix on the anterior surface involves the wound of entrance. The comminuted bone has evidently been removed through enlargement of the wound caused by the missile. There appears to be no bony union at the seat of operation. The shoulder is moderately full." Ou October 8, 1866, Dr. E. D. Hudson, of New York, fitted Allen with an apparatus, and forwarded the photograph, from which the wood-cut (Fig. 423) is taken, with the following report: "Arm very little shortened, very much atrophied; small fistulous ulcer. New growth of bone, two inches; interspace three inches. Functions of the forearm somewhat impaired; arm much debilitated. The apparatus is very gratifying, improving the functions of his arm, enabling him to carry his hand to Ids head." The reports of the pension examining surgeons, Fl(3 ^^^^s it appeared Dr. VV. H. Craig, of Albany, in 183S, and Drs. Bontecou, Crair, and Porter, in 1873, add two years and more aricr an excision of no new facts. The disability is regarded as-total, in the phraseology of the Pension Office. {^ conChl™ J'TcU^ This pensioner was paid March 4, 1-574. ment. [From a photograph.] Fis. 422.—Cicatrix after a decapitation of the humerus. [From a photograph. 1 ■WOODHULL (A. A.), Catalogue ofthe Surgical Siction ofthe Army Medical Museum, 1866, p. 537. Ml) INJURIES OF THE UPPER EXTREMITIES. [t HAIMX. In many of the cases, the Museum possesses specimens of the parts excised, as well as illustrations of the appearances of the cicatrices: Case 1525.—Major T. G. Morrison, 63th Indiana, aged 33 years, was wounded at Big Shanty, October 4,18G4. Surgeon A. Goslin, 48th Illinois, in charge of the Fifteenth Corps Hospital, excised the head and four inches of the shaft of the right humerus, about eighteen hours after the injury, through a single straight incision, chloroform being used. The patient was sent to Atlanta, entering hospital on October 12th, and on October 29th was transferred to No. 1, Chattanooga, and to Oilieers' Hospital, Nashville, January 12, 1835. He was furloughed in March, aud after some treatment at No. 6, New Albany, was finally discharged May 15, 1335, and pensioned. Examiner W. A. Clapp, of New Albany, August 31, 1835, reported: "Gun- shot wound of the right shoulder; the ball passed through the head of the humerus. Resection of the head and four and a half inches of the shaft of the bone was subsequently performed. There is no bony union, and amputation will probably be the result. The wound is still suppurating." In March, 1837, Major Morrison visited the Army Medical Museum, and a photo- graph (Vol. IV, No. 176, S. S. Phot. Series) was taken, and is represented by Figure 1 of Plate XVIII. At the time of his visit the major had a tolerably good use of his hand and fingers; could write freely, and could flex the forearm at a right angle to the arm; pronation and supination were partially preserved. The major stated that in January, 1886, an exfoliation from the remaining portion of the humerus was removed by Drs. Crosier and Reed at New Albany, after which the wound soon closed. A photograph of the pathological specimen accompanies No. 176, and is represented by the adjacent wood-cut (FlG. 424). The specimen consists of five and a quarter inches of tho upper extremity of the right humerus; the head is completely detached from the shaft at the base of the tuberosities, and there is loss of substance on the inner aspect of the surgical neck, involving nearly one-half of the bone and three inches in length. There is a cleanly cut hole just external to the base of the greater tuberosity, marking the point of exit of the ball; a detached fragment four inches in length extends from its posterior border, down the posterior aspect of the shaft, com- municating at one part with the fracture on the internal aspect. The track of the ball is well marked through the cancellous structure of the base of the head. The head itself is not injured. This officer states that at the moment of injury he was using his field glass, the arm being raised at nearly a right angle with the body, the ball striking obliquely on the inner aspect of the surgical neck near the margin of the articular surface, passing directly through the bone outward and slightly upward, and emerging at the point above referred to, just external to the base of the greater tuberosity. Examiner W. A. Clapp, September 5, 1873, reported: '"' There is no restoration of bone, and the arm is almost entirely useless. The wounds are healed. The upper part ofthe right arm is very much attenuated and is perfectly flexible." The pensioner was paid June 4, 1874. Case 1526.—Bugler J. H. Ewing, Co. L, 8th Illinois Cavalry, aged 22 years, was wounded at Muddy Run, near Cul- peper, November 8, 1833, and was taken to the Cavalry Corps Hospital, where he was operated on by Surgeon E..W. H. Beck, 3d Indiana Cavalry, who forwarded the specimen to the Army Medical Museum with the following history: "A large mini6 ball struck this man obliquely from the enemy's left, as he sat on his horse, his side fronting their line. The ball struck the inferior angle of the scapula, glancing upward m the direction of, and striking, the neck of the humerus. About three inches of bone was broken into fragments and continuity destroyed; indeed there was the largest number of, and the smallest sized, pieces that ever came under my observation. I send you the largest pieces. It was with difficulty I got all the small fragments extricated, so deeply and firmly were they embedded in the tissues around. The ligaments were broken, and the head of the bone partially displaced from the socket; a straight incision was the only one used. No large vessels or nerves were injured by either the ball or operation. Only one small surface artery was tied; very little blood was lost. The Avound was closed by sutures and straps, save the necessary aperture. Circulation was good in the arm the next morning; the patient had slept; he took nourishment, and was lively and hopeful. On the 9th, he was sent twenty-two miles in an ambulance to the Corps Hospital." The specimen consists of the head and four and a half inches of the shaft of the left humerus, excised for comminution of the upper third by a conoidal ball, which is attached, battered. The humerus was partially dislocated, but the epiphysis is uninjured. A card photograph, showing the appearance after recovery, stands with the specimen, which is represented in the accompanying wood-cut (FlG. 425). On November 10th, two days after receiving the injury, the patient was admitted to Columbia College Hospital, Washington. In the middle of January, 1834, an abscess formed in the deltoid region and a small fragment of necrosed bone was eliminated. By the end of January the wound was entirely healed. On March 25, 1864, the hospital report states that Ewing could slightly flex the left forearm, and that the power of pronation and supination and of moving the hand was perfect. Ewing was discharged from service September 26, 1834. On June 25, 1865, he visited the Army Medical Museum, and a photograph was then taken, and is represented in Figure 4, Plate XVII. He had little motion at the left shoulder joint, but the movements of the forearm were unimpaired. Examiner P. H. Long, of Mechanicsburg, Pennsylvania, November 15, 1868, reported that in consequence of the excision, "though the wound is now7 healed, his arm hangs helplessly at his side; no bone' existing in the upper portion for a space of perhaps five inches. The arm is flexible in every direction, and requires a brace to prevent it from being a constant source of interruption." Examiner W. D. Scarf, of Bellefontaine, Ohio. September 6, 1873, states that the patient "suffers pain at times in the balance of the arm below the end of the humerus." The pensioner was paid December 4, 1873. FlO. 424.—Excised upper extrem- ity of the right humerus. [From a photograph.] Fie. 42").—Excision of the upper extremity of tbe left humerus for shot fracture. Spec. 11)31. SECT. Ill] EXCISIONS AT THE SHOULD KII. 5f)l FlG. 426.—Upper por- tion of right humerus primarily excised for shot fracture. Spec. :J405. In the cavalry, there was a slight predominance of excisions at the right shoulder, attributed, bv Dr. G. C. Harlan, to the advanced position of the pistol arm in mounted men. Cask 1327.—Private George Howe, Co. F, 10th Michigan Cavalry, aged 19 years, was wounded at Flat Creek Bridge, Tennessee, August 21, 1*64. On the next day he was admitted into Holston Hospital, Knoxville. Surgeon H. L. W. Burritt, U. S. V., furnished the following notes: "Gunshot fracture of the upper third of the right humerus, implicating the shoulder joint. The ball entered the centre of the shoulder and emerged behind the posterior border of the deltoid near its insertion; severe hemorrhage from the wound. Forty-six hours after the injury, resection ofthe head and three inches of the shaft ofthe humerus was performed through a single straight incision from between the aeioniion and coracoid processes downward, of sufficient extent to expose the involved bone; the long head of the biceps was unimplicated, and was avoided by the scalpel; thirty-five fractured pieces of bone were removed. The anterior circumflex artery was ligated. Chloroform was used. Reaction was not very prompt, owing to previous loss of blood and a ride of twenty-three miles in an ambulance. At the time of the operation the pulse was 127, small and frequent, and feeble; patient complained of fainting from loss of blood; on the whole, he was rather indifferent to surrounding objects and much depressed. August 28th, he complains of the irksonieness of his supine position; in other respects, he expresses himself as being quite comfortable; the pulse is regaining its natural volume; suppuration already commenced; tonics and stimulants given freely. August 30th, if tliere be any change, it is for the better; appetite and spirits are fine. September 7th, patient still improving; treatment continued. 12th, the surgical wound looks finely and is granulating; the ligature came away somewhere about a week since. 22d, the wound is nearly healed up, there being only one slight suppurating point; he eats quite heartily. 30th, is doing well; wound closing; a solution of muriate of ammonia was applied externally; quinine and milk-punch given, with eggs, beef soup, milk, and oysters for diet. October 23d, the wound is nearly closed, and there is but very little discharge, and no tenderness; pulse, 83; feels well; symptoms all favorable; swelling about twenty-five per cent, in excess of the sound side.'' The specimen (Fig. 423), contributed to the Museum by the operator, consists of the head and two and a half inches of the shaft of the right1 humerus. The epiphysis is not implicated, but the shaft is broken into many pieces. The patient was transferred, on October 26th, to Asylum Hospital; furloughed on the 31st; admitted into Harper Hospital, Detroit, on November lGth; furloughed and readmitted, and, finally, discharged from the service May 2, 1833, aud pensioned. Examiner D. F. Alsdorf, of Michigan, reported, September 4.1837: * * "Wound still discharging; he has been gradually losing the use of the shoulder joint since pensioned, and cannot raise the arm now at all. He can move the forearm and use it in eating, i&c, but is totally disabled for manual labor." On October 4, 1839, Dr. Alsdorf reported that "all voluntary movements of the right arm are impossible; he can handle light articles; disability total." This pensioner was paid December 4, 1873. Case 1528.—Private Martin F------, Co. I, 8th Illinois Cavalry, aged 20 years, was wounded at Jack's Shop, near Rochelle, Virginia, on September 22, 1863, and was admitted into the hospital of the Cavalry Corps. Surgeon A. Hard, U. S. V., transmitted the following history: "F------was shot in the shoulder by a minie ball; he was stooping forward in the act of firing when he received the wound, the regiment being dismounted as skirmishers. A wet cloth or lint only was applied to the wound on the field. He was brought to Culpeper, some thirty miles, on the 23d, and was examined in presence of Surgeons G. L. Pancoast, medical director of the Cavalry Corps; E. W. H. Beck, surgeon-in-chief of the 1st Cavalry Brigade; Mitchell, in charge of Corps Hospital, and Acting Assistant Surgeons Rogers and Bliss. There was a unanimous decision in favor of resection. In their presence I performed the operation, making a longitudinal incision through the deltoid muscle, opening the joint with the scalpel, turning out the head of the bone and sawing it off as near the injured portion as possible, as the specimen will show. Only one small arterial branch required ligating. The wound was closed by sutures and adhesive straps, and no lint was inserted; this, in my judgment, being the better plan to pursue. Chloroform was employed during the operation. I have placed the ball in the specimen as nearly in the position in which it was found as could be arrived at." The specimen (Fig. 427) consists of the head and three inches of the shaft of the humerus, perforated through the surgical neck by a conoidal ball, and excised. The articular surface has sustained no loss of substance, but two fissures run through it, and another follows the line of the anatomical neck. The remainder of the specimen is much comminuted. Two days after the operation, the patient was transferred to Stanton Hospital, Washington. Acting Assistant Surgeon C. H. Osborne noted: " Condition of patient on admission was weak; wound suppurating freely; granulations healthy. November 1st, wound healing finely, appetite good; passive motion to be diligently employed. December 21st, wound entirely healed, with considerable mobility of the shoulder joint; no fragments of bone were discharged during treat- ment; prospects flattering of recovery with a useful limb." The patient was furloughed in December; was readmitted, and finally discharged from service April 6, 1864, and pensioned. Assistant Surgeon T. W. Stull, 8th Illinois Cavalry, certified that F------was wounded "by a musket ball which frac- tured the head and neck ofthe humerus ofthe right arm, rendering it necessary to resect at the shoulder joint." Examiner N. E. Ballou, of Illinois, January 10, 1837, reported: "Gunshot wound of the right shoulder, in which resection was had and four inches of the bone removed. The right arm is wholly useless for manual labor; there are issues on each side of the shoulder which discharge large quantities of pus." In his bien- nial report, September 4, 1873, Dr. Ballou makes no mention ofthe issue, but states that "the arm is shortened and is incapable of use." This soldier received his pension on December 4, 1873. 1 Through an inadvertence, this specimen is described in the Catalogue of the Surgical Specimens of the Army Medical Museum, 1866, p. 87, as ''the head and two and a half inches of the shaft of the left humerus." FlG. 4^7. —The head and three inches of the shaft of the humerus ex- cised for shot fracture. Spec. 1715. FIR. 4-28.—Head ''>•>_ INJURIES OF THE UPPER EXTREMITIES. [CHAP. ix. A case belonging to this category, an example of successful excision after fracture of the upper part of the right humerus by a shell fragment, is of especial interest as illus- trating how much of the humerus may sometimes be removed with comparatively satis- factory preservation of the functions of the arm. The elbow and forearm were well supported, and an excellent pseudarthrosis resulted: Case 1529.—Private John F. Reardon, Co. C, 6th New York Cavalry, aged 22 years, was wounded at Culpeper, October 11, 1833, and entered Armory Square Hospital on the following day. Surgeon D. W. Bliss, U. S. V., found that his right humerus was shattered by a fragment of shell, which was removed from its lodgement under the deltoid muscle. It was four inches long, one inch broad, and weighed nine ounces. Surgeon Bliss excised the head and six inches of the shaft of the humerus through a straight incision on tlie outside of the limb. During the after-treatment the elbow was well supported. The patient recovered without a bad symptom, and with a remarkably useful limb. In March, 1838, Reardon was re-enlisted in the general service, and was assigned to duty as an orderly in the Army Medical Museum. From that date until the present (March, 1875) he has served continuously, suffering very little inconvenience from the mutilation he has undergone. Without difficulty he can place his right hand on the top of his head; he can lift a weight of two hundred pounds or more with the injured limb without pain. The movements of the forearm and hand are not in the least impaired, and there is great freedom of all the movements of the arm except abduction. The muscular development of the arm equals that of its fellow. No apparatus is requisite, and altogether the result is most satisfactory aud successful. The case effectually disproves the dictum of the older military surgeons on the inutility of excisions of the humerus in cases in which it may be necessary to saw the shaft below the insertion of the deltoid. Reardon was pensioned. Examiner J. O. Staunton reported, December ancUive'and a"half 9, 1873: "There is about three inches shortening of the arm; some atrophy of the muscles; a large cicatrix. inches of the shaft jje jias some use 0f the liancl when the elbow is supported ; but the limb is useless for purposes of manual cised for shell frac- labor." The appearance ofthe excised portion of bone, presented to the Museum by Surgeon D. W. Bliss, is ture. Spec. 1738. represeiited in the wood-cut (FlG. 428). The appearance of the limb is shown in FlG. 3 of Plate XIV.1 The result of another case of this series, the pensioner having survived the injury and operation seven years or more, is illustrated on Plate XVII, opposite page 536: Case 1530.—Captain J. P. Quindlen, Co. E, 81st Pennsylvania, aged 33 years, was wounded at Deep Bottom, August 16, 1884. He was admitted to a Second Corps field hospital on the same day, and excision of the head and three inches of the shaft of the right liumerus was performed by Surgeon J. Wilson Wishart, 140th Pennsylvania. He was subsequently treated in Officers' Hospital, Camac's Woods, Philadelphia, and was furloughed in November, 1864. He was discharged from service May 15, 1835. and pensioned. Examiner Wilson Jewell, of Philadelphia, November 18, 1865, reported: "A ball penetrated the right shoulder joint. To save the arm the head of the humerus was removed by resection, but the arm is left powerless for manual or any other kind of labor, aud the wound is still discharging." In June, 1888, Dr. Wishart contributed a photograph to the Museum exhibiting the condition of the arm, a print copied in Figure 1 of Plate XVII, with the following notes : "The dark spot upon the chest indicates the point of entrance of the ball; the two spots in the line of the cicatrix, the points from which there is still discharge." In a letter of May .21, 1883, Captain Quindlen says: "My right arm, measuring from the top of the shoulder to the tips of the fingers, is about two and a half inches shorter than the left arm. I can, with ease, lift my right hand to my mouth, and, with some trouble, put it on the top of my head, but cannot begin to strike out or strike the backs of my hands together; and can, with ease, lift about twenty-five pounds from the ground. My business is that of a house painter, but I can do but little at it with my right arm. I, to-day, would not give my right arm, poor as I am, for ten thousand dollars and all the artificial arms in the country. The discharge from my arm is at present very small, some days hardly perceptible, again, some days as much as a small teaspoonful." Dr. Francis Zerman, of Philadelphia, in an affidavit dated January 8, 1872, states that he attended on Mr. Quindlen, and that he "suffered from a severe wTound in the right breast, which never healed, but continually discharged; that his lungs, in consequence of the severe depletion of the system, became affected; that he died November &> 1871, and that the primary cause of his death was the wound above referred to." A plaster-cast and also a photograph of the cicatrix at the shoulder were furnished to the Museum in the following case, by Professor Armsby, of Albany: Case 1531.—Sergeant J. H. Pratt, Co. F, 142d New York, aged 32 years, was wounded at Darbytown Road, October 27, 1834, and was taken to a Tenth Corps field hospital, where excision of the head of the humerus was performed by Surgeon N. Y. Leit, 78th Pennsylvania. On October 30th, the patient entered Hampton Hospital, and in May, 18,33, was transferred north, and admitted to St. Mary's Hospital, Rochester, May 2, 1885, and July Cth was sent to Ira Harris Hospital, Albany, where he was discharged September 22, 1835, and pensioned. Assistant Surgeon J. H. Armsby, U. S. V., contributed a plaster-cast (No. 2433 Surgical Sect., A. M. M.): "A cast ofthe left thorax and arm ten months after a primary excision of three inches of the upper third of the liumerus. The bullet appears to have entered posteriorly two inches below the summit of the shoulder, aud to have passed out anteriorly, just above the outer fold of the axilla. The incision is six inches in lengtli, and the cicatrix broad and irregular. Tlie arm is somewhat atrophied at the junction of the upper thirds. It is not known whether 1 An account of this case was published in the preliminary Surgical Report of Circular 6, S. G. O., 1865, p. 56, with an illustration which has been frequently reproduced, e. g. in BlLLUOTU und Vox PlTHA (Handbuch); FllAXKLlx (E. C.) (The Science and Art of Surgery, 18C7, Vol. I, p. 710); Hamilton U'. H.) (Princ. and Pract. of Surg., 187~», p. 3U4). SECT. III.] EXCISIONS AT THE SHOULDER. 553 union occurred."—Cat. Surg. Sect, 183G, p. 537. In June, 1GG7, Mr Piv.ti. was Bupplied with a prothetic apparatus by Dr. E. D. Hudson, of New York, who reported a shortening of one inch, with considerable atrophy, and very limited power of motion. Dr. Hudson forwarded to the Museum a photograph of the patient, showing tho appearance ofthe limb at thi3 date, represented by Figure 3, Plate XVII. The last certificate of examination is made by Pension Examining Sur,-eon N. E. B:dlou, of Sand- wich, as follows : " Gunshot wound of left shoulder, in which a resection of three inches of bone wan had, including the head of the humerus. Arm shortened and manual labor performed with difficulty. Tho pensioner was paid December 4, 1873. Caries of the shaft of the liumerus was not infrequent after primary excisions of its upper extremity for shot fracture. In some cases, there were small but repeated exfolia- tions of bone; in others, a necrosed ring of bone was thrown off; in a few instances, the greater part of the diaphysis became necrosed. The following is one of the less serious cases: Case 1532.—Private G. D. Brockett, Co. C, 29th Ohio, aged 24 years, was wounded in the shoulder at Buzzard Boost, May 7, 1334; was operated on in a Twentieth Corps hospital, and thence, on May 12th, was sent to Hospital No. 1 at Nashville. Surgeon B. B. Breed, U. S. V., noted: "Excision ofthe right humerus; about three inches, including the head of the bone, being removed. Operation was performed on the field May 7th. Anaesthetic unknown. Patient recovered rapidly under local applications of water-dressing, and tonics, stimulants, and supporting treatment. The wound healed, leaving considerable motive power of the arm." On October 20th, the photograph represented in the cut (FlG. 420) was taken, and a print was contributed to the Mnseum by Dr. Breed. The patient was furloughed; and he was discharged from service July 22, 1335, and pensioned. Examiner J. H. Warren, of Ohio, May 10, 18G3, reported the wound still discharging, and slight use of the hand, and on September 15, 1333, reported the arm a3 useless. Dr. J. L. Chapel, of Trumbull County, Ohio, certified, January 31, 1837: "I have been acquainted with G. D. Brockett, and have attended upon him since August, 1335. He has suffered, and is suffering, from necrosis of the middle third of the right humerus, caused by excision of the upper third of the bone, which was disarticulated and four inches tnkeu out. The arm has continued to discharge pus, with occasional-spicuke of bone, ever since the operation. The arm is of no utility as far as manual labor is concerned." This man's pension was increased, and he was paid March 4, 1374. A successful case, illustrated in Plate XIV, was a remarkable example of preserva- tion of control over the motions of the arm after excision of a C3nsiderable portion of the upper extremity of the humerus, and especially of the power of abduction, usually lost after this operation: Case 1333.—Lieutenant Horace G Jacobs, Co. G, 6th Maine, aged 18 years, was wounded at Rappahannock Station, November 7, 1833, by a conoidal ball, which entered the left shoulder posteriorly, two inches from the acromion process, frac- tured the upper extremity of the humerus, and made its exit an inch and a half below the middle of the clavicle. He was sent to Washington, and received .at Armory Square Hospital. Surgeon D. W. Bliss, U. S. V., reported : "A ball, supposed to be conoidal, entered posteriorly two inches from the acromion process, passing through the head of the humerus, fracturing off the upper two-thirds of the head of the bone comminuting the inner portions and about two inches of the shaft cf the humerus. Exit one and a half inches below tho clavicle, at the middle third. November ICth, head of the humerus and about two inches ofthe shaft exsected; the G-incision made through the soft parts; ordinary hsemorrhage; patient under chloroform. No vessels required ligation. The patient came out of the anaesthetic well. At the time of operation, the parts were swollen and ecchymosed; his constitutional condition was good, but he was SDmewhat feverish. The patient made a good recovery." The operator transmitted the pathological specimen (FlG. 430) to the Army Medical Museum. Tbi3 officer was furloughed January 12, 1334, and, returning to Washington, was treated in quarters, by Surgeon T Antiscll, U. S. V. On May 28, 1834, tho wound had healed, and Lieutenant Jacob3 was discharged from service (8. 0.133, A. G. O.), and pensioned. Examiner A. G. Pcabody, of Machias, Maine, reported substantially the facts already detailed regarding the injury and operation. Mr. Jacobs was subse- quently employed in tho office of the Commissary General of Subsistence. In January, 1833, he called at the Museum, and a photograph was taken of the injured shoulder. It h represented by the first figure in Plate XIV, opposite page 529. At that time his control over the mutilated arm was more complete than in any other case of excision of the upper extremity of the humerus for shot injury that had come under observation at the Museum. He could put his hand on the tcp of his head and could lift a heavy weight. Tho amount of shorten- ing was precisely three inches. The favorable result thus happily achieved was lasting; for, in January, 1875, Mr. Jacobs could use his arm even better than ten years before, and was on duty in the Treasury Department. His genera] health was excellent, and his control over the movements of the left arm was so perfect, that by any but a close professional observer the mutilation he had undergone would be unnoticed. 7u Fig. 42:).-Appearances six months after excision of the uprer part of the right humorrs for shot fracture. [Card Phot, S. G. O., Vol. II, p. ii.] Fig. 430.—Ex- cLei upper ex- tremity cf tho lclt humerus, shatter- ed by a mus!;ct ball. Spec. 17 JI. 551 INJURIES OF THE UPPER EXTREMITIES. [oiiap. ix. Table XXXI. Summary of Two,Hundred and Thirteen Cases of Recovery after Primary Excision of the Head and Portions of the Shaft of the Humerus for Shot Injury. N'amk, Age. and Militant descuiption. Albert, 11., Pt., G, 173d New York. Algers, U. D., Pt., D, 1st N. York Engineers, age 23. Allen, 8. C, Pt., B, 93d N. York, age 21. Allender, S. S., Pt., C, 124th Illinois. Anderson, W.J., Pt., A, 1st Georgia Sharpshooters, age 34. Baker, L., Pt., —, 2d Rhode Island, age 25. Baldock, L., Pt., A, 110th Ohio, age 35. Barrett,- W., Serg't, G, 6th Ohio Cavalry. Barton, H., Pt., D, 28th Virginia, age 27. Bcrdel, J., Serg't, G, 47th Ohio, age 27. Betz, G. W., Serg't, H, 104th Ohio, ase 27. Bigger, C. P., Lieut., A, 46th Virginia, age 24. Bodge, G. E.. Pt., B, 13th JSew Hampshire age 22. Booth, D. R., Pt., G, 3d Arkansas, age 2L. BoothmaD, W., Pt.. B, 173d New York, age 18. Braushaw, D. IF., Pt., A, 43d North Carolina. Brink, J. H., Pt K, 11th Pennsylvania Cavalry, age 19. Brockett, G., Pt., C, 29th Ohio, age 24. Erooks, W., Pt., G, 57th Indiana, age 38. Bryan, J. J., Pt., G, 6th Georgia. Burger, S., Pt., A, 102d Illinois, a°e 30. Burns, John, Pt., A, 2d Massachusetts, age 21. Burns, TT.. Serg't, K, 37th Georgia, age 21. Carqueville, XV., Corp'l. I. 4th New York Cavalry, age 40. Date of Injury June 14 1863. Aug. 28 1864. Hay 10. 1864. Mav 22 18o3. Dec. 5, 1834. Julv 13 1864. June 3, 1864. Sept. 1, 1863. Nov. 11. 1863. June 1, 1864. Nov. 27, 1864. June 17, 1864. May 10, 1864. Sept, 20, 1863. June 14, 1863. May 25, 1864. May 21, 1863. May 7, 1864. May 27, 1864. Mav 16, 18*64. June 15, 1864. Julv 3, 1863. Nov. 30. 1861. Sept. 19 1864. Nature of Injury. Compound comminuted frac- ture of upper third of left humerus by a conoidal ball. Shot fracture ofthe upper third of right humerus. Fracture of head of right hu- merus by shell; extensive muscular laceration. Comminuted shot fracture of upper third of left humerus. Conoidal ball fractured the neck of the right humerus. Left humerus terribly com- minuted below anatomical neck by a conoidal ball. Minie ball passed thro' head and neck of left humerus and lodged in parietes of chest. Shot fracture of left humerus. Musket ball passed thro' left shoulder, fracturing the upper portion of the humerus. Conoidal ball fractured the upper third of left humerus. Fracture of upper third of left humerus by a conoidal ball. Compound comminuted shot fracture of head and shaft of left humerus. Gunshot fracture of the right humerus. Shot fracture of the head of the right humerus. Gunshot fracture of the right humerus; also fracture of lower maxilla. Conoidal ball fractured the left humerus. Shot fracture of upper third of right humerus. Compound shot fracture ofthe right humerus. Gunshot fracture of the head of the left humerus. Comminuted shot fracture of the head and upper third of humerus. Gunshot wound of right shoul- der joint, ball passing thro' head of humerus. Mini6 ball entered the left shoulder and embedded itself in the head of the humerus Shot fracture of the left hu- merus. Compound comminuted frac- ture ofthe left humerus by a conoidal ball. Date of Opera iiox. June 14 1863. Aujr. 28 1854. May 10, 1864. May 2! 1863. Dec. 5, 1864. July 14, 1864. June 3, 1864. Septi, 1863. Nov. 12, 1863. June 3. 1864. Nov. 27, 1864. June 18, 1864. Mav 11, 18"ti4. Sept. 21, 1863. June 14, 1863. May 25, 1864. May 21, 1863. May 7, 1864. May 27, 1864. May 17, 1864. June 15, 1864. July 4, 1863. Nov. 30, 1864. Sept. 21, 1864. Operation and Operator. Excision of five inches of bone, including the head, by A. A. Surgeon M Schuppert. Removal of head and three inches of shaft through a straight incision. Head and four inches of hu- merus excised thro' a linear incision. Removal of the bead andupper thud of the shaft of humerus Head and two and a half inches of humerus resected. Head and three inches of shaft excised through a straight incision, by Surg. E. Bentley, U. S. V. Excision of head and shaft of humerus four inches below acromion, by Ass't Surgeon W. M. Houston, 122d Ohio. Head and five inches of shaft of humerus excised through a straight incision. Removal of superior portion of humerus, including the head; bone sawn acrofes four inches from the anatomical neck, by Ass't Surg. F. M. Letcher, P. A. C. S. Head and upper third of hu- merus removed, by Surg. A. C. Messenger, 57th Ohio. Excision of head and three inches of shaft of humerus, by Surgeon J. H. Rodgers, 104th Ohio. Resection of head and three inches of shaft of humerus. Excision of the head and three inches of shaft of right hu- merus Excision of the head and four and a half inches of shaft of humerus. Excision of the head and two inches of the shaft of the humerus. Excision of head and three inches of shaft of humerus. Excision of head and neck of right humerus, by Surgeon G. C. Harlan, 11th Pennsyl- vania Cavalry. Excision of the head and two inches of shaft of humerus. Excision of the head and six inches of shaft of humerus, by Surgeon E. B. Glick, 40th Indiana Head and three inches of shaft of the humerus removed, by Surgeon C.B. Gibson, C.S. A. Excision of the head and four inches of shaft of humerus. June 20, 1867, arm amputated at shoulder joint, by Dr. M. Reese. Excision of the head and two and a half inches of shaft of humerus, by Surgeon W. H. Heath, 2d Massachusetts. Resection of the head and two inches of shaft of humerus. Head and three inches of shaft of humerus excised. Result and Remarks. Disch'd Sept. 29,1863; pensioned. October, 1866, loss of motive power in right arm. Disch'd Mar. 11,1865. Notapcn- sioncr in Nov., 1874. Disch'd Nov. 30, 1865; pensioned. Oct , 1873, arm useless for pur- poses of manual labor. Spec. 2845, A. M. M. Disch'd Oct. 2, 1863; pensioned. Sept., 1873, has no power to move arm; has some use of fingers. Transferred for exchange, Feb- ruary 20, 1865, with compara- tively useful arm. Disch'd July 14, 1865. Not a pensioner. Disch'd Ap'l 17,1865; pensioned. Sept., 1873, disability total, third grade. Spec. 5655, A.M.M. Disch'd May 4, 1864; pensioned. Sept., 1873, disability total. third grade. August, 1864, limb shortened two inches; movements of forearm unimpaired.1 Disch'd July 13,1865; pensioned. May, 1867, arm flexible in every direction. Died Oct. 10, 1871. Disch'd June 23, 1865; pensioned. Sept., 1873, wound suppurates at times; arm useless. Recovered. Arm bids fair to be useful. Disch'd Nov. 12,1864; pensioned. Sept., 1873, disability total, 3d grade. Retired February 9, 1865. Disch'd Jan. 31, 1864; pensioned. Sept., 1873, "His arm is of no use to him.'' Retired from service Jan. 2,1865. Arm almost entirely useless, but had lair use of hand. Disch'd Sept. 22, 1863; pensioned. Sept., 1866, arm hangs power- less at his side. Photo. 208, Surgical Series. Disch'd July 22, 1865; pensioned. Sept, 1866, arm useless for labor. Disch'd May 18,1865; pensioned. Sept., 1873, arm and hand use- Transferred May 19, 1864; doing well. Disch'd Dec. 17,1864; pensioned. May, 1874, extensive ulcera- tion through intercostal muscles into pleural cavity; distressing cough. Disch'd Oct. 27,1863; pensioned. Sept., 1873, disability total, 3d grade. Transferred for exchange, Feb 14, 1865. Disch'd July 31,1865; pensioned. Sept., 1873, arm useless. 1LETCUEU (F. M.), Resection of Superior Third cf Humerus, in Confederate States Med. and Surg. Jour., 1864, Vol. I, p. 118. SECT. III.] EXCISIONS AT TIIE SHOULDER. 555 Name, Age, and Military Discriptio.n. Castlcbnry, Z., Pt., D, 23d Alabama, age 19. Charles, R. A , Rorg't, A, 16th Pennsylvania Cav'lry. Chisholm, A., P Confed'rato Stat age 17. Christian, S., Pt, —, 20th Massachusetts, ago 23. Date of Inj out, May 13 1864. Oct. 13, 1863. A, 1st An-. 19, Battery, 1861. Mav 17, 1864. Clark, W., Tt., —, 20th In- diana Battery, age 28. Clcghorn, J. E. F., Pt. 1st New Jersey Cav age 27. alry Cockrell, R., Pt., II, 6th Mississippi, age 35. Cole, S., Pt., G, lObth Now York, age 19. Connors. P., Pt, H, 13th New Jersey, age 43. Contant, E. H., Pt , A, 75th New York, age 23. Cosgrove, M., Pt., B, 59th Massachusetts, age 36. Costley, G, Serg't, K, 4th Colored Troops, age 27. Crane, S. B., Pt., H, 13th Iniantry. Creasy, J., Pt., A, 69th Ohio, age 16. ;ntes, S., Pt., diana, age 21 Croft, M., Pt., A, 149th Pennsylvania, age 31. Cross, J., Pt., A, 77th New York, age 34. Decker, J. M., Pt., A, 7th Infantry, age 31. Dekraker, M., Pt., A, 5th Michigan, age 24. Dickenson, G., Serg't, K, 20th Connecticut, age 22. Dickson, R., Pt., D, 3d Maine. Dillbridge, J. L., Pt., K, 23d Michigan. Dobell, J. D., Corp'l, C, 19th Illinois, age 24. Doolittle, M., Pt., E, 1st Michigan, age 28. Dougherty, J. O., Pt., D, 155th Pennsylvania, age 27. Oct. 28, 1864. Nov. 27, 1863 Deo. 6, 1864. Julv 9, Julv 30, 1864. Mav 2' 1863. May 12, 1664. Sept. 09, 1864. Dec. 29 18U2. May 14, lfc'64. Julv 30, lbo4 June 1, 1864. May 3, 18b3. Julv 2, 1663. June 18 1864. July 3, 1863. June 1, 1662. May 14 1864. Sept. 20, 1863. Slay 5, 1864. April 1 1865. Nature of Injuivt. Opera- tion. Extensive comminution of tho upper portiou of tho right hu- mt'i'iis, involving the joint. Conoidal ball fractured head of the right humerus. Gunshot wound of the right shoulder joiut. Mini6 ball fractured tho right shoulder. Head of left humerus badly shattered by gunshot. Shot fracture of head of left humerus. Min'u ball fractured the right shoulder. Musket ball grooved the pos- terior portion ofthe head and shattered tho surgical neck of the left humerus. Shot fracture of head of right humerus and wound of left forearm. Comp'd comminuted fracture of upper third cf right hu- merus, involving joint, by eani.ter shot. Gl unshot fracture of the upper third of the left humerus. Conoidal ball fractured head of right humerus; also wounds of right hand and left hip. Comminuted fracture of upper third cf right humerus by a conoidal ball which lodged in scapula. Shot fracture of upper third of the right humerus. Onnshot fracture of the left shoulder joint. Mini6 ball perforated the left 6houlder joint. Wound of right shoulder joint by a conoidal ball. Musket ball perforated head of the right humerus. Conoidal ball comminuted the head of the right humerus, opening tho joint. Extensive fracture of upper portion of right humerus by a fragment of shell. Wound of right arm and shoul- der by conoidal ball and buck- shot. Comminuted shot fracture of upper extremity of right hu- merus opening the joint. Shot fracture cf head and neck of right humerus, with great laceration. Shot fracture of the right hu- merus beneath tho internal edge of the deltoid. Compound comminuted shot fracture of the head of the left humerus. Operation and Operator. May 13 1864. Oct. 16, 1863, Aug. 20, 1864. May 17 1864. Oct. 29, 1864. Nov. 30 1863. Dec. G, 1864. July 11, 1864. July 31 1664. Mav 27. 1863 May 12, 1864. Sept, 30, 1864. Dec. 29, 1862. ' May 17, 1864. Julv 30, 1864. June 1, 1854. May 3, 1863. Julv 4, 1863. June 18, 1864. July 5, 1803. June 3, 1862. May 14, 1664. Sept. 23, 1863. May 5, 1864. April 1, 1865. Removal of head and upper portion of shaft of humerus, six inches in all. Excision of Iho head and four inches of shalt of humerus, by A. A. Surg. N. Barnes. Excision of upper third cf hu- merus through a simple lon- gi*udi»al incision. Removal of tho head and a poriion of shaft of humerus, by Surg. N. Hayward, 20th Massachusetts. Head and small portion of shaft of humerus excised, by Surg. (i. E. Cuopcr, U. S. A. Resection of the head and a small portion of tho shaft of humerus, bv Surgeon 11. K. Clark, 10th N. York Cavalry. July 21, 1864, removal of re- mainder of humerus and the heads of radius and ulna, by A. A. Surg. J. B. Cutter. Rcscclion of the head and two inches of shaft of humerus. Head and one and a hall inches of the shaft of the humerus removed, by Ass't Surgeon R. P. Weir, U. S. A. Removal of the head and three inches of shaft of humerus. Excision of head and portion of shaft of humerus, by Surg. M. D. Benedict. Excision of the head and a portion of the shaft ofthe hu- merus, by Surg. T. F. Oakes, 56th Massachusetts. Excision of the head and two inches of the shaft of humerus. Removal of four inches of the humerus, including the head, by Surgeon G. S. Walker, 6th Missouri. Head and about two and one- half inches of the humerus excised. Head and three inches of the shaft of humerus removed through a straight incision. Excision of the bend and four inches of shaft of humerus, by Surg. W. Humphrey, 149th Pennsylvania. Removal of the head and two and a half inches of shalt of humerus, by Surgeon G. T. Stevens, 77th New York. Excision of the head and one inch of the shaft of humerus. Head and three inches of shaft of humerus resected, by Surg H. F. Lyster, 5th Michigan. Excision of head and a small portion of che shaft of the humerus, by Surgeon J. A. Freeman, 13th New Jersey. Excision of the head find live inches of shaft of humerus. Resection of the head and two inches of shaft of humerus, by Surg. C. S. Frink, U. S.V. Head and two inches of the humerus removed, through a straight incision, by Surgeon W. P. Johnson, 16th Ohio. Excision of the head and a portion of the shaft of the humerus, four and a half inches in all. Removal of the head and one and a half inches ofthe shaft of humerus. Result and Remarks. Recovered June 25, 1864.' Disch'd June 3, 1865; pensioned. March, 1867, the arm is of no service for labor. August 3ist, doing well; recov- ered in October. Disch'd Jan. 31,1805 ; pensioned. Sept., 1873, muscular atrophy; arm useless. Disch'd Aug. 4,1865 ; pensioned. Sept., 1873, disability rated to- tal, :'d grade. Disch'd Oct. 20,1864 ; pension'd.2 Sept, 1861), arm hangs pendu- lous and useless. Photos 112, 148. Healed kindly. Transferred for exchange. March 1, 1865. Disch'd June 13, 1865; pensioned. Sept., 1873, disability equal to loss of arm for manual labor. Spec. 3954, A. M. M. Disch'd Sept. 20,1865; pensioned. Sept, 1813, arm useless; ois- ability total, 3d grade. Spec. 4356, A. M. M, Disch'd June 18,1865; pensioned. Sept., 1873, disability total, cd grade. Spec. 2346, A. M. M. Disch'd Jan. 16. 1865; pensioned. Sept., 1873, has fair use ot fore- arm and hand. Disch'd April 4,1865; pensioned. Sept., 1673, disability total, 3d grade. Disch'd Ap'l 27,1833; pensioned. September, 1873, arm useless for manual labor. Disch'd July 26,1865; pensioned. July, 1871, able to ilex forearm to right angle with arm. Grasp of hand feeble Disch'd Oct. 6, 1864; pensioned. Sept., 1873, muscular atrophy of arm and forearm. Disch'd Aug. 23, 1665; pensioned. September, 1873, total loss of use of left arm for manual labor. Disch'd Sept.12,1863; pensioned, March, 1874, limb almost en- tirely useless. Disch'd Ap'l 24,1865; pensioned. Sept., 1873, disability total, 3d grade. Disch'd Mar. 29,1865; pensioned. Dec. 7, 1870, has considerable use of arm. Disch'd Aug. 18,1865; pensioned. Sept., 1873, has about one-fourth ordinary motion in all direc- tions. Disch'd Nov. 10,18a'2; pensioned. March, 1874, disability total, 3d grade. Disch'd June 9, 1865; pensioned. Jan'y, 1874, arm nearly useless, Disch'd Ap'l 19,1864; pensioned. Sept., 1864, arm useless and painful. Disch'd Sept.12,1864; pensioned. Sept., 1874, disability total, 3d grade. Disch'd July 25,1865; pensioned. Sept., 1873, can flex the elbow, and, to a slight extent, the fingers. ' O'Keefe (D C), Surgical Cases of Liter est Treated at Institute Hospital, Atlanta, Ga., May and June, 1864, in Confederate States Medical and Surgical Journal, 1865, Vol. II, p. 30. 2 Cutter (J. B.), Cases of Excision of Bones, in Am. Jour. Med. Sci., 1866, Vol. LI, p. 139. 556 INJURIES OF THE UPPER EXTREMITIES. [chap. ix. 50 74 Name, Are. and Military Description. Drake. J., Pt., G, 14th Ohio, ago 28. Driscoll, D., Pt., 1,147th N. York, age 21. Dulaney, —, Colonel, 7th Conicd'ato States Cavalry. Dwycr, C, Pt., A, 1st Mary- land Cavalry, age 23. Edgar, W. D., Corp'l, K, 4th Ohio, age 25. Eisele, P., Pt., 1,2d Missouri, age 34. Ewing, J. H., Bugler, 8th Illinois Cavalry, age 31. Fisher, J., Sergeant, K, 17th Indiana. Fisher, R., Corp'l, C, 7th N. York Artillery, age 27. Fisher, T. T., Lieut., E, 27th Kentucky, age 22. Fishley, C. H., Pt., D, 52d Ohio, age 20. Fox, J., Pt., G, 27th Ohio, age 21. Francher, M., Pt., I, 8th Illinois Cavalry, age 26. Francisco, H. C, Pt., A, 8th East Tennessee, age 20. Frank, R., Pt., A, 11th Ohio, age 22. Fuller, A. C, Serg't, F, 58th Pennsylvania, age 29. Gaumer, J., Corp'l, B, 80th Ohio, age 36. George, T. C, Pt., B, 7th Wisconsin, age 22. Gibson, S. J., Pt., K, 31st Ohio. Gill, A. C., Pt., C, 20th Indiana. Girst, J.,Pt.,B, 78th Illinois, age 28. Goldston, W. A., Lieut., K, 1st Tennessee, age 25. Good ver, J.. II., Corp'l, F, iOSth New York, age 22. Graham, W. J., Pt., G, 100th Pennsylvania, age 19. Grant, W. R., Pt, B, 25th North Carolina, age 36. Griffith, T. T., Pt, A. 59th Virginia, age 37. Hall, D, Pt, E, 85th In- diana, age 24. Hall, J. M.. Pt., H, 7th Texas, age 22. Date of Injury. Sept. 1, 1864. June 18, 1864. Aur\ 14, 1864. Aug. 16, 1864. Mav 3, 18')3. Nov. 25, 18C3. Nov. 8, 1863. June 25, 1863. June 8, 1864. May 31, 1864. June 27, 1864. July 4, 1864. Sept. 23, 1863. July 10 1864. Feb. 24, 1804. Sept. 29, 1864. Nov. 25. 1863. ' June 18 1864. Sept. 19, 1863. May 12, 1864. Sept. 1, 1864. Aug. 6, 1864. Feb. 6, 1664. Aug. 19, 1864. May 26, 18J3. May 8, 1864. Nov. 18, 1863. Nov. 30, 1864. Nature of Injury. Musket ball comminuted the head of the left humerus. Gunshot fracture of the upper thirl of the left humerus. Extensive shot comminution of Ihe head and upper portion of shaft of humerus. Comminuted shot fracture of the head of right humerus, with laceration of soft parts. Mini6 ball fractured the surgi- cal neck of right humerus; missile lodged against the head of the bone. Shot wound of right shoulder j jint; fracture of head of hu- merus. Conoidal ball fractured- neck and shaft of the left humerus and injured the scapula. Conoidal ball passed through the head of the right humerus and lodged behind scapula. Conoidal ball lodged in the head of the right humerus. Shot fracture of upper third of the right humerus, injuring the joint. Shot fracture of the head of the left humerus. Mini6 ball comminuted upper articular extremity of right humerus. Head of the left humerus split and neck comminuted by a conoidal ball. Comp'd comminuted fracture of left humerus at anatomical neck by conoidal ball. Comp'd shot fracture of upper third of right humerus. Comminuted shot fracture of the head of the left humerus. Shot fracture of left humerus. Minid ball passed transversely through the left humerus two inches from shoulder joint. Shot fracture of right humerus. Severe wound of left shoulder by conoidal ball. Conoidal ball fractured the up- per third ofthe left humerus. Comminuted shot fracture of head and upper third of shaft of humerus. Oblique fracture through surg- ical neek of right humerus by conoidal ball. Mini6 ball comminuted the head and neck of the left hu- merus. Comp'd comminuted shot frac- ture of left humerus; shaft fissured. Shot fracture of upper extrem- ity of the right humerus. Minio ball lodged in the head of the left humerus, commi- nuting it greatly. Gunshot fracture of the left shoulder. Date of Opera- tion. Sept. 2, 1864. June 18, 1864. Auar. 15, 1864. Aug. 16, 1864. Mav 5, 1863. Nov. 25, 18G3. Nov. 8, 1863. June 27, 1863. June 8, 1864. May 31, 1864. June 27, 18C4. July 5, 1864. Sept. 23, 1863. July 11, 1864. Feb. 24, 1804. Sept. 30, 1864. Nov. 25, 1803. Ju-e 19, 1864. Sept. 19. 1863. May 12, 1864. Sept. 2, 1864. Aug. 6, 1864. Feb. 9, 1864. Aug, 19 18C4. Mav 23, 1863. May 8, 1861. Nov. 18 1863. Nov. 30, 1864, Operation and Operator. Head and two and a half inches of shaft of humerus excised, bv Surg. C. N. Fowler, 105th Ohio. Head and one anda half inches of shaft of humerus excised, by Surg. A. S. Coe, 147th New York. Resection of the head and four or five inches of the shaft of humerus, by Dr. II. McGuire. Head and two inches of the shaft of the humerus excised, by Surgeon C. M. Clark, 3Jth Illinois. Head and ivppsr third of hu- merus excised. Removal of the head and three inches of shaft of humerus by Surg.A.McMahon, 64th Ohio. Head and four and a half inche.i of the shaft of the humerus excised, by Surg. E W. H. Bock, 3d Indiana Cavalry. Head and two inches of shaft cf tho humerus removed, by Surg. I. Moses, IJ. S. V. Head and one inch of shaft of humerus removed, by Surg. J. XV. Wishart, 140th Penn. Excision of head and two inches of shaft of humerus, by Surg. E. Shippcn, U. S. V. Head and three inches of shaft of the humerus removed, by Surg. II. M. Duff, 52d Ohio. Resection of tho head and four inches of shaft cf humerus, by Surgeon A. B. Monahan, 6 id Ohio Head and three inches of shaft of humerus excised, by Surg. A. Hard, 8th Illinois Cavalry. Excision of the head and two inches of shaft of liumerus, by Surg. J. H. Rodgers, 104th Ohio. Heal and four and one-half inches cf humerus excised. Resection of the head and four and one-half inches of shaft of humerus. Excision of the head and two inches of shaft of humerus. Excision ofthe head and three inches of shaft of humerus, by Surgeon D. C. Ayers, 7th Wisconsin. Excision of the head and four inches of shaft of humerus. Removal of the head and por- tion of the shaft of humerus, about seven inches in all. Head and three inches of shaft of the humerus excised, by Surg. A. Wilson, 113th Ohio Head and five inches of shaft of the humerus removed, by Surg. A. M. Wilder, U. 8. V. Excision of the head and two inches of shaft of humerus, by Surg. J. Dwindle, 106th Pennsylvania. Removal of the head and two inches of neck cf humerus, by Surgeon W. V. White, 57th Massachusetts. Head and three and a half inches of shaft of humerus removed, by Surgeon C. II. Ladd, 5Cth 'North Carolina. Resection of the head and six inches of"shaft of humerus. Head and two and a half inches of humerus excised, by A. A. Surgeon J. H. Green. Excision of the head and two inches of shaft of humerus, by Surgeon J. R. Crane, 7th Texas. Result and Remarks. Disch'd June 25,1805; pensioned. Sept., 1874, disability total, 3d grade. Disch'd May 15,1865; pensioned. Sept., 1873, has no power to raise arm, but has some uso of forearm. Recovered; can hunt, shoot, and play a good game of billiards.1 Disch'd Ap'l 11,1865; pensioned. Sept., 1873, arm useless. Disch'd Oct. 23,1863; pensioned. Sept., 1873, arm hangs useless at side. Disch'd July 18,1864 ; pensioned. September, 1873, limb nearly totally useless. Di~ch'(i Sept. 27,1864; pensioned. Sept., 1873, the arm is almost useless. Spec. 1931, A. M. M., and Photo. 55. Returned to duty Jan'ry 9, 1854. Disch'd May 25,1865; pensioned. Died July 24,1870, of phthisis. Spec. 384, A. M. M. Disch'd Mar. £9,1865; pensioned. Arm useless; can grasp with hand to a limited extent. Disch'd Jan. 31,18;>5; pensioned. Sept., 1873, unable to extend arm or lift it from tho body. Disch'd Aug. 3. 1865; pensioned. Serit, 1873, the arm cannot be extended or raised. Disch'd April 6,1864; pensioned. Sept., 1873, can perform little or no manual labor. Spec. 1715, A. M. M., and Photo. 125. Disch'd Mar. 3,1865; pensioned. Jan'y, 1874, muscular atrophy and total paralysis of loft arm. Disch'd Dec. 27,1864; pensioned. Sept.,1873, extremity atrophied; grasp of hand fseble. Disch'd July 8, 1865; p:nsioned. Sept., 1874, shoulder tender and painful; arm useless Disch'd May 13,1664; pensioned. Sept., 1873, disability total, 3d grade. Disch'd Feb. 9, 1865; pensioned. Sept., 1873, disability total, 2d grade. Disch'd Oct. 30,1834; pensioned. Sept, 1873, disability one-half. Disch'd Dec. 27, 1864; pensioned. August, 1874, arm useless in the performance of manual labor. Disch'd May 1, 1865; pensioned. Sept, 1873, arm hangs useless. Disch'd Sept. 26.1864; pensioned. Sept., 1873, disability rated total. Disch'd Sept. 26,1864; pensioned. Sept, 1873, disability equiva- lent to less of hand for manual labor. Disch'd Mar. 29, 1865; pensioned. Sept, 1073, limb attenuated and atrophied. Recovery rapid. Writes, in 1871, that he " can plough, cut wocd, and play tho violin almost as good as ever." Retired March 20, 1865. Disch'd May 18,1864; pensioned. Sept, 1871. has no uso of shoul- der joint whatever. Transferred to Provost Marshal, February 24, 1865. ' McGuire (H.), Clinical Remarks on Gunshot Wounds of Joints, delivered, January 10, 1865, at Howard's Grove Hospital, in The Richmond Medical Journal, 1856, Vol. I, p. 149. SECT. III.] EXCfSIONS AT THE SHOULDER. 557 Name, Ace, and Military DnsCKII'TlON. Unmmo d. .If, Ser.v't, Pur- July 3, ell's Battery, age 22. Hammond, W, Corp'l, K, July 30, lidth New York, age 44. 1804 Hanna, T. R, Corp'l, G, Nov. 30, 125th Ohio, age 43. 1Sj4. Harbaugh, J. E. Pt, D, 6th May 3, Infantry, age 27. 1803. Harding, A. A, Lieut, G, i May 14, 21st Wisconsin, age 25. j 1804. Hardy. J. K, Corp'l, E, 79th Nov. 21, Indiana, age 26. I lfc63. Harlow, J. M, Pt, I. 1st June 16. Mass. Aitillery. age 22. I 1804. Hartman, J, Pt, H, 187th June 18, Pennsvlvacia, age 39. I 18>>4. Mav 27, 1604. 6ii Hatfield, E. F., Pt, C, 46th Ohio, age £7. Hays. A. A., Pt, E, 8th South Carolina, age 24. Heinrich, J.. Pt, C, 12th Wisconsin, age 23. Helm, C. B, Pt, E, 31st Wisconsin. Hennessey, J, Pt, E, 17th New York, age 18. Hickenlooper, H, Corp'l, E, Cth Iowa, age 23. HilL R. C, Pt.. I, 57th Pennsylvania, age 23. Holder, H., Pt., I, 25th N. Carolina, age 19. Holloman, N. P., Pt, H, 3d North Carolina, age 26. Holloway, J. P., Pt, A, 41st Virginia, age 22. Howe, G, Pt, F, 10th Mich- igan Cavalry, age 19. Hunt, T, Corp'l, D, 118th Ohio, age 46. Jacobs, H. G, Lieut, G, 6th Maine, age 18. Jamison, J. A , Lieut, Clai- borne's Staff, age 23. Jarvis, T. J., Capt, B, 6th Vorfh Carolina, age 18. Jaycox, J. H. Corp'l, B, 143d New York, age 31. Je:.!;ins, A, Pt, D, 53d Ohio, age 2Z. Jenks, J. G, Pt, F, 15th Infantry, age 17. Johnson, J, Pt, A, 7th Col- ored Troops, age 23. Jordan, J, Corp'l, C, 69th Ohio, age 22. Mav 24 1SG4. Oct. 5, 1864. Mar. 19 1865. Sept 1. 1864. Nov. 25, 1863. June 17 1864. Julv 2, 1863. July 30, 1864. Aug. 24, 1664. May 14, 18.14. Nov. 7, 1803. Nov. 30, 1864. Mav 14, 1864. July 20, 1864. Julv 3, 1804. July 27, 1864. Oct. 13 18J4. May 14 1664. Nature of Injury. Conoidal ball comminute 1 the upper portion of the left hu- merus. Head and neck of right bu- rner.is badly comminut'd, and circumflex artery partially divided, by a mini6 bill. Shot fracture of upper third of the left humerus. Comp'd comminuted shot frac- ture of the head of the right humerus. Mini6 ball fractured the left humerus and penetrated tho shoulder joint. Shot fracture of upper third of the right humerus. Shot fracture of the head of the left liumerus; also wound of face with loss o. right eye. Gunshot wound of the left shoulder. Shot fracture of upper third of left humerus, extending into joint Shot fracture of the head of the right humerus. Minie ball comminuted the upper portion of the left hu- merus, fractured four ribs, and injured lung. Shot fracture of the head of the left humerus. Comminuted shot fracture of the head of right humerus. Shot fracture of surgical neck of the right humerus; shaft splintered more than three inches. Radiating fracture of the head of left humerus by a conoidal ball. Comp'd comminuted shot frac- June 18 rurc of right humerus. 1864 Conoidal ball fractured head July 3, of right humerus and lodged 1863. in the glenoid cavity. A minie ball passed directly July 30, through left shoulder joint 1864, and shattered the head and shaft of the humerus. Comminuted shot fracture of Aug. 26 npper third of right humerus, 1864 involving shoulder joint. Shot fracture of the head of the ' May 14, right humerus. 1804. Opera- tion. July 3, 1863. July 30, 1664. Dec. 1, 1864. May 3, 1803. Mav 14 1864. Nov. 25, 1863. June 17, 1864. June 18, 1864. May -St, 1864. May 24 1864. Oct 7, 1661. Mar. 19 1835. Sept. 3, 1864. Nov. 25, 1803. May 5, 1864. Operation and Operator. Excision of head and thre- inches of shal'i of hu:ncrus,by Surg. W. A.lireene.C.S. A. Excision ofthe head and three inches of the shaft of tho hu- merus.by Su-g. II. F. Lyster, 5th Michigan. Excision ot head end a portion of shaft of humer.is, by A. A. Surg. J. C. Thnr| e. Head nnd one inch of shaft of humerus resected, by Ass't Surg. J. S. Pilling?, I'.S. A. Romoval of head and two and a half inches of the shaft of humerus, by Surg. S. Marks, 2.1lh Wisconsin. Head nnd one inch of the shift of humerus rcseeto i, bySurg. C Scliussler, (,th Indiana. Excision of the head and four inches of shaft of humerus. Excision of head and upper third of humerus. Excision of the head and four inches of shaft of humerus by Surg. D. Halderman, 4Cth Ohio. Removal of head and three inches ot shaft of humerus. Removal of the head and seven inches of the shaft of humerus andir.ictured ponions of ribs, by Surg. J. J. Whitney, 18th Wisconsin. Resecaion of three inches of upper extremity of humerus. by Ass't Surg. M. T. Bab- cock, 141st New York. Head and three and a half inches cf shaft of humerus removed, by Hurg. E. Bat- well, 14th Michigan. Excision of head and neck of humerus, by Surgeon N. W. Abbott, 80th Illinois. Excision of he3d and a portion of the shaft of t'ac humerus a little below tho surgical neck, by Surgeon H. F. Lyster, 5th Michigan. Removal of head and one inch of the shaft of humerus. Removal of the head and four inches of shaft of humerus through a straight incision. Excision of the head and two inches of shaft of humerus. Conoidal ball perforated the head of left humerus, com- minuting it, as also about two inches cf the shaft. Shot fracture of upper third of the left arm. Shot fracture of upper third of right humerus. Head and upper third of the left humerus shattered by a conoidal ball. Comminuted shct fracture of the left shoulder. Mim6 ball comminuted head of the right humerus. Shot fracture of upper third of the left humerus. Conoidal ball shattered nnd lodged in the head of the left humerus Nov. 10, 1863. Dec 1, 1864. May 14, 1861. July 21 1834. July 3, 1864. July 27. 1664. Oct. 15, 1664. May 14, 1864. Result and REsrARKs. Head and two and a half inches of shaft cf humerus removed, by Surg. H. L. W. Burritt U. S. V. Excision of head and four and a half inches of tlie shaft of humerus, by Surgeon C. W. McMillen, 1st E'st Tennessee. Excision ofthe head and three inchesof shaft of humerus, by Surg. D. W. Bliss, U. S. V. Head and two inches of shaft of left humerus removed, by Surg. J. R. Ludlow, U. S. V. Resection ofthe head and four inchei of shaft of liumerus. Excision of the head and five inches of shaft of humerus, by Surgeon II. K. Spooner, 61st Ohio. Head and five inches of shaft of humerus removed, by Surg. A. C. .Messenger, 57th Ohio. Head and two inches of shaft of humerus excised, by Surg. W. C. Jacobs. 81st Ohio. Removal of the head and three inches of shaft of humerus. Head and two and a half inches of the humerus excised, by Surg. L. Slusser. OSth Ohio. Exchanged in Sept.. 1813. Limb atrophied; use of hand and forearm perfect, that of arm somewhat impaired. Disch'd June 28. 1805; pensioned. Sept.. 1873, limb useless for manual labor. Disc'a'd Sept. 25,1805 ; pensioned. Died January 25, 1871. Disoli'dNov II, 1863; pensioned. Dec , 1668, entirely unable to raise arm from bodv. Resigned Sept 28. * 1864; pen- sioned. Sept., 1873, complete loss of use of shoulder joint. Disch'd December I, 1C01, and peasioned. Disch'd Nov. 9, 1864 ; pensioned. Sept., 1873, has limited use of arm. Disch'd Feb. 22,18"5; pensioned. Sept, 1873, arm totally useicss Disch'd Mar. 17,18 5; pensioned. *e t, 1873, disability total, 3d grade. Recovered, and furloughed Aug. 2j, 1864. DiseYd June30,1865; pensioned. Sept, 1873, has no control over the arm. Disch'd July 8,1865; pensioned. Sept, 1873, disability equiva- lent to loss of hand. Disch'd June 8. 1835: pensioned. Sept,1873, arm useless for man- ual labor. Disch'd Mar. 28,1864; pensioned. Ap'l,1872, can move arm inward and outward; has use of fingers and hand to some extent. Disch'd Sept. 28,1604: pensioned. Sept.. 1873. disability rated to- tal, 3d grade.' Furloughed July 28,1864 ; doing well. Recovered, and paroled Novem- ber 12, 1863. - Recovered; retired from service January 23, 1865. Disch'd May 2, 1865; pensioned. Dec, 187.;" arm useless for man- ual labor. Spec. 3405, A. M. M. Disch'd Dec, 8, 1864 ; pensioned. Sept, 1873, disability total, 3d grade. Disch'd May 28,1864 ; pensioned. Nov, 1864, wound still dis- charging. Biennial examina- tion waived Spec. 1767, A.Mi M. Recovered; transferred to Pro- vost Marshal March 14, 1865. Recovered; furloughed August 10, 1861. Disch'd June 18,1865; pensioned. Sept, 1673. muscular atrophy in region of wound. Spec. 43-6. A. M. M. D'scii'd Mav 12,1865; pensioned. Sept, 187!. disability for labor equivalent to loss of hand. Di.-eVd Ju:io20, 1805. - cpt.,1873, limb useless for purposes of manual labor. Disch'd Nov. 19, 1865; pensioned. Sept, 1873, arm swings help- lesslv at side. Disch'd Ap'l 7, 1865; pensioned. Sept, 1673, slight motion at shoulder; arm useless for labor. l Lyster (II. F.), Operations on the Shoulder, in Am. Jour. Med. Sci., 1865, Vol. L, p. 362. 0-.)S INJURIES OF THE UPPER EXTREMITIES. [CHAr ix. NO. Name Am, and Military Description. Date OF I Injury.1 Nature of Injury. Date of Opera tion. 106 i Keeler. XV., Pt, M. Sth New June £3, York Artillery, age ~6. i 1S64. 107 Kccslev. P.. Pt, A, ICth Mar. 21. Illinois, age 24. j 1865. US Kennedy, H„ Pt,, G, 6th iJune27, i Missouri, age ~2 | 1804. 109;Kenyon, J. S, Pr.. H. Sth Aug. 25, New York Cavalry, age 19. I 1864. , Kinnett. A. G, Pt, C, S7th May 27 Indiana, age 21. . Itol. Compound comminuted fiac- June 23 ture of the neck and upper j 1864. third of the right humerus by a rifle baJL Shot fracture of upper third of Mar. 21 the right arm: also three 1865. fingers of the right hand shot away. Gunshot fracture of the right 'June 27, humerus. I 1664. Compound shot fracture of the ! Aug. 25, upperthird of right humerus, j 1864. involving joint. Operation and Operator. Knapp, n. J, Pt., H, 29th May 8, Ohio, age 18. 18o4. Lahmers, C, Pt, E, 80th Nov. 25, Ohio. 1863 Lamb, L„ Pt, A, 28th Massachusetts. Laney, L. B, Pt, B, 12th New Hampshire, age 35. Dec. 13, 1862. June 3, 18-j4. Minie ball comminuted the right humerus. Mav 28. 1S64. 115 La Rock, J, Pt, C, Sth May 12, j Vermont, age 40. I lto5. 116! Lauer. G. C, Pt. E, 2d New Mav 3, 1803. Max. 29. 1805. Jersey, age 117 Lemka, A, Pt, K, 198th | Pennsylvania, age 21. 118 Lewis F, Sergeant, I, 93d Colored Trooi s. Lewis, J, Pt, F, &3d New Jersey, age 19. June 16, 1664. June 22, 1804. Lncis. N. J.. Serg't, D. 38th June 22, North Carolina, age IS. Ic64, 121 Lloyd, J. W., Pt, G, 11th New Jersey, age 24. Lord W, Sergeant, G, 25th N. York Cavalry, age 35. McCue, J, Pt, E, Sth Illi- nois, age 23. 124 McDonald, M. D., Lieut, C, Sth Alabama, age 25. 125 MeMurrav, J. M, Pt, F. 123d New York, age 22. Julv 2, 1663. Nov. 12, 1864. April 9, I860. July 30, 1864. Julv 20. 1664. 126 Mallory, T. F., Lieut , C, Sth Sept. 17 | South Carolina, age 20. 1S62. 127 Martin. G, Pt., I, 5th Con- , necticut, age 35. 12S Mason, J. S, Pt, F, 105th Ohio, age 20. June 22. 1864. June 29, 1864. Mayer, F., Pt, B, 98th June 18, Pennsylvania, age 24. 1631. Meek, G. X, Pt, B, 97th Aug. 16, Indiana, age 25. 1864. 131 Mi'irs, M. C, Pt, G, 4Sth July 2. \ irgh.ia. age 22. I 1S63. I 132 Mingo, H, Pt, E, 2d New Nov. 12, York Cavalry, age 32. 1864 Shot wound cf right humerus, i May 8, badly shattering the head. , 1864. Mime ball fractured the head Nov. 25, of the left humerus. I 1S03. Shot fracture of left shoulder De-. 13, joist. | iS02. Wound of the right shoulder , June 3, joint by a conoidal ball. 1864. Extensive comminut'n of head May 13, of right humerus and lacera- : 18J5. tion of soft pans by a mini6 ball. Shot fracture of head cf right May 3, humerus. 18o3. Comminuted shot fracture of Mar 29. upper portion of left humerus. ■ 1805. I Conoidal ball perforated up- June 17. per portion of 1ig.1t humerus; 1S64. also shot wound of left fore- j arm; primary amputation. Minie baU passed directly thro' June 22, left shoulder joint, shatter- 1604. ing the head of the humerus. Gunshot fracture of tbe head June 23, of humerus; a!so fracture of 1864. the right iibula. 1 Conoidal ball entered tbe left July 4, arm about the mid lie, frac- 1803. tured humerus, and lodged in the hea I of the bone. Coaipo.-.i.d comminuted shot Nov. 14, fracture of the head of left 1S04. humerus. Gunshot wound of the left April 9, arm. j 1S05. Gunshot wound of left shoul- i July 30, der joint. | 16"i4. Gunshot fracture of the left July 22 shoulder joint 1S64. Fracture of the head of left Sept. 18, humerus by shell fragment 1862. June 23, 1804. Left humerus badly crashed by a conoidal ball. Shot fracture of upper portion of right humerus. Shot fracture of the left hu- merus. June 29, 1864. June 18, 1864. Minie ball fractured the head Aug. 16, and shaft of the left humerus. 1804. Minie ball perforated the left! July 5, sh.'-uiah r, fracturing the head ;.nd neck of the humerus. Compound fracture of the up- per extremity of the right humerus by conoidal balL 1663. Nov. 12, 16C4. Excision of the head aud two inches of shaft of liumerus, by Surgeon A. Churchill £th New York Artillery. Excision of the head and a por- tion cf the shaft of humerus, four inches in all. bv Surgeon W. A. Gott, 25th Wisconsin. Resection of head and three inches of shaft of humerus. Head and three inches cf the shaft of humerus excised, by Surg. XV. D. Ferguson, Sth New York Cavalry. Removal rf the head and four inches of shaft of humerus. Rf.?i lt and Remarks. Exc;sion of the head and two inches of shaft of humerus, bv Surgeon A. K. Fiiield, 2^th Ohio. Head an I one inch of s'.i aft of humerus removed, by Surg. E. J. Buck, iSth Wisconsin. Removal of t'ue head and two inches of shaft of humerus. Excision ofthe head and three inches of shaft of humerus. Excision of the head and two inches of shaft of humerus, by .Surgeon C. M. Clark, 3Jth Illinois. Excision of head and about four inches cf shaft of humerus. Head and one inch of the shaft ofthe humerus removed thro' a V-shaped incision. Head and upper portion of the shaft cf humerus removed, by Surgeon M. C. Lathrop, 98th Colored Troops. Resection ofthe head and two and a half inches of shaft of humerus, by Surg. J. Riley, 33d New Jersey. Head and three inches of shaft of humerus removed; also excision of six inches of right fibula, by Surgeon P. W. Young, 36th North Carolina Exeision ofthe head and three inches of the shaft of the humerus. Excision of head and one inch of the shaft of humerus, by Surgeon E. B. Nims, 1st Ver- mont Cavalry. Excu-li >n of head and six inches of shaft of humerus, by Surg. J. B. Dickson, 47th Indiana. Removal of the head and four inches of shaft of humerus. Excision of two and a half inches of the upper extremity of the humerus, including the head, by Surg. J. Chapman, 123d New York. Head and a portion of the shaft of humerus, three inches in all. excised. Excision of the head and two inches ofthe shaft of humerus, by Surgeon E. L. Hi-sell. 5th Connecticut. Removal of four and a half inches of the upper extremity of the humerus, bv Surg. C. W. McMillen, 1st East Tenn. Head and four inches of shaft of humerus excised through a straight incision. Resection cf head and three inches ofthe shaft of humerus. Excision of head, neck, and two inches ofthe shalt of the humerus. Exe:?ion ofthe head and three inches of shaft of humerus. by Surgeon J. W. Smith, 2d Ohio Cavalry. Disch'd Feb. 25, 1865; pensioned. Oct 1.1866, flap amp'n at shoul- der joint, at Soldiers' Home, Philadelphia. Disch'd July 17,1S65; pensioned. Sept, 1874, not a pensioner. Transferred to Provost Marshal Decembers, 1864; considerable use of arm. Disch'd Feb. 3, 1865; pensioned. Sept.. 1873, has only a very nn id' rate rue of the arm. Spec. 67-1 aud 1:70. A. M. M. | DlM'h'd M: y26. 1865; pensioned. (Ut, I6O1., can grasp and lift light weights directly upward, but in no other direction Disch'd May 19,1865; pensioned. Sept, 1673, shouller weak and minions of arm greatly impaired. Disch'd June 9, 1864; pensioned. Oct, 1673. disability rated to- tal. 3d grade. Disch'd Nov. 2, 1864; pensioned. Died March 18, 1874. Disch'd June 19,1865; pensioned. Sept, 1673, has no control over hand. Disch'd Nov.30,1865; pensioned. Sept., 1873, arm useicss. Disch'd May 5. 1864; pensioned Sep, 187:;. total loss of use of arm. Disch'd July 20.. 1665; pensioned. July, 1874, arm useless for man- ual labor. Dischd Jan. 20, 1866. Not a pensioner in Sept, 1874. Disch'd Feb. 13,1865: pensioned. Sept, 1873, ase of arm much impaired. Retired November 28, 1864. Disch'd April 8,1864; pensioned. Accidentally killed July 4,1867; railroad accident. Disch'd June 20,1865; pensioned. Died July 10,1874. Spec. 3798, A. M. M. Disch'd June 5,1865; pensioned. Arm useless for manual labor. Furloughed August 31, 166-1; recovered. Disch'd Feb. 16,1865; pensioned. Died February 15, 1672. Sent to Provost Marshal Mar. 6. 1603 No bony union ; pronation and supination nearly normal. Disch'd Aug. 31,1666; pensioned. September, 1873; band is well nourished; has fair power of grasp; can't lift heavy burdens Disch'd Nov. 12,1864; pensioned. Sept., 1873, arm nearly useless for manual labor. Disch'd Sept. 21,1864; pensioned. Aug, 1866, has some little use of hand and wrist Disch'd June 9, 1865; pensioned. Sept, 1873, arm and shoulder atrophied; limb almost useless. Transferred for exchange Nov. 12, 1863; recovered. Di-ch'd Due. 5. 1865; pensioned. (»ct, io7:i. arm considerably a'rophi'd: unable to perform mest kinds of labor. STAT III] EXCISIONS AT THE SHOULDER. 559 1 N Name, Ace, and Military ' Description. Morrison, R. A, Serg't, G, S£d New York, age 29. Morrison, T. G, Major, 66th Indiana, age 33. M----, M, Pt, G, 10th Illinois. Date ok Injury. Nature of Injury. Oct. 14, lt03. Oct 4, 1864. June 27, 1864. Nelson, P., Pt, B, 6th Wis- Aug 19, cousin, age 30. i lsU4. Newell, T. J, Sergeant, E, June 1, 112th New York, age 30 i 1B64. Nicoll. D , Pt, E, Knapp's Oct 28, Penn. Battery, age 23. 16o3. Nixson, J.. Pt.. A, 24th New Dec 13,| Jersey, age 32. It02. Gunshot fracture of the head of right humerus and wound of the right forearm. Conoidal ball commiuuted the head of right humerus and split the shaft for a distance of four inches. Extersive comminution of the head of the humerus and glenoid cavity; ball lodged in neck of scapula. Opera- tion Oct. 17, 1663. Oct. 5, 1864. June 27 1864. Operation and Operator. j O'Malley, P, Pt, K, 9lst Pennsylvania, age 44. | O'Reilly, M, Pt, B, 3d In- iantry, age 21. Ostrander, D. H, Captain, A, 108th New York. Page, G. W, Pt, 11th Mas- sachusetts Bat'ry, age 26. Oct 25, 1664. July 2, 1663. Oct. 28, 1864. Julv 23. 1804. j Musket ball fractured the head |Aug.21 of the right humerus. I 1864. Shot fracture of the left hn- [ June 1, merus. i 1604. Minie ball shattered the head Oct. 31, of the right humerus and 1663. lodged Minie ball fractured the lower. Dec. 13, middle, and upper thirds of 1862. the left humerus and lodged in the glenoid cavity. Shot fracture ofthe head ofthe Oct 25, left humerus. j 1864. CoDoidal ball perforated surg- July 3, ical neck of the left humerus; 1863. longitudinal fracture several inches down shaft. Siiot fracture of right shoulder Oct 28. joint; ball passed through 1864. the head of humerus. Shot wound through the head July 23. of the left humerus. 1604. 151 152 153 154 155 156 157 Parron, H. T., Pt, C, 26th June 15, Viiginia. age 19. 1864. Parrort, M, Corporal, A, May 14, 42d Indiana. 1604. Perry, R. C, Captain, B, 111th New York, age 29. May 18, 1864. Phillips. J. F., Pt, D, 20th July 28. South Carolina. i604. Pomeroy, N. B, Corp'l, F, 27 th Massachusetts, age 23. Pratt J. H, Sergeant, F, 142d New York, age 22. May 16, 1S64. Oct. 27, 1864. Compound shot fracture of the June 15, left humerus. j 1864. Shot fracture ofthe upperpor- May 14, tion of right humerus. I 1864. Comminuted shot fracture of May 16, the head and continuity of 1804. the left humerus. Conoidal ball fractured upper third of left humerus; lodged three inches above elbow. Shot fracture of left humerus by a conoidal balL Quindlen, J. P., Captain, E, [Aug. 14, 81st Pennsylvania. 1864. Reardon, J. F, Pt, C, 6th New York Cavalry, age 22. Regan, T., Pt, F, 58th Illinois. Reilly, J., Pt, K, 5th New Jersey, age 40. Reynolds, J, Pt, E, 27th Michigan, age 51. Oct 11, 1863. April 9, 1604. Mav 5, 18 J2. Mav 12 1664. Richard, C. A, Saddler. A. Oct 14. 16th Pennsylvania Cava! ry. 1863. Richards. J. E.. Captain, B, Nov. 30 2d Arkansas, age 27. j 1864. I Richardson. N, Pt, C, 27th Mav 3, Indiana, age 25. . 1603. Robbins, W.. Pt, K. 49th July 12. New York, age 16. 1864. Minie ball fractured the apper portion of left humerus; also wound of cheek. A minie ball passed through the head of right humerus. assuring the upper extremity of shaft. Comp'd comminuted fracture of uppi-r i rto'i of the hu- merus oy ai'rairmeat • t" shell. (luuoiu't wound of right shoul- der joiLt. Fracture of the head and upper part of the right humerus by a minie ball. Shot fracture of the head of right humerus. Shot fracture of upper third of right humerus, extending into the joint Comminuted fracture of upper extremity of left humerus. Conoidal ball passed through head of left humerus and was cut out from biceps muscle. Head and considerable portion of shaft of left humerus shat- tered by shot. Mav 16, 1664. Oct. 27, 1864. Aug. 14 1864. Oc. 12, 1863. April 10, if'34. May 6, 1662. Mav 12, J6*C4. Oct. 16, 1863. Nov. 30, 1864. May 3, 1863. July 12, le64. Excision of the bead and two und a hall inches of humerus, by Surg. E. Bentley, U. S. V. Head and four inches of the shaft of humerus removed, bv ,'urgcon A. Goslin, 48th Illinois. Excis'on of three inches ofthe upper extremity of humerus, and extraction of spicula; from glenoid cavity and of ball from scapula, by Surg. <;. C. Cooper, V. S A. Removal of the head and two and a half inches ofthe shaft of the humerus. Removal of the head and a portion of 6haft of humerus. Head and one-half inch of the shaft of the humerus excised thro' a Y-■duped incision, by Surgeon A. McMahon, 64th Ohio. Excision of ihe head and upper third of the shaft of humeius. bv Ass't Surgeon G. M Mc- Gill. U. S. A. Excision of the he„d and three inches ofthe shaft of humerus. Removal of the head and two and a half inches of the shaft of humerus, by Ass't Surgeon B. Howard. U. 6, A. Upper fouith of humerus, in- cluding the head, removed, by Surg. J. Scott, 7th West V irginia. Excision of the head and five inches of shaft of humerus Removal of the head and three inches of shaft of humerus. Excision of five inches of upper extremity of humerus, in- cluding the head. Excision of the head and four inches of the continuitr, by Surgeon A. N. Dougherty, U.S. V. Excision of the head and three inches of shaft of humerus. Head and three inches of shaft of the humerus resected. Head and three inches of shaft of the humerus removed, by Surgeon N. Y. Leit, 70th Pennsylvania. Removal of the head and two inches of shaft of humerus, by Surgeon J. W. Wishart, 140th Pennsylvania. Head and fractured portion of shaft of humerus removed, by Surg. D. XV. Bliss. U.S.Y. Head and two inches of shaft of the humerus removed, by Surg. H. M. Crawford, 58th Illinois. Excision of the head and about two inches of the shaft of humerus. Excision of the head and atout four inches of the shaft of humerus, by Surgeon S. S. 1'ruuch, 20th Michigan. Excision ofthe head and three inches of the shaft of the humerus. Head and four inches of shaft of humerus resected, bv Surg. McFaddeo, C. S. A. Removal of the head and two and a half inches of the shaft of humerus, by Ass't Surg. B. Howard, U. S. A. Removal of the head and three and a half inches of the shaft of humerus, by .Surg. G. F. Stevens. 77th New York. Result and Remarks. Disch'd 1'eb. 13, 1864 ; pc-r.soncd. Sept, 167:!. no bony reproduc- tion; arm use.ess tor manual labor. Disch'd May 15,1665; pensioned. Sept, 167.!. upper part cf arm very much attenuated and per- fectly flexible. Recovered ' rapidly, with a good and useful hand. Disch'd May 31,180"; pensioned. Kept. 1873, arm completely nseles«. Disch'd Oct. 3. 1804 ; pensioned. Sept. 1673. arm useless. Disch'd May 17, 1865; pensioned. Aug. l?0y. disability for man- ual labor equivalent to loss of limb. Spic. 3233, A. M. M. Disch'd Apl 11,1863; pensioned. Sept, 1673. limb permaneiitly flexible and useless for labor. Disch'd June 21,1865; pensioned. Died August 2, 1865, from ma- larial disease. Disch'd Mar. 28,1864 ; pensioned. Sept, 1673, no bony reproduc- tion ; arm useless for labor. Spec. 1376. A. M. 31. Disch'd Apl 17,1865; pensioned. Dec, 1873, use of arm greatly impaired. Disch'd Dec 16,1864; pensioned. Sept, 1873, arm and forearm atrophied ; motions of hand and fingers good. Retired Feb-uary 6, 1605. Disch'd Mar. 4 1865; pensioned. July, 1866, arm pendulous and entirely useless. Appointed 1st Lieut. U. S. A. Jan. 22, '867, and retired from active service Dec. 31, 1870, upon the lull rank of Lieut-Col. Recovered. Disch'd April 3,1865: pensioned. Sept, 1673, disability total, 3d grade. Disch'd Sept. 22, 1865; pensioned. Sept, 1613. arm shortened and manual labor performed with difficulty. Spec. 2433, A M.M. Disch d May 15, 1865: pensioned. Died November 8, 1871. Disch'd Apl 30, 18-14 : pensioned. Jan, 1675, arm useless for labor. Specs. 1738 and 4699, A. M. M. Disch'd June 27.1865; pensioned Sept, 1673, arm useless; joint anchylosed. Disch'd Oct. 21,1862; pensioned. Died in June, 1670. Disch'd Dec. 31,1864; pensioned. Died September 4, 1872. Disch'd Sept. 3, 1864. Not a pensioner in February. It75. Transferred for exchange March 1, 1665. Disch'd Mar. 18.1864; pensioned. Sept, 1673. arm and hand use- less. Spec. 1092, A. M. M. Disch'd Mar. 28.1865: pensioned. Sept, 1873, arm useless for manual labor. » BaTWELL (E.), Notes on Exseetiom, in The Philadelphia Med. and Surg. Reporter, 1604, Vol. XII, p 201. 560 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. 150 Name, Age. and Military Description. Date of Injury Codgers, J. XV., Pt, II, ' Nov. 21 KiOth Pennsylvania. 1803. Rodgers, W. F., Pt, II, 28th Alabama, age 30. Rosa, J. XV.. Pt, L, 2d N. York Artillery, age 24. Rose, G. B, Pt, K, 11th Connecticut, age 21. Rudd, W., Pt, D, 47th Alabama, age 19. Rutli, A. M, Lieut, B, 2d South Carolina, age 23. Sands, T, Pt, F, 118th Pennsylvania, age 30. Schmitz, H, Pt, K, 26th Iowa, age 29. Schutte, II. W, Corporal, I, 105th Illinois, ago 26. Scott, W. H, Pt, E, 12th Virginia age 36. Sears, H, Serg't, I, 131st New York, age 28. Shaw, J. R, Pt, L, 3d New York Cavalry. 171 Slattery, M. J., Pt, D, 5th Louisiana, age 20. Smith, A, Pt, Battery G, 1st New York Light Artil- lery, age 21. Smith, A. H, Pt, G, 20th Indiana, age 26. Smith, L, Civilian, age 56. Snyder, G, Pt., D, 91st Pennsylvania, age 41. Southard, G., Pt., A, 121st Ohio, age 21. Spencer, XV., Serg't, K, 55th Illinois, age 22. Stackhouse, J, Pt., D, 92d Ohio, age 36. Stahl, J. S., Pt., H, 4th Wisconsin. Stewart, J. P, Pt., F, 103d niinois, age 24. Stewart, S. K., Pt, C, 6th Texas Cavalry, age 27. Stewart, R, Pt, K, 139th Pennsylvania, age 29. St vers J, Pt, A, 4'Ah. Ohio, age 28. Sulliger, T, Pt, T, 55th Ohio, age 28. Swoyer. J, Pt, C, 1st mi- nes Artillery, age 25. Sept 19 1863. May 21 1864. Sept. 17 1862. May 6, 1864. Aug. 1, 1863. Feb. 6, 1865. Oct. 16, 1864. June 22 1864. Feb. 6. 1865. May 27 1863. Julv 22 1863. July 9, 1864. Oct. 31, 1864. May 25, 1864. Feb. 25, 1865. June 21 1864. Dec. 15 1864. June 23 1864. Feb. 25 1864. June 14, 1863. Feb 15, 1865. Dec. 4, 1864. May 12, 1864. Nov. 18, 1863. Aug. 10, 1861. July 4, 1864. 186 S'/'.-es. I.. Musician, Stuart's July: Cavalry. 1863. Nature of Injury. Shot fracture of left shoulder joint. Shot fracture cf the head of the right humerus. Shell wouu 1 of the right shoul der, fracturing the humerus. Fracture of the head and com minution of the neck of the left humerus by a musket ball. Minie ball buried itself in the head of the humerus, com- minuting it. Minie ball passed through the head of the left humerus. Shot fracture of upper portion of left humerus. Shot fracture of the head of the left humerus. Comminuted fracture of head of right humerus by a round ball. Conoidal ball fractured head of left humerus. Comp'd comminuted shot frac- turo of upper third of the left humerus. Conoidal ball perforated head of right humerus and frac- tured the neck of the scapula. Comminuted fracture of head and neck of left humerus by musket ball. Shot fracture of left humerus. Shot fracture of right humerus. Conoidal ball entered about two inches below head of left humerus,passed through joint under scapula and out. Fracture of the upper tburd of the right humerus by miniG ball. Comminuted fracture of.head and neck of left humerus, ex- tend'g into joint; ball lodged in head of bone. Fracture of upper portion of right humerus by fragment of shell. Compound shot fracture ofthe left humerus. Shot fracture of head of the lett humerus. Shot fracture of upper extrem- ity of left humerus. Shot fracture of head of the left humerus. Shot wound of the left upper extremity, opening the joint. Minie ball fractured the upper portion of the right humerus. Date of Opera- tion Nov. 21, 1863. Sept. 19 1863. May 25, 1854 Sept. 17 1862. Mav 7, 1804. Auff. 1. 1803. Feb 6, 1865. Oct. 16, 1864. June 22 1864 Feb. 7, 1865. Mav 27 1803. July 23 1863. July 10, 1864. Nov. 1, 1864. May 25, 1864. Feb. 26, 1865. June 21 1864. Dec. 16, 1804. June 23, 1864. Feb. 26, 1864. June 16, 1863. Feb. 15 1865. Dec, 6, 1834. May 12 1864. Nov. 18 1863. OPERATION AND OPERATOR. Comminuted fracture of head ,Au, 1864 ; pensioned. Sept, lt«73, arm useless for manual labor Recovered. Furloughed July 27, 1864, with a prospect of a useful arm. Disch'd Nov. 15, 1864 ; pensioned. Dec, 1873, arm enlirely useicss for purposes of manual labor. Spec. 2020. A. M. M. Discli'd.lune27,1365; pensioned. Sept, 1671, lii^s of power ana use of arm. Disch'd Aug. 28,1865; pensioned. Sept., 187.1, arm perfectly use- less. Disch'd July 20,1865; pensioned. Sept, 1873. motion and union to a limited decree; can elevate arm to a right angle; hyper- ajsthesia of hand and arm. Disch d April8, 1865 ; pensioned. Sept., 1873, arm nearly useless. Disch'd Feb. 28,1863; pensioned. Sept, 1873, arm useless for labor. Retired March 18, 1865. Disch'd Dec. 16, 1864; pensioned. Sept, 1873, disability rated total. May, 1865, nearly healed. Disch'd Aug. 30,1865; pensioned. Sept , 1873, arm useicss for manual labor. Disch'd May 29, 1865; pensioned. Sept, 1873, arm shortened about three inches and partially atro- phied. Disch'd June 11,1864; pensioned. Sept, 1873, arm useless for manual labor. Disch'd May 16,1865; pensioned, i Sept, 1873, arm atrophied and powerless, and the disability equivalent to loss of the limb. October 31, 1803, recovered. Disch'd Oct. 1, 1862; pensioned. Sept, 1873, motions of forearm good ; little abduction possible. Disch'd Nov. 10,1864; pensioned. Sept.. 1873, almost total loss of use of arm. Disch'd Nov. 8, 1864. March, 1865, arm entirely useless. Disch'd Nov. 30,1864; pensioned. Kept, 1673, joint anchylosed and muscles atrophied ; cicatrix adherent to bono ; arm of little use. Spec. 1721, A.M. M. Disch'd May 6, 1865; pensioned. Sept, 1873, arm useless for manual labor. Disch'd Mar. 7, 1666. No com- mand over arm or forearm. Not a pensioner. Disch'd May 17, 1865; pensioned. July, 1874, tolerably service- able limb ; no atrophy. Claim for increase of pension rejected. Recovered; furloughed Sept. 10, 1864. Disch'd June 2, 1865; pensioned. Deo, 1866, disability equal to loss of hand 71 562 INJURIES OF TLIE UPPER EXTREMITIES. [CHAP. IX Fig. 431.—Apparatus figured in Dr. Harlan's report of this case Detailed abstracts of fourteen of the two hundred and thirteen reported successful primary excisions of the head and portions of tbe shaft of the humerus for shot injury precede the foregoing tabular statement; but the subject is of such interest and importance that some further examples from this group will be selected. Surgeon George O.Harlan, 11th Pennsylvania Cavalry, adopted, in the following instance, an ingenious plan of counter-extension and of maintenance of the limb at rest: Case 1534.—Private J. Brink, Co. K, 11th Pennsylvania Cavalry, aged 19 years, was shot, as the regimental surgeon reports: "At short range, while mounted, by guerillas coucealed in bushes by the way-side, May 22, 1833, near Windsor, about twelve miles from Suffolk, Virginia. He was taken immediately to the regimental hospital at Suffolk in an ambulance wa^ott. He was a good deal exhausted by hasmorrhage, which had been only partially checked, by a surgeon near at hand, with lint and bandage. The wound of entrance was in the median line ofthe right side ofthe chest two inches below the axilla. The wound of exit was in front of the shoulder, two inches and a half below the acromial end of the clavicle. The joint Avas not opened, but the humerus was terribly shattered below its head. He was etherized, and five inches ofthe bone, including the head, were removed by means of a free straight incision through the deltoid, the periosteum being carefully dissected from tlie fragments, and the sharp end of the bone sawed off squarely below the fracture by an ordinary amputating saw. Only one ligature was needed, and the wound was brought together by bad-wire sutures, except a space at the lower end, left as a drain, in which a piece of lint was inserted. A straight splint was applied to the back of the arm. which was loosely bandaged to the side by a roller. Morphia was administered freely, and water dressings applied to the wound. On May 22d, the patient was doing well; there was slight febrile action, yet a good deal of pain. Tlie splint and bandnges were removed, and extension was made from the lower end of the arm, and counter-extension by means of adhesive strips applied to the front and back ofthe chest and passing over a block above the shoulder, as suggested by Dr. II. Lenox Hodge in the treatment of fractured ihigh.1 These points were connected by an iron bar extending from several inches below the elbow to the back above the shoulder and bent at both ends (i'l3. 431). This kept tlie limb in a favorable and comfortable position and maintained its length, and left the wound free fir the application of dressings. He could now be moved in bed, or raised to the sitting posture, without pain. June 3d, doing well. The discharge has been profuse, bit is diminishing. The wound gaped when the s iCirers were removed, on the fourth day, leaving a healthy granu- lating surface. He is taking punch and quinia, and full diet. June Sth, doing well; edges of the wound cicatrizing. June 9th, had a chill this morning ; his tongue is coated, and he has dizziness and sick stomach. June 10th, the dizzinebs and nausea continue; the granulations have become pale and flabby, and the discharge dark and t'.in and sanious; pulse feeble, and expression anxious. These symptoms, in connection with the fact that a patient died of pyaemia in the same ward, on the Sth, left very little hope of recovery. Under active stimu- lation and most careful nursing, however, he gradually improved; and when the regiment received marching orders, was sent to general hospital, June 24th, still very feeble. March i3, 1833, Brink called at my olSce to-day. He has been employed for some time as a telegraph operator, always using the right hand at his work. He has perfect use of the forearm and hand, and partial use of the arm. He can place the hand on the opposite shoulder and carry it readily to the mouth in eating, when he always uses it by preference. The wounded arm is about an inch shorter than the sound one. Two inches and a half of new bone have been formed—its rounded extremity reaching to within an iuch and a half of the acromion. It is flattened on its posterior surface and rounded anteriorly, and nearly equals the rest ofthe shaft in thickness. The pectoralis major, deltoid, and scapula muscles seem to be entirely wasted away, but the action ofthe coracobrachial^, biceps, and triceps is unimpaired, except, of course, by the want of support at the shoulder joint. He states that he was discharged from the Chesapeake Hospital on September 23, 1333; that the wound continued to discharge slightly for some time afterward; that he carried the arm in a sling for two months after leaving the hospital, and then commenced to use it; that he noticed the new bone harden rapidly after that time, but that it was not perfectly firm for a year and a half after the time when he was wounded." Dr. Harlan contributed a photograph of the patient (FlG. 432;, taken some five years after the operation. The records ofthe Chesapeake Hospital confirm the patient's account. He entered there June 23d, and was discharged September 23, 1333. He was pensioned. Examiners C. Marr, of Sciantou, and G. Urquahart, of Wilkesbarre, describe the injury and operation, and the last pension report states that the pensioner was paid March 4, 1374. Case 1535. -Private L. Baker, Co. B, 2d Rhode Island, aged 25 years, was wounded at Prince Street Prison, Alexandria, and was removed to the Third Division Hospital. The following was reported by the operator, Surgeon E. Bentley, U. S. V.: "Gunshot wound of the left shoulder. Ball entered in front, three inches below the point of the shoulder, passed backward PIG. 432.—Cicatrix of an excision at the shoulder five years after the operation. Gross (S. D.), System of Surgery, 5th ed , IC72, Vol. I, r>. 1011. SECT. III.l EXCISIONS AT THE SHOULDER. 563 and upward, and emerged from near the acromion procrss. July 14th, excision of four inches of humerus, including head, by a straight incision six inches long; two ligatures; but little haemorrhage Anaesthetic: chloroform. The bo-.ie below the anatomical neck was terribly comminuted, part of it reduced almost to a powder, mixed with the blood and driven into the tissues. The soft parts, severely lacerated, bled freely after injury; bleeding checked by persulphate of iron and compress. The patient at the time of operation was somewhat weakened by confinement and loss of blood, but otherwise iu fair condition. Water dressings. September 20th. wound doing well; abscesses have formed which have delayed the healing somewhat. Water and solution of sulphate of zinc has been the only local treatment. Stimulants internally. September 3'Jtli, wound nearly healed; in good health." The patient was transferred to the First Division Hospital on October 8th, and thence to Sickles Hospital, February 24, 1^05, and was discharged the service, for disability, June 2, 1833. He has never applied for a pension. Case 1538.—Private L. Baldock, Co. A, llCth-Ohio, aged 30 years, was wounded at Cold Harbor, June 3, 1884. Surgeon William M. Houston, 12Jd Ohio, reported that: "'A conoidal musket ball passed through the left deltoid muscle, and, striking the humerus at its surgical neck, a little anterior to tho centre, passing slightly upward through the head of the bone, struck the bony wall of the chest, glanced downward, and was found lodged beneath the integuments, about half way down the side of the chest. The patient was immediately conveyed from the field to the hospital of the Third Division, Sixth Corps, and having been anaesthetized with chloroform, Surgeon W. M. Houston, 122d Ohio, assisted by Surgeon Robert Barr, 67th Pennsylvania, performed resection. A straight incision, about five inches long, was made, passing through the wound of entrance; the head of the humerus was disarticulated, and, by means of a chain saw, tbe shaft was sawn through at a point about four inches below the ac omion process of the scapula, to which point the fractures extended. There was considerable blood lost, but no vessels were ligated. The patient reacted favorably. The wound was approximated with adhesive strips, and simple dressings were applied On tbe succeeding day, he was conveyed in an ambulance wagon to White House Landing, and from thence to hospital in Washing- ton, where he remained until August 17th, when he received a furlough for sixty days, and proceeded to his home, at Piqua, Ohio. At the expiration of his furlough, he went to Columbus, where he remained until March 7, 1833, when he was trans- ferred to hospital at Camp Dennison. He was discharged April 14, 1835. The wound was entirely healed in eight months, Excised reparation having been somewhat delayed in consequence of At Fig. 43::.- upper extremity of the neglect and exposure after leaving hospital at Washington. left humerus after shot , . , , ,T , or. , t^-., T> i t i • i i i i fracture. Spec. rs5'>. this date (November 30, 1»jJ), Baldock enjoys good health, but complains, occasionally, of pain in the shoulder and elbow. The sawn end of the humerus is about three inches from the centre of the glenoid cavity. The movements of the forearm and hand are unimpaired. He can apply his fingers to the top of the corresponding shoulder, and by inclining his head can touch any part of his face or head. Ho can carry an ordinary pail full of water with the injured member, and finds it very useful in hoeing and other light work." Together with this report, Dr. Houston forwarded to the Museum the excised portion of the humerus, which is represented in the wood-cut (Fig. 433). On June 25, 1833, Examiner Samuel S. Gray, of Piqua, forwarded the photograph represented in the wood-cut (Fig. 434) to the Museum, and a second photograph, showing another aspect ofthe cicatrix. Both of these photographs ire mounted with the specimen. Cas;: 1337.—Corporal J. II. Jaycox, Co. B, 143d New York, aged 31 years, was wounded at Peach Tree Creek, July 2 j. 1:34. He was sent to a Twentieth Corps hospital, and, on the next day, the upper extremity of the left humerus was excised by Surgeon II. K. Spooner, Gist Ohio On July 25th, the patient was transferred to Chattanooga. There is no report of his treatment there, although he remained there for several months. In December, 1834, he was sent to New York. Surgeon B. A. Clements, I J. ^. A., reported from St. Joseph's Hospital, that there had been a: "Gunshot fracture ofthe arm by a minie" ball entering the upper third anteriorly, passing through and shattering the humerus, involving the head of the bone. Resection of the head and five inches of the shaft had been performed in the field hospital. * * When the patient arrived here, the incisions and wound were entirely healed. Tlie patient has good use of his arm." This soldier was discharged June 16, 1665, and pensioned. Examiner J. L. Hasbrock.'of Monticello, reported, Marcli 9, 1867: "Its weight, with no other support than muscular and tendinous connections, causes the whole arm to become very much swollen, and worse than no arm. I should advise him to have it amputated, both for comfort and convenience." Examiner D. H. Decker, September 4,1873, noted: "The muscles are somewhat atrophied in the region of the wound. There are no evidences of inflammation, and the operation of resection I deem perfectly successful." There is a plaster cast in the Museum from this case,1 indicating a very satisfactory result.—(Cat. Surg. Sect, 1833, p. 539.) Fig. 434.—Cicatrix after an excision at the shoulder. [From a photograph.] It has been heretofore suggested that many of the reports of pensioners regarding their disabilities must be received with grains of allowance, and that a humane indispo- 1 Numbered 432t>, Surgical Section, A. JI. M. Many of the successive reports of the hospital surgeons or pension examiners recall Thackeray's exclamation : " How varied are the notions of critics I" Those conversant with the later writings of Professor B. V. Langknbeck. will not forget the passage quoted in a note on page 510, ante, where the advantages of a lame! and powerless upper limb are insisted on, since the member may, at least, servo to maintain the equilibrium of the body. 564 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX, Bition to deprive the mutilated men of the benefits of the laws enacted for their relief mav possibly, in some instances, have unduly biassed the pension examiners,—considerations that must always be held in view in judgiug of the accounts of the ulterior results of operations of this and similar groups. The estimates of the operator, of the patient, and of the government official regarding the merits of an operation often widely differ. Case 1538.—Sergeant T. J. Newell, Co. E, 12th New York, aged 36 years, was wounded at Cold Harbor, June 1, 1884, and, on June 10th, was admitted into Harewood Hospital, Washington. Surgeon R. B. Bontecou, U. S. V., noted: "Admitted, with resection ofthe upper third ofthe left humerus in consequence of a gunshot wound; extent of injury unknown. Operation performed on the field, June 3d. On admission the constitutional state of the patient and condition of the injured parts were good; parts healing readily under treatment of simple dressing and a supportive nourishing diet, but with no restoration of bony structures; the muscles of the forearm and arm remain well developed and useful." Newell was discharged from service October 3,1834, and pensioned. Examiner John Spencer, October 15, 1886, reported: "The whole upper half of the humerus, from the middle of the humerus to the humero-scapular junction, resected. The arm is useless above the hand and forearm; disability is permanent, and I cannot con- scientiously rate it less than equal to loss of .the hand." Examiner H. B. Osborn, on September 8, 1873, reported substantially as above, adding that the arm was still useless. This pensioner was paid March 4, 1874. The photograph from which the cut (Fig. 435) is taken was sent from Harewood Hospital, and is shown at page 8, Vol. II, Card Photographs. In a letter dated Sherman, New York, July 28, 1674, the pensioner remarks: " My arm is as useful to me as it ever will be; it often gathers and breaks, or rather it has to be lanced. *■ * I have the use of ^^ilSSiiP^^^BSpW^^ ^s J my narid> Dut cannot put it to my mouth only as I take the other hand. I can vSJ^^^^^%^^^ ^lU^K phtce it on the table and hold my fork, but cannot feed myself with it. * * My arm is of but little account, yet I would not have it off for anything." Case 1C39. -Corporal W F. Stewart, Co. G, 127th Illinois, aged 20 years, was wounded at Vicksburg, December 23, 1833, and on the same day was placed under chloroform, and Surgeon E. Andrews, 1st Illinois Light Artillery, excised the head of the left humerus. He reports that: "The head of the humerus was split by a bullet, fragments of which were found in the bone. A buckshot was also found in the bone close to the track of the ball." After the operation the patient was placed on the Hospital Transport Steamer City of Memphis and transferred to St. Louis. He was admitted to Lawson Hospital, January 17, 1833, doing well, and was discharged the service, and pensioned April 2, 1831 Examiner J. W. Trader, of Sedalia, Missouri, September 3, 1374, reported: "Gunshot wound of the left shoulder joint, and resection of the upper third of the humerus." The disability was rated total. The pensioner was paid September 4, 1874. Case 1540.—Corporal R. Fisher, Co. C, 7th New York Heavy Artillery, aged 32 years, was wounded at Cold Harbor, June 8, 1834. He was admitted to a Second Corps hospital, and, on the 10th, Surgeon J. W. Wishart, 140th Pennsylvania, excised the head and one inch of the shaft of the humerus by a straight incision through the middle of the deltoid. The patient was sent to Washington, and entered Armory Square Hospital on the 1-th, and was finally discharged from service May 25, 1885. Surgeon D. W. Bliss, U. S. V., noted on his discharge papers: "Excision of right shoulder joint from gunshot wound.'' Assistant Surgeon J. IT. Armsby, U. S. V., in charge of Ira Harris Hospital, Albany, contributed to the Army Medical Museum a photograph of Fisher, taken at Albany, represented in the cut (Fig. 433), and also specimen No. 334, Section I, A. M. M. This specimen consists of a cast of the right thorax and arm, eleven months after the excision of four inches from the upper extremity of the humerus. The cicatrix is six inches in length, is parallel with the long axis of the arm, and has split tlie deltoid. The position whence the head of the humerus was removed is marked by a decided impression. Examiner R. L. Rea, of Chicago, December 17, 183G, reported: "Had four inches ofthe upper end of the right humerus removed; arm useless." The Chicago Board, Drs. W. A. Knox, J. M. Woodworth, and S. J. Jones, June 1, 1870, report: "Resection of four inches of the right humerus, including the head. No increase from this cause, but the applicant is in the last stage of tuberculosis, which was probably brought about by exposure in the service. Fisher died July '24, 1370. Dr. W. R. Marsh, formerly Surgeon 2d Iowa, testifies " that Fisher's death was caused by phthisis pulmonalis supervening upon a gunshot wound, etc., that the cicatrix of said wound indicates that tho ball entered year after excision the right breast near the fourth rib and passed diagonally through the right lung and through the shoulder joint." Kio. 435.—Cicatrix after excision of the upper extremity ofthe humerus. [From a photograph.] Fir,. 436.—Cicatrix one at the should- r. SECT. 1II.1 EXCISIONS AT THE SHOULDER. 565 While multiplying illustrations of this most interesting advance in modern surgery, the general deductions from the statistical record must not be overlooked. The usual slio-ht preponderance of operations on the left side is exhibited.1 Consecutive amputation at the shoulder joint was called for in three cases.2 Only ten instances have been heard from, at the close of a decennial period, of deaths subsequent to discharge on account of this operation. One hundred and fifty-eight of the mutilated men were pensioned. In twenty-two of the cas?s the excised portions of bone are preserved in the Museum. Case 1541.—Private A. Zicsse, Co. A, lfith Michigan, aged \\2 years, was wounded at Poplar Grove Church, September 30, lH.i I. Suraeon W. 11. DeWitt, jr., U. S. V., reports that he was struck by a minio ball in the right shoulder, and sent to a Fifth Corps hospital, aud thence to City l'oiut. Excision of the upper extremity was practiced either on the field or at the base hospital. On October 7th, the patient was sent to Washington, and entered Lincoln Hospital. Assistant Surgpon J. C McKee, U. S. A., reported : "Gunshot wound of the upper third of the right humerus, with comminution involving tbe shoulder joint. On October 3d, exsection was made of the head of the humerus with about two and a half inches of the shaf. The name of the operator is unknown. The patient improved very rapidly after entering t!:e hospital. By December '23th, the cicatrix was clean and free." Dr. McKee had a photograph prepared January 10, 1835 (C/itrib. Surg. Phot., S. G. 0., Vol. II, p. 14). It is copied in the adjacent wood-cut (Fig. 437). At that dtite this soldier had perfect use of his hand, but had little control over the movements of the arm and forearm. He was sent to Detroit and dis- charged, and pensioned June 2, 1835. Examiner J. B. Scovell, of Detroit, December 14. 133 j, described the course of the missile as : ''Carrying away the bead of the humerus and destroying the use of the joint," etc. This pen- sioner was paid September 4, 1674. Details of several of the operations enumerated in the tabular statement have been published already in the medical journals. References have been given to these abstracts whenever the cases have been recognized. Still later facts or illustrations have been received in some of these examples, as in the following: Cas^ 1542.—Private R. C. Hill, Co. I, 57th Pennsylvania, aged -23 years, was wounded at the Wilderness, May 5.1831. Surgeon O. Evarts, 20th Indiana, reported, from the hospital ofthe 3d Division ofthe Second Corps, that resection at the left shoulder was practised on the field for shot fracture. The patie.it was sent to Washington, and entered Finley Hospital. Surgeon G. L. Pancoast, U. S. V., corroborated the above report, and noted the favorable progress of the case, and the soldier's discliarge for disability, September 28, 1834. Dr. H. F. Lyster, formerly Surgeon Sth Michigan, transmitted to the Surgeon General's Office, March 15, 1633, a copy of the report of this case, published in the American Journal of the Medical Sciences for October, 1635, and copies of the abstracts of two other case3 there published, with daguerreotypes of the cicatrices.3 Examiner G. McCook states, January 3, 1365, in regard to the pensioner, Hill: "He cannot lift his arm to his head, nor does he possess ability to use the arm at common labor." Examiner J. P. Hosack, of Mercer, Pennsylvania, December 25, 1835, reported : '■ From a wound of the shoulder joint, it had been considered necessary to perform resection of the head of the left humerus. Want of proper dressing, and suffering in the hands of the enemy for nineteen days, has left a very unfavorable result, much more so than usual from such operations. The deltoid muscle is entirely absorbed, and the end of the liumerus is lodged in the axilla instead of in the glenoid cavity." On September 13, 1873, Dr. Hosack substantially reiterates this description, in reporting the biennial examination of the. pensioner. Fig. 437.—Cicatrix a fortnight after an excision at the shoulder. [From a photograph.] Fig. 438.—Cicatrix after an excision of the upper part of the left humerus. [From a daguerreotype.] 1 In two hundred and five (i<)5) of the two hundred and thirteen (213) operations enumerated in Table XX XI, the side implicated is reported, uinety-eight being on the right, and one hundred and 83ven on the left side. •-' Cases 21, lufi, 101, Privates Burger, Keeler, and Kosa, 8 Lyster (H. I'.), Operations on the Shoulder, etc. (Am. Jour. Med. Sci., 1865, Vol. L, p. 362). The latter are enumerated as Cases 43 and 79 of Table XXXI. The abstracts are accompanied hy drawings, and the EDITOR of the American Journal justly observes that " the figures, as represented in the daguerreotypes, from which the wood-cuts were engraved, seem to have been reversed." This error is rectified in FIG. 438, and in the cuts 412, 443, printed on page 567. engraved from the daguerreotypes furnished by Dr. LYSTER. 506 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. It was formerly thought inadvisable to excise the upper extremity of the humerus for shot injury when the injury extended far down the shaft,1 but that precept has been repeatedly disregarded, with good results: Cask 1543 —Corporal G. Martin, Co. I, cth Connecticut, aged 35 years, received, at Marietta, June 22, 18:3-1. a gunshot fracture ofthe left humerus. lie was taken to a Second Corps field hospital, where, on the 24th, the head and several inches of the shaft were excised by Surgeon E. L. Bissell, 5th Connecticut. On September 2d, the patient was admitted to hospital at Chattanooga, and was subsequently treated in hospitals at Nashville, Jeffersonville, and Xew Haven. He was transferred from the latter to the Veteran Reserve Corps, April 23, 166*5. and finally discharged the service August 31. 1336. E. D. Hudson, M. D., of New York, reported, May 24, 1333, that he had furnished Martin with an apparatus, and forwarded a photograph, represented in the wood-cut (FlG. 439), with the following state- ment: '"Loss of six inches of the head and continuity of the humerus. Linear incision some seven inches in length. Arm shoitened three inches and considerably atrophied; wound healed; deep fossa of cicatrix; hyperostosis from humeral end of the clavicle; hand and forearm normal; no command of forearm. Usefulness of the limb very satis- factory in lifting and pushing, and the forearm can be carried up beyond a right angle, and will improve by practice." On his application for pension, E L. Bissell, M. D., certifies: ' Martin was wounded at Resaca, in the right forearm, the wound being of such a nature as to enable him to continue with his regiment." and that at Marietta '• he was severely wounded in the hit shoulder. He was sent to the Brigade Hospital, Twentieth Corps, where an operation of resection of the head of the humerus was performed by myself. On or about June 27th. he was transferred to the hospital at Kingston, Georgia." Dr. Bissell also testifies that he finds "Martin has recovered from the operation, but that he has no control of the arm nor will he ever have." The Examining Board at Boston: J. W. Foye, J. B. Treadwell, and IT. Chase, reported that "A gunshot entered the left shoulder from the rear, at the articulation, and passed through it Two inches ofthe shaft .-Appearance of cicatrix two of the bone- with its head- were removed> and tl,e arm is useless and pendant.' On years after primary excision of the upper September 5, 1873, the Board reported: " Hand is well nourished; he has fair power of extiemity of the humerus. , . ..... , , •■ ,. i-r. .. i» grasp, but cannot lift heavy burdens; disability total. Case 1544.—Private J. Trombly, Co. H, 1st Michigan, aged 23 years, was wounded at the Wilderness, May 5, 1334, by a minie ball, and taken to a Fifth Corps hospital, where excision of the upper extremity of the left humerus was performed by Surgeon J. Ehersolc, 19th Indiana. "The head and a portion of the shaft of the humerus were removed through a longitudinal incision commencing at a point midway between the acromion and coracoid processes, and extending five inches down the coraco-hrachialis, dividing the fibres of the deltoid, pectoralis major, and biceps muscle:" The patient was sent to Washington, and placed in Harewood Hospital. The case pro- gressed favorably, and in a few weeks the wound hud healed, and " there was fair use ofthe forearm." At this time Dr. Bontecou had a photograph taken, from which the annexed wood-cut (Fig. 440) is copied. This soldier was discharged November 13, 1864, and pensioned. Furgeon Robert 0 Abbott, U. S. A., directed him to report to Dr. E. D. Hudson, a skilful designer of surgical apparatus, with a view to the adjustment of some appliance to augment his control of the movements of the limb. Dr. Hud- son, who has described the case,2 stated : " The arm was of ordinary length, considerably atrophied, flexible, ungovernable by the will, unable to swing forward; pectoral muscle impaired; no effort at reproduction of lost part —functions of supinators, pronators, flexors, and extensors of the band and fingers normal. With scapular aud humeral appliance, oscillatory shoulder joint, and auxiliaries to pectoral muscle, he carries the arm forward across the chest, flexes the forearm to an acute angle, carries hi3 hand nearly to his mouth—and departed with his trunk-valise in the hand of his mutilated vu-.. 140.—Cicatrix as it appeared a arm, greatly rejoiced at his restored condition. With practice, he will so few months after an excision of the up- r ... ,. ,. i ji • i i » r> per p rt of ihe left humerus for shot far regain the use of his arm as to hardly appreciate any loss." Drs. fracture. Brown, Noyes, and Webber, constituting a Pension Examining Board at Detroit, Michigan, reported, December 17, 1373: "A resection of the upper extremity of the left humerus, about four inches of bone being removed " This is an under estimate, as shown by the specimen copied in the wood-cut (FlG. 441). It is reported in the Catalogue of the Sur/i-al Section, 1S63, p. 109, as a Chancellorsville specimen received without history, but was subse- quently fully identified. I The precise length of bone excised was specified in one hundred and ninety instances. The amount of the shaft removed, with the head, was stated as: luilf an inch in I case, an inch in 11 cases, an inch and a half in 10, two inches in 43, two and a half in 24, three in 46, three and a half in 7, four in 23, four aud a half in 11, five in 7, five and a half in 2, seven or eight inches (or possibly, in one instance, nine) in 5 cases. In twenty-three cases, this point is not indicated. The insertion of the deltoid is usually described as at about the middle of the humerus (Hexle, Sappey, Ghay). In sixteen humeri just measured, from adult male skeletons in the Army Medical Museum, the extreme lengths were from twelve and a half to fifteen inches. The marks of the deltoid insertion were "about the middle," in all cases; but approaches the lower part of the middle third in proportion to the lengths of the upper extremity. * Hudson (E. D.), Remarks on Exscctions, with Cases and Plates, New York, 18o4, p. 12. Fig. 441.—Excised upper extremity of humerus fracture I by a ball that lies in the medullary cavity. Spec. 2U2o. SECT. III.] EXCISIONS AT THE SHOULDER. 567 FlG. 442 —Cicatrix after primary excision of the upper portion of the right humerus, [from a photograph.] Other cases are illustrated by wood-cuts taken from photographs made under disadvantageous circumstances, as at camps or villages. Cask 1515.—Corporal W. Hammond, Co. K, l~')tli New York, aged 44 years, was wounded at Petersburg, July 30, 1831. Surgeon F. F. Buraieister, GDtli Penn- sylvania, reported his admission on the following day, at the base hospital of tho Second Corps, at City Point, with an excision of tho upper extremity of the right humerus for comminution by a conoidal ball. The operation had been performed on the field hy Surgeon H. F. Lyster. 5th Michigan, assisted by the regimental surgeon, W. Van Steenburg, 120th New York. The patient was transferred to Alexandria, August 11,1831, and, progressing favorably under supporting treatment, was transferred to Xew York, March 23,1835, and, after several other transfers, was discharged from McDougall Hospital, Fort Schuyler, Juno 28, 1835, and pension?d. An apparatus was furnished him May 26, 18CG, by Dr. 1*'. D. Hudson. On October 15. 1886, Examiner E. Bradley reported : " The hand is atrophied and cold; a good arm and no hand would be better than this pendulous and powerless arm and small cold hand." Examiner T. F. Smith reported, September 13, 1873: " The hand is cold and clammy." Case 154G.—Private D. Nicoll, Co E, Knapp's Penn-vlvania Battery, nged 23 years, was wounded at Wauhatchie Valley, October 23, 183 J. He was removed to the field hospital at Chattanooga, where excision of the head and oiif-half inch of the shaft of the humerus was perf;rmcd on the 30th by Surgeon A. M McMalion, 64th Ohio. The patient was transferred to hospital at Murfreesboro' in November, and thence to New York, where he entered St. Joseph's Hospital, Central Park, Marcli 30, 1834. Surgeon B. A. Clements, U. S. A., furnished the following history: ''Minie ball entered at the outer aspect of the right shoulder and lodged, after shattering the head of the humerus. Operation October 30, 1833: A straight incision just external to the biceps teDdon, apparently six inches long, with a small incision from the wound joining the long one, thus, Y. The head only appears to have been removed. The wound did well, but, the bone being necrosed, abscesses formed It was over two months before he could leave his bed. After admission to this hospital, about May 10, 1834, several pieces of bone, and a disc of bone the whole calibre of tlie humerus, were removed. The result was very good. The arm is three-fourths of an inch shorter than its fellow. The upper extremity ofthe liumerus is not drawn under the coracoid process There is very little power in the deltoid. He can carry a bucket of water." In October, 1884, the patient was transferred to the Veteran Reserve Corps, and was finally discharged, and pensioned May 17, 1835, and was paid March 4, 1874. Examiner J. A Young, of Monmouth, Illinois, reported, November 7, 1883, that: "The head of the right humerus, with about three inches of the shaft of the bono, has been removed; the pensioner is unable to elevate the arm or advance it without the assistance of tbe left hand. Forearm, hand, and fingers are in good condition." A plaster cast of the wounded limb (Cat. Sur/. Sect., 1883, p. 533, Spec. 3233), contributed by Acting Assistant Sur- geon G. F. Shrady, is thus described in the Catalogue: ''A cast of the right thorax and arm, showing the result of a primary excision of the head of the humerus, nearly a year after the injury The wound of incision was, for six inches, parallel to the biceps tendon, joined by a smaller one from the wound of injury, making the whole Y-shaped. The cicatrix is about three inches in length and quite deep * * The upper extremity of the humerus is not drawn under the coracoid process, aud the arm is three-fourths of an iuch shorter than its fellow." Cass 1547.—Private M. Dekrakcr, Co A, 5lh Michigan, aged 24 years, was wounded at Petersburg, June 18, 1834. Surgeon O. Evarts. 20th Indiana, reported, from a Second Corps field hospital, a 6hot wound of the shoulder; and Surgeon A. F. Sheldon, U. S. V., recorded the patient's admission at Campbell Hospital, Washington, with "an excision of the head of the right humerus on the field," and his discharge March 27, 1865. The regimental surgeon and operator, Dr. II. F. Lyster,1 has described the case at length in the article of the American Journal of Medical Sciences, Vol. L, p 383, already cited. This soldier was pensioned. Examiner J. Nichols reported, March 29, 1885: "Wound yet unhealed and arm entirely useless; there will be partial restoration in six months." Examiners G. K. John- son and Z. E. Bliss reported, December 7, 1870: "He has considerable use of his arm," and, in September, 1673, the same Board: " The arm is now one and three-fourths inches shorter than the left, and is necessarily much weakened." In another portion of their report it is stated that "the result is a very good one.'1 FlG. 413.—Cicatrix after excision of the upper extremity of the humerus. 1 Lysteu (II. F.), Operations on the Shoulder, etc. (Op. ait., Am. Jour Med. Sci., 18G5, Vol. L, p. 3C4), remarks of the three primary excisions recorded by him: " These three cases were operated upon within a few hours after tho injury had be n sustained, and weie all of a class where the necessity of active surgical interference is universally admitted. Tha only questions that arose wero: Shall we amputate at the shoulder? or, Shall we resect the head and neck of the humerus ? These questions cannot always be easily decided, and I have no doubt that arms have baen sacrificed which could have been saved, and would have been, had the surgeons considered the operation for resecting as affording an equal chance for the patient's recoverj-. So far as my experience teaches me, though I have rarely seen the operation performed in the hospitals or in the field, the results of the only cases in which I have ever performed the operation have all been so favorable that they would seem to warrant the resection whenever the nature ofthe injury will allow, especially in recent gunshot wounds. la many instances the extent of f.acturo down the shaft of the humerus, the laceration of the muscular tissue, or the injury of the axillary vessels or axillary plexus of nerves, or, judging from the track of the ball, the anticipated sloughing cf tho brachial artery, will necessitate amputation at tho shoulder without delay or hesitation. This is also very generally the case in shell wound.., owing to the extensive laceration or to tho internal destruction of all the tissues of that region, even when the skin remains almost entire." 563 INJURIES OF THE UPPER EXTREMITIES. . [CHAP. IX. An instance of primary excision of tbe upper extremity of tbe left humerus after shot fracture, followed l>v necrosis of the shaft and disease of the elbow joint, and secondary extirpation of the remains of the humerus, and exsection of the upper extremities of tbe radius and ulna, has already been published i The official report is appended : Cast. 1543.—Private J. E. F Cleghorn, Co K, 1st New Jersey, aged 27 years, was wounded at Mine Run, November •27. 1833. Surrreon G. L. Pancoast, U. S. V., reported that this man -was 'received at the Cavalry Corps hospital the day of his injurv. with a gunshot wound of the left shoulder." On November 30th, Surgeon H. K. Ck.rk, 10th New York Cavalry, excised the head of tbe left humerus and a small portion ofthe shaft. No particulars of this operation were reported. Surgeon E. Bentley. U. S. V., stated that tbe patient was transferred to Old Hallowell Hospital, at Alexandria, oa December 5th. The injured limb was much inflamed, and i- an abscess formed at the elbow joint. This was freely incised on December 7th, and the discharge of pus was very profuse. Simple dressings with a sustaining general treatment were employed for the next four months," when, on the approach of warm weather, the patient was removed to Ward Hospital, Newark. At this time the wound was healed, with the exception of a slight fistulous sinus, communicating with the sawn extremity ofthe shaft ofthe bone, although the entire shaft and condyles of the humerus subsequently became necrosed Assistant Surgeon J. T. Calhoun, U. S. A., reported that, " on July 21, 13.14, the patient was placed under the influence of a mixture of ether and chloroform, and that Acting Assistant Surgeon J. B. Cutter removed the entire remaining portion of the humerus, including the elbow joint, making a straight incision the whole length ofthe arm on its outer aspect. No ligatures were applied Silver sutures were used Union by first intention took place nearly the entire leugth of the incision, and in three weeks after tbe operation was performed the patient was well and about. There was as yet no sign of the bone being renewed, although ail of the periosteum thut could be had been left." Tho result was satisfactory, aud, on October 29,133-1, the man was discharged from hospital and army aud pensioned. In November, 1331, an apparatus was fitted to the arm by Dr. E. D. Hudson, G33 Droadway, New York, who made a careful report of the case, stating that, after- a comminution of the head of the left humerus by a miuie ball, the upper third of the bone was excised at a field hospital, and that from consecutive disease, eight months subsequently the rest of the humerus, with the upper por- tions of the ulna and radius, were removed. The first operation appeared to have been clone through a straight anterior incision, the second through a longitudinal incision extending the length ofthe upper ann. Dr. Hudson remarked that the arm was healed, but " entirely flexile, muscles contracting zig-zag fashion, with contraction of an inch aud a half, and much atrophy. There was no restoration of bone. There was strong power of flexion in the carpus and metacarpus, but the extensor antagonism was impaired." A detailed account of the ingenious apparatus, a sort of exoskeleton, devised by Dr. Hudson in this case, is printed in the paper cited from the American Journal of the Medical Sciences, 1835, p. Ill, and is accompanied by a wood cut. Drs. Cutter and Hudson sent several photographic illustrations of this case to the Museum. 'Ihe pathological specimen removed in the second operation (FlG. 444) is copied, from a photograph, in the adjacent wood-cut. A photograph of the appearance of tbe limb two vears after the secondary operation (FlG. 445) is also copied The Pension Examiners express an unfavorable opinion of the results of this operation. Examiner C. Rowland, of Brooklyn, New York, does not hesitate to say that: "The arm is worse than useless, and the sooner it is amputated at the shoulder joint tbe better for the applicant." Examiner W. M. Chamberlain, of New York City, reported, September 10, 1833, that: " The limb hangs pendulous and useless." This pensioner was paid March 4, 1574. There are no late accounts of the condition of his limb at the Pension Bureau. Extirpations of the humerus2 after caries following shot injury are very uncommon.3 Fig. 444.—Necrosed diaphysis and lower epi- physis of left humerus, with pens of the ulna and radius, removed after an excision i f the upper extremity of the bone for shot fracture. Fig. 415.—Appearance of limb two years after an exci- sion of the humerus for shot inj ury. 1 Photographs of Surgical Cases and Specimens, Washington, 1866, Vol. Ill, pp. 12 and 48; also a paper by Dr. J. E. Cutter (Am. Jour Med. Sci., 1866, Vol. LI, p 130). * An hoiiored teacher of surgery. Professor Gross, states (A System of Surgery^ 5th ed., 1872, Vol. 11, p. 1C88) that: "Professor Langenbeck has, on several occasions, resected the entire humerus on account of gunshot injury." I have been unable to verify the cases referred to by Professor Gross, and I'rufessor B. von LAXGXXEECii (in his Chirurgische Beobachtungen aus dem Kriege, Berlin, ISTI, S. 99), although he gives a summaryof his operations, does not mention these. But he ci'cs (I. c, p. 140) a very interesting case, from the Franco-Prussia:) War, 1S70-1S71, in which, at different times, the head, the shaft of the humerus, and the elbow joint were removed. The case does not come strictly under this head, since the first operation was not primary, but it is too interesting- to be unnoticed in this connection. It will be adverted to hereafter. 3 It is possible that Dr. Gross has reference to the following case, tabulated by Dr. C. HL'ETER (Die Resectionen, u. s. w., in LANGENBECK's Archiv., :>,7, B. VIII, S. 99, No. '-j'), which was treated at the Royal clinic at Berlin, in 1865: 'A boy, aged G; dry caries ofthe head ofthe humerus with anchylosis of the joint; res.«tion of the head of the humerus; periostitis of humerus and ulna; successive cxtracticn of the diaphysis of the humerus, and of small sequestra of the epiphyses cf the elbow and of the diaphysis of the ulna. Recovery." The name of the oper.itcr is not rveortled. SECT. III.] EXCISIONS AT THE SHOULDER. 569 Fig. 446.—Upper extremityof the left humerus cxciseil for shot fracture. Spec. ^849. Primary Unsuccessful Operations.—There were eighty cases referred to this category, of tbe two hundred and ninety-three primary cases referred to on page 548. Tbe imme- diate causes of death are recorded in about half of the cases.1 Twelve of tbe specimens are preserved in the Museum: Cask 1549.—Private Nicholas C------. Co. 0, S?t.h New York, aged 40 years, was wounded at Cold Harbor, Juno 3, 13o4, and was admitted into a Second Corps hospital. .Surgeon W. S. Cooper, 125th New York, reported: " Gunshot wound of the left arm ; resection at the shoulder joint by Surgeon P. E. Hubon, 28th Massachusetts ; simple dressings.'' On June C-t\\, the patient was transferred to Columbian Hospital, Washington, where Surgeon T. R. Crosby, U. S. V.. noted : "Gunshot wound of the left breast; furloughed July 21, 1831; readmitted September 24th ; furloughed November 3d." He probably died while on his way hame. as his wife claimed a widow's pension from November 3. 1S34, stating that her late husband was wounded in the breast by a musket ball, and that his arm was struck by a shell and the bone shattered from elbow to shoulder, and that he died on or about the above date, having been last heard from at Columbian Hospital, Washington. The specimen (FlG. 443) consists of the head and three and one-half inches of tlie shaft of the left humerus, excised for extensive comminution below the surgical neck. The capsule of the joint was opeued. The pathological preparation was contributed to the Army Medical Museum by the operator.—(Cat. Surg. S:ct . 1333. p. S3 ) Case 155'.—Private C. L. Britton. Co A, '22(1 Massachusetts, aged 27 years, was wounded at Cold Harbor, June 3, 1334. He was admitted to a Fifth Corps field hospital, where Surgeon W. R DeWitt, jr., U. S. Y, noted: " Gunshot wound. Resection of the head and shaft of tlie right humerus." Transferred to Washington, the patient entered Stanton Hospital on June 12th. Surgeon J. A. Lidell, U S. V., recorded: "Gunshot wound of the ri-.rht shoulder. Resection of tbe head and about three inches of the shaft of the humerus on the outer side; incision about eight inches in length; anaesthetic unknown. The operation was performed on the field, June 3d, by Surgeon Isaac H. Stearns, 22d Massachusetts; particulars unknown. The patient says he was in good condition at the time of operation. Treatment: Simple dressings, stimulants, and tonics. Patient doing well and wound granulating finely June 30, 1334."' Pyaemia supervened, and death occurred July 9, 1334. Ca>k 1351.—Private J. Houghey, Co. H, 116th Pennsylvania, aged 22 years, was wounded at Cold Harbor. June 3,1334. He was admitted to a Second Corps field hospital, and thence sent to Washington and admitted to Harewood Hospital. Surgeon R. B. Bontecou, U. S. Y., recorded: "Admitted June 7th, suffering from gunshot wound of the right arm, the ball entering the anterior surface about half way down, fracturing and comminuting the shaft, and emerging at a point opposite on the posterior aspect. Resection ofthe head and about three inches ofthe shaft of the right humerus was performed, on the field, on June 3d, bv Assistant Surgeon W. B. Hartman, 110th Pennsylvania. On admission, the conditiou of the injured parts was good. The bone was very much comminuted; the soft parts were healthy, suppuration not having set in. The constitutional state of the patient was also good. The wouud occasioned by the resection filled up rapidly, with healthy granulations. The discharge of pus was not excessive. He was under a stimulating and supporting regimen, with occasional anodynes. June 23tb, d jiug well. About the middle of July, the wound became very unhealthy, with profuse sanious discharge and some tendency to gangrene. There were no symptoms of pyaemia. The patient steadily sank, notwithstanding the free use of stimulants and a supporting nourishing diet throughout. He died July 23. 1331, of exhaustion." Case 1552—Sergeant G I Cleaver, Co. L, 3d Indiana Cavalry, aged 27 years, was wounded near Kuoxville, February 2J, 1864, and was admitted to hospital on the following day. Surgeon A. M. Wilder, U. S. Y., made the following special report: "Wounded by a conical bullet passing through the left arm at the upper third, producing a compound comminuted fracture of the humerus, extending into the joint. I removed the head of the humerus and fragments of bone to the extentof nearly three iuc'.n s of the shaft, removing the sharp ends of the souud bone with a chain saw. Tbe bullet was found in the wound. Very little blood was lost. The patient rallied well from the operation. This case was treated in Hospital No. 5, Kuoxville, in charge of Assistant Surgeon H. L. Burritt, U. S. Y., from whom I obtained the further history or termination ofthe case. February 2-th, patient has vomited for twenty-four hours ; no better; bowels regular; not much oedema; very little purulent discharge; patient looks cheerful; pulse 110. February 25th, pulse 112; skin and tongue in good condition; wound presents a sloughy appearance; some discharge of pus. February 2Gth, discharge of pus more; patient improved in appearance; no pain. February 27th, free suppuration; pulse 100; skin hot; complains of pain in the shoulder. March 8th, patient steadily improved from the date of last note. March 10th, patient worse; wound stops discharging pus but has a healthy look; slight chills, with vomiting (stomach has been irritable from the first); pyaemia feared. March 11th, typhoid symptoms developed ; ichorous discharge from the wound ; patient sinking rapidly; died at two o'clock P. M. The treatment was stimulant from the beginning." The specimen shown in the adjoining wood-cut (FlG. 447) was contiibuted to the Museum by the operator. It consists of the head and nearly four inches of the shaft of the left humerus excised for a severe fracture through the surgical neck. A conoidal ball tore the bone obliquely through the shaft with extensive splitting, but with little comminution, and lodged beneath the inner portion of tbe head. Tue articular surface of the bone was not injured, but the joint was opened. 'The assigned proximate causes of death were: Pyaemia, 13 cases; gangrene, 5; erysipelas, 4; exhaustion, la; tetanus, I; haemorrhage, 3; intermittent fever, 1; phthisis, 2. In thirty-six cases no immediate cause of death is recorded. 72 Fir.. 447.—Head ard nearly four inches of the shaft of the left hu- merus excised fjr shot fracluie. Spec. 2260. 570 INJURIES OF THE UPPER EXTREMITIES. Table XXXII. [CHAP IX. Summary of Eighty Fatal Cases of Primary Excisions of the Head and Portions of the Shaft of the Humerus for Shot Injury. x ; Name, Age, and Military Description. 13 23 Alexander, T., Pt., A, 3d Iowa, age 23. Allen, J. P.. Pt., D, 48th North Carolina. Babcock, D., Pt., B, I24fh New York, age 19. Barnes, II. L., Pt., A, 34th Massachusetts. Bazarth, J., Pt., A, 17th Iowa, age £3. Dcedy, O. E., Pt., C, 118th New York. Box, G. F., Pt, A, 17th * Mississippi. Branson, J., Serg't, A, 128th Indiana. Britton, C. L„ Pt., A, 22J Massachusetts, age 27. Brockelbank, L. C, Pt., H, 4th N. Y. Artillery, age 25. Brownson, I. It., Capt., I, 14th Connecticut, age 37. Cahill, N., Pt., C, 88th New York. Campbell, J. H., Pt., B, 28th July 30 Colored Troops. 1864. Date OF Injury June 4, 1863. Sept. 9, 1864. May 24, 1864. Juno 5, 1864. Oct. 13 1861. Sept. 30, 1864. July 3, 1863. Aug. 12, 1864. June 3, 1864. May 19, 1864. May 3, 1863. June 3, 1864. Nature of Injury. Carlin, J., Pt., E, 73d Penn- sylvania, age 37. Carroll, M., l't., K, 81st Pennsylvania, age 22. Cleaver, G. P., Serg't, E, 3d Indiana Cavalry, age 27. Clements, J. O., Corp'l, E, 12th New Jersey, age 22. Conner, \V., Private, B, 62d Pennsylvania. Erwin, XV., Captain, D, 11th Missouri. Finney, H., Pt,, C, 18th Massachusetts, age 22. Force, D., Private, I, 104th Ohio, age 34. 22 \ Grady, W. S., Major, 25th North Carolina. Grecnleaf, G. H., Pt., G, 9th Maine, age 20. Gricr, R. M., Pt., IT, 1st Pennsylv'a Rifles, age 20. Junel5 1864, June 4, 1864. Feb. 20, 1864. May 3, 1863. May 12, 1864. April 1, 1865. - Mav 9, 1864. Aug. 6, 1864. June 30, 1864. Juno 30, 1864. June 27, 1864. Minie ball caused a compound fracture of the left humerus and passed through the left lung, just touching the ver- tebra. Shot fracture of left humerus below the surgical neck. Shot fracture of upper portion of right humerus, involving the joint. Fracture of head and neck of June 5, right humerus by a musket ball which lodged. Mini6 ball caused extensive comminution of the head of the left humerus. Oblique fracture of the right humerus by a musket ball which lodge.l in the bone. Shot' fracture of head of right humerus, and wound of right side of thorax beneath axilla. Shot fracture of upper third of lett humerus, Fracture of right shoulder by a shell fragment. Shot fracture of the right hu- merus. ExteDsi ve comminution of neck of the right humerus by a conoidal ball which lodged. Extreme comminution below surgical neck of left humerus by shot. Comminuted shot fracture of head of left humerus with great laceration of soil paits Shot fracture of the right hu- merus. Compound shot fracture ofthe head of the left humerus; also fracture of the right hu- merus. Oblique shot fracturj through surgical neck of left humerus, extending into joint. Shot fracture of the head of left humerus. Shot fracture of the head of ---humerus. Shot fracture of the right hu- merus. Shot fracture of the right hu- merus. Minie ball fractured the upper extremity ofthe left humerus. Compound shot fracture of up- per third of right humerus and upper third of left radius. Musket ball thoroughly com- minuted the head and neck of the right humerus. Comminuted shot fracture of surgical neck of the left hu- merus ; epiphysis uninjure 1; also wound through lung. Date of Opera tion. June 5, 1863. Sept. 11 1864. May 24 1864. 1864. Oct. 14, 1864. Sept. 30, 1864. July 4, 1863. Aug. 12 1864. June 3, 1864. May 19 1864. May 3, 1863. June 3, 1864. July 30 1864. June 15 1864. June 4. 1864. Feb. 20, 1S64. May 3, 1863. May —, 1864. April 5, 1865. May 10 1864. Aug. 6, 1864. June 30, 1864. June 30, 1864. June 27, 1864. Operation' and Operator. Head and three and a half inches of shaft of humerus excised, by Surgeon-General J. C. Kughes of Iowa. Excision of the head of the humerus, by Surgeon D. F. Wright, P. A. C. S. Head and four inches of shaft removed through a straight incision, by Surgeon S. II. Plumb, 8Cd New York. Head ar.d about three inches of shaft cf humerus excised, by Dr. Baldwin, C. S. A. Removal of the head and a small portion cf the shaft of the humerus through a single Straight incision Excision of the head and frac- tured portion of humerus, by Ass't Surg. J. W. Gray, 98th New York. Excision of the head and three inches of the shaft of the humerus. Excision of the head and four inches of shaft of humerus, by Ass't Surgeon E. Lynn, 60th Illinois. Head and three inches of shaft of the humerus removed, by Surgeon I. H. Stearns, 22d Massachusetts. Head and three inches of the shaft of humerus removed. Entire upper third of the right humerus removed. Resection of head and three and a half inches of shaft of humerus, by Surgeon P. E. IIuLon, 28th Massachusetts. Excision cf the head and five inches of shaft of humerus, by Surgeon >i. J. Potts, 23d Colored Troops. Head and upper third of the humerus excised. Excision of tho head and three inches of shaft of humerus, by Surgeon A. N. Dougherty, U.S. V. Amputation of right arm at middle third, by Surg. J. \V. Wishart, 140th Penn'a. Excision of the head and four inches of the shaft of tho hu- merus, by Surgeon A. M. Wilder, U. S. V. Head and a portion of shaft of the humerus removed. Excision of the head and por- tion of the shaft of humerus on the field. Excision of upper five inches ofthe liumerus, including the head, by Surg. JI. XV. Fisk, 11th Missouri. Removal of head and portion of shalt of humerus. Head and six iaches of shaft of the humerus removed, by Surgeon J. II. Rodgers, 104th Ohio. Four inchei of the upper ex- tremity of the humerus, in- cluding the head and neck, removed, by Surgeon F. N. Luckcy, 2"th North Carolina. Head aud three and a half iaches of shaft of humerus excised thro' a slightly con- vex incision, by Surgeon T. II. Squire, 8Dth New York. Excision ofthe head and three inches of shaft of humerus, by Surgeon J. J. Comfort, 1st Pennsylvania. Result and Remarks. Never rallied from effects of chlo- roform ; died twenty hours after operation. Died September 13, 1864. Died JuneS, 1864, of pyaemia. Died June 16, 1804, of mortifica- tion. Died December 2, 1804, of ex- haustion. Died October 1, 1834, ere route to General Hospital. August 19th, great irritability of stomach, and diarrhoea; died August 21, 1863. Died October 31, 1864. Died July 9, 1804, of pyaemia. Died June 10, 1804, of exhaustion. Died June 3,1863, of exhaustion. Died November 5, 1864. Spec. 2849, A. M. M. Died August 12, 1864. Died June 22, 1864. Died June 14,1864, of exhaustion. Died March 11, 1864, of pyaemia. Spec. £230, A. M. M. Died June 22, 1803. Died at the field hospital, May —, 1864. Died April 7, 1865. Died June 26,1804, of exhaustion. Died Sept. 14, 1864, of pyaemia. Died October, 1804, of bilious remittent fever. Died August 9, 1864. Spec. 2788, A. M. M. Died July 11, 1834, of exhaus tion. Spec. 4148, A. M. M. sect, in. EXCISIONS AT THE SHOULDER. 571 Name. Age. and Military Dkscuiption. Griffin, J.. Pt., D, 22d Wis- 'July 20, eonsin, ncv 21. I 18l!4. Grimes, J. .'/., Pt., D, 45th Nov. 30, Alabama, ago li). 18J4. Hardinger, D., Pt.. C, 100th Aus. 0, Ohio, ago 2J. 18o4. Haughey, J., Pt., II, 110th June :!, Pennsylvania, ago 22. 1864. Higgins, J., Pichardson's Juno 6, Battalion, Artillery. 1864. Hudson. W., Sergeant D, i Fob. G, 121st Pennsylvania, age 29. 1805. Hall, D., Private, C, 81st June 12, Indiana. 1864. Hupgood, R.H,Pt, D. 12th ' May 4. North Carolina, ai;o 22. I 18o4. Inge, J. V., Pt.,'B, 5.'th Aug. 5, Virginia, age 26. i lbo4. Jerras, J., Pt, D, Cth Wis- Feb. 0, consi:i, age 2t. | 1865. Johnson, H., Pt., I, Ulth May28, Illinois, age 28. _ ls\>4. Jones, G. W., Pt, G. G! Colored Troops, age 26. Kalrighter, H., Pt, D, 8th Maryland, age 24. Keyes, A. F., Lieut., Sth Maine, age 25. A, Knau, L., Pt., C, 178tU Sew York. Laden, M., Pt, K, 63d New York. Lawson. G., Pt., A, 86th New York, age 35. McNeily, J. R., Captain, D, Hampton Legion, ago 27. Mackin, J. H., Corporal, F, 15.~th Pennsylvania, age 22, July 15, 1864. Mav 12, 1864. Oct. 27, 18G4. May 3, 1864. Sept. 17, 1862. May 7, 1864. June 13, 1864. Mav 5, 1864. Martin, T., Pt., C, 25th New April 1, York. 1865. Meek, J., Pt, C, 104th Ohio, age 33. Mumford, J., Pt., C, 43d North Carolina, age 23. Myer, N., Pt, K, 3d Indiana Cavalry, age 32. Nelson, P., Pt., H, 100th New York, age 26. Page, D., Corporal, A, 33d Indiana, age 27. Pelton, J. M , Lieutenant, C, 211th Penn'a, age 26. Peterson, J. H., Pt., E, 31st Colored Troops. Pickard. J., Pt., 7th Co. 1st New York Sharpshooters. Pickens, J., Pt, E, New Jersey, age 30. Feb. 20, 1865. May 16, 1864. Feb. 20, 18G4. April 1, 1865. June 22, 18G4. April 2, 1865. July 30, 1864. June 4, 1864. Nov. 27, 1863. N'.vruiiF, of Injury. Shot fracture of bead of left humerus. Shct fracture of upper third of right humerus. Comminuted shot fracturo of upper third of right humerus, iivolvins,joint. Mi-.iie ball fractured and com- minuted tho shaft of tho right humerus. Missile comminuted tho head of left humerus and lodged in tho ohost. Shot fracturo of upper portion of the lefc humerus. Shot fracturo o> upper third of humerus. Musket hall comminuted the upper portion of humerus. ?liot fracturo of upper third of tho right humerus and partial fracture of scapula. Fracture of the head of right humerus by a conoidal ball. Compound fracture of upper third of right humerus by a conoidal ball. Severe shell wound of right shoulder. Shot fracture of upper third of the left humerus. Extensive comminuted shot fracture of upper part of right humerus, periosteum stripped to capsular ligament Head and surgical neck of left humerus extensively shat- tered by a musket ball. Shot fracture of left humerus. Comminution of upper third of left humerus by a miniS ball. Shot comminution of the head and shaft of left humerus and coracoid process of scapula. Gunshot wound of left shoul- der joint Shot fracture of upper third of the left humerus. Fracture of upper third of left liumerus by a 6hell fragment. Gunshot wound of shoulder... Fracture of upper third of right humerus, extending into the joint, by a minie ball. Head of right humerus broken into several unequal frag- ments by shot; an oblique fracture extended down shaft. Comminuted shot fracture of four inches of upper extrem- ity of right humerus; also wound of chest Shot fracture of head of left humerus; an oblique fracture extended through the surg- ical neck. Shot fracture of head of hu- merus, clavicle, and scapula. Gunshot fracture of shoulder joint. Fracture of the head of right humerus by a conoidal ball. Opera- TION July 21, 1864. Dec. 1, 1864. Aug. 6, 1864. Juno 3, 1864. Juno G, 1864. Fob. G, 1865. June 12, 1864. May 4, 1861. Aug. 5, 1864. Feb. 8, 1865. May 23, 1864 July 15, 1864. May 12, 1864. Oct. 29, 1864. May 4, 1864. Sept, 17, 1862. May 7, IS64. June 13, 1664. May 5, 1854. April 1, 1865. Feb. 20, 1865. May 16, 1864. Feb. 20, 1864. April 1 1865. June 22, 1864. Anril 5, 1865 July 31, 1864. June 4, 1864. Nov. 27, 18u3. On:ration and Operator. Excision of the head and three inches of shaft of humerus. Excision ofthe head and throe inches of shift, by Surgeon Ringgold, 4.'.th Alabama. Head and five inches of -haft of humerus excised, by : Jurg. G. A. Collamoro, ICUhOhio. Head and three inches of shafi of humerus excised, by Surg. XV. B. Ilartman, 116th Penn. Head and throe inches of shaft of humerus removed by lat- eral incision through deltoid. Head nr.d two inches of nhuft of the humerus removed. Upper extremity of humerus excise!, by Surgeon C. J. V/alton, 21st Kentucky. Head and three inches of shaft of humerus excised. Excision of the head and one inch of shaft of humerus. Head and upper portion of shaft of humorus excised. Head and upper third of shaft of humerus excised, by Act Staff Surg. C. B. Kichards. Removal of head and portion of the shaft of the liumerus, by Ass't Surg. J. M. Study, U. S. V. Excision of the upper extrem- ity of humerus including the head. / Excision of the head and seven inches of shaft of humerus through a straight incision, by Surg. D. G. Rush, 101st Penn. Headand two and a half inches of shaft of humerus excised through a straight incision, by Ass't Surgeon J. Homans, jr., U. S. A. Excision of the head and four inches of humerus, by Surg. J. N. Lyman, 57th Penn'a. Excision of the head and about two and a half inches of shalt of humerus. May 23d, sec- ondary haemorrhage from ax- illary artery; amputation ut shoulder joint, by Surgeon It. B. Bontecou, U. S. V. Removal of three and a half inches of the humerus includ- ing the head. Removal of head and a portion of the shaft through an incis- ion made directly in front. Head and six inches of shaft of humerus excised, by a Confederate surgeon. Excision of the head ::nd three inches ofthe shaft of humerus. Excision of the upper half of tho humerus. Head and six inches of shaft of humerus excise! through a straight incision, by Ass't Surgeon H. L. XV. Burritt, U. S. V. Head and two and a half inches of shaft of humerus removed, by Surgeon W. O. McDomald, U. S. V. Resection ofthe head and four inches of shaft of humerus. Head and two inches of shaft of humerus removed, by Surg. VV. O. McDonald, U. S. V. Head and three inches of shaft of the humerus excised, by Surgeon D. Mackcy 29th Colored Troops. Excision of head and one and a half inches of the shaft of humerus. Excision ofthe heal and three inches of shaft of humerus. Result and Remarks. Died July 29, 1864, of gangrene. Died Mar. 15, 1865, of erysipelas Diad September 27, 1864. Died July 25, 1864. Died July 21, 1864, of pyaemia. Died February 22, 18G5, of ex- haustion Died July 1, 1864. Died June 5, 1864, of exhaustion. Die 1 Aug. 10,1804, of erysipelas. Died Feb. 22, 1865, of tetanus. Died July 14, 1864. Died January 25, 1865, of con- sumption. Died June 5, 1864. Died Nov. 15, 18G4, of pyaemia. Spec. 3805, A. M. M. Died May G, 1864, during trans- portation. Died October 22, 1862. Died May 31, 1864. Died June 17, 1864. Died June 12. 1864, of exhaus- tion. Died .Mav 17, 1865. Spec. 4208, A. M. M. Died Mar. 15, 1865, of pyaemia. Died June 19, 1864. Died February 25, 1864, of gan- grene. Spec. 2227, A. M. M. Died April 15,1865, of erysipelas. Spec. 4139, A.M. M. Died July 7, 1864, of pyaemia. Died April 14, 1855. Spec. 4161, A. M. M. Died September 15, 1864, of ex- haustion. Died June 9, 1864. Died December 7, 1863. Spec. 2705, A. II. JI. , corroborates the statements of Dr. Rice, and adds that " about eight weeks previous to the death of said Nicholson suppuration commenced in the spot where the shoulder joint had been removed." Case 1553.—Private J. Ruddy, Co. A, G3<1 New York, aged 'M years, was wounded at Petersburg, April 2, 1835. Surgeon F. M. Hammond, U. S. V., at the First Division Hospital of the Second Corps, and Acting Staff Surgeon J. Aiken, report pimply that the patient had a shot wound ofthe left shoulder, and was sent on to Wash- ington, where he was received into Harewood Hospital on April 4th. Surgeon IJ. B. Bontecou, U. S. V., reported: "Gunshot wound of the left shoulder and back, the ball entering at the head of the humerus and making its exit near the anterior portion of the scapula, fracturing the head of the humerus and the acromion process. On April 22d, the wound being in a suppurating condition, the patient was placed under the influence of ether, and the head and about four inches of the shaft of the humerus were removed. The after-treatment was supporting, with simple dressings, and the result was favorable." The photograph represented in the cut (Fre. !")1) was taken while the patient was at Harewood Hospital, and was contributed to the Museum by tbe operator, Dr. Bontecou. This soldier was discharged from service July 12,18 jo, and pensioned. Examiner J. S. Delevan, of Albany, reported, September 8, 1836: " Ball entered the left shoulder. Th;; shoulder joint was resected, with a portion of the humerus. Tbe limb cannot be used at all, excepting that the hand can be opened and shut, but he cannot carry anything in it. The elbow joint cannot be bent fully, and for all practical purposes it is useless to him, and in my opinion permanently so; disability total." Dr. P. F. L. Reynolds, of Albany, certified as follows: '' Said John Ruddy died at Albany, June 3, 1838, from the effects of a gunshot wound; the ball which occasioned it having passed through the upper lobe of the left lung and out of the left shoulder, resulting in the wasting away of his system, and was the sole cause of bis death." The two foregoing cases are classified with the successful intermediary cases, although the patients succumbed, .respectively, five and three years subsequently to operations. In numerous instances it is difficult, because of conflicting testimony, to determiue how far u'timate fatal results are to be attributed to injuries and dperations. In this work, patients who survived severe operations until discharged, or pensioned, are classified as recovered. Case 1559 —Private J. K. Clarke, Co. E, 10th Pennsylvania Reserves, was wounded at Fredericksburg, December 13, 1832. Assistant Surgeon J. Barbour, 1st Pennsylvania, recorded a "gunshot wound near the shoulder." The patient was sent to Carver Hospital, December 18th. Surgeon O. A. Judson, U. S. V., reported that " the ball entered about three inches below the acromial process of the right side, passed upward and inward, fracturing a portion ofthe shaft and the head of tbe humerus badly. Resection was performed, January 7, 1833, by Surgeon J. Wilson, U. S. V. A U-shaped incision was made, and the head and about three ir.ches of the shaft of the bone were removed by the chain saw. The wound was healed by tbe 1st of March. The local dressing was of water, with an occasional admixture of whiskey when the wound showed indications of indolence. At the date of operation the limb was much swollen, the discharge fetid and sanious, the skin hot, the pulse at one hundred, the tongue coated, with cephalalgia loss of appetite, and general depression." In a letter to Dr. J. H. Brinton, of May 2, 1833, Surgeon J. Wilson, U. S. V., stated: "The operation was performed January G, 1833. 1 considered the case tending rapidly toward pysemia. From the date of tbe operation the untoward symptoms began rapidly to subside. You will observe by the sketch [a drawing had been made, under Dr. Brinton's directions, by Hospital Steward Stauch, from which Fig. 4, Piratic XIII, is copied] that the sutures of the flap were inserted farther from the margin than usual. This I did that I might bring firmly together the soft parts, in order to secure as much union by the first intention as possible " Surgeon Wilson has published an extended narrative of this case, with accompanying observations on prolonged anaesthesia.1 This soldier was discharged June 5, 1833, and pensioned. Examiner reported, June 4, 1833: "Ball unremoved, and probably is lodged beneath the scapula. Most of the motions of the arm are perfect, but it is powerless and useless for labor now." Examiner J. Voss, of Clarington, reported, September 4, 1873 : " The arm for use is worthless." 1 WILSON (J.), Case of Exsection of shoulder-joint, in the Am. Med. Times, 1863, Vol. VI, p. 232. FlG. 451.—Cicatrix after an intermediary excision of the head of the humerus for shot fracture, [from a photograph.J Pig. 452.— Upper extremity of right humerus excised for shot fracture. Sp. 633. 576 INJURIES OF THE UPPER EXTREMITIES. fCHAP. IX. Table XXXIII. Summary of ±Vinety-One Cases of Recovery after Intermediary Excisions of the Head and Portions of the Shaft of the Humerus for Shot Injury. 16 ame, An i■:, and Military inscription. Addison, J., Serg't, C, "23d July 30, Colored Troops, age 22. 1864. Arnold, P.. Corp'l, F, 47th Mar.28, Pennsylvania, age 20. 1805. Bnsney, E., Pt., E, 2d Con- June 1, necticut Artillery, age 16. 1864. Bed;, J. L., Pt., I, 16th Mar. 8, Illinois, age 22. 18 j5. Belter, M., Pt., B, 2d Mich- Sept. 30, igan Cavalry. 1862. Bell, It., Pt., C, 3d Massa- April 8, chusetts Cavalry. 1863. Bickford, G., Pt., C, 11th Dec. 13, New Hampshire. 1862 Blakeman, A. C , Lieut., I, May 12. 61th New York, age 21. 1864. Bleecher, M., Pt.. H, 79th Oct. 8, Pennsylvania. 186; Booth. T., Pt., B, 8'oth New Aug. 30, York. 1862. Borger, F. A., Serg't, D, 8th July 3, Vi ginia, age 25. 1863. Boyle, W., Pt., D, 50th Ohio, April 7, age 31. 186; Bright, W., Pt., A, 12th April 2, Mississippi, age 25. 1865. Bryant, G. H., Captain, D, April 7, 2i!fh Wisconsin. 1864. Butler, XV.. Pt., G, 20th New Aug. 30, York State Militia. 1862. Canfield, L. C, Pt., A, 15th Autr. 18, -Michigan, age 32. 1864, Clapp, G. C, Pt., G, 37th Sept. 19, Massachusetts, age 35. 1864. Clark, J. K., Pt., E, 10th Dec. 13, Pennsylvania Reserves. 1862 Cleveland, J. J., Pt., K, 10th Au:r. 1, Connecticut. 1864. Coolream, P., Pt., B, 61st May 8, New York, age 45. 1664. Cox, P. A., Pt., E, 14th July 20, West Virginia, age 29. j 1864. Date OF Injury. Natuke of Injury. Shot fracture of the head of the right humerus. Mini6 ball carried away half an inch of the articular sur- face of the left humerus. Gunshot wound of right shoul- der; missile lodged iu head of humerus. Shot fracture of upper third of the right humerus; secretions from joint escaping through wound. Conoidal ball grooved the head of left humerus and lodged ur.derthe integument at back of neck. Fracture of head and neck of right humerus by conoidal ball; fracture extended two inches downward. Head of right humerus com- minuted by a shell fragment. Shot wound through the head of the left humerus. Fracture of right humerus, in- volving shoulder joint; ball lodged in surgical neck. Comminuted shot fracture of upper third of left humerus. Minie ball perforated the neck of left humerus, producing a compound comminuted frac- ture. Shot fracture of the right hu- merus ; scapula involved. Minie ball fractured the head of right humerus. Head of right humerus shat- tered by musket ball; longi- tudinal fracture thro' upper three inches of shaft. Musket ball extensively shat- tered the ritrht humerus and comminuted the head of the bone. Inner portion of head ani neck of the left humerus carriel away by musket ball. Upper third of right humerus shattered by minie tall. Head and shaft of right hu- merus badly fractured; ball passed beneath scapula and could not be found. Musket ball gouged the neck of ri4. Vug. 30, 186.-. May 5, 1864. June 3, 1864. Aug. 30. 1862. Mav 6, 18»4. Mav 5, lb.il. Mar. 31, 1865. July 1, 1862. June 27, 1862. May 5. 1862. Aug. 1G, 1864. May 5, 1864. July 20, 18J4. June 18, 1863 June 21 1861. Nov. 16, 1863. Aug. 25 1861. Mnyl>, 1864. May 3, 1863. May. 9, 1864. Nature of Injury. Conoidal ball lodged in hea I of left liumerus, splitting it. Comp'd comminuted shot frac- turo of tho head and shaft of tho right humorus. Fracture of tho hoad of the left humerus by a conoidal ball. A minio ball split head of right humerus into three parts and separated the greater tuberos- ity atepiphysoal lineof union. Conoidal ball fractured the left humerus. fracture of the head of right humerus by a musket ball; shoulder dislocated; bono de- nuded of periosteum. Upper two-thirds of epiphysis of left humerus carried away nnd remainder broken into many fragments; capsule opened ; also wound of left forearm, leg, and thigh. Shot fracturo of right humerus and anterior and posterior border of glenoid cavity. Comminuted shot fracture of upper third of left humerus. Minie ball passed through the neck of right humerus, frac- turing and comminuting shaft. Minie ball carried away one- third of hea I of left humerus, fractured the remaining two- thirds, aDd crushed the cora- coid process of scapula. Shot fracture of the head and neck of the left humerus. Compound fracture of upper third of left humerus by a conoidal ball. Head and upper part of shaft of left humerus very much com- minuted by a conoidal ball. Minie ball perforated tLe head of left humerus and emerged over the scapula. Righthumerus very much com- minuted by a musket ball; shoulder joint involved. Fracture of upper third of the left humerus by a conoidal ball. Conoidal ball completely de- stroyed the integrity of head of right humerus ani frac tured the surgical neck. Shot fracture of upper third of the left humerus. Shot wound of left shoulder joint, with compound commi- nuted fracture of upper third of humerus Conoidal ball perforated neck of right humerus, fracturing and splitt'g upper end of shaft Upper portion of right humerus badly comminuted by a minie ball. Comminuted shot fracture of the external border of the right scapula aDd head ofthe humerus. Opera- tion. May 27 1861. May 18, 1861. July 6, 1861. Sept. 4, 1862. May 17, 1864. June 29 1864. Sept. 14 1862. June 1, 1864. May 15, 1864. April 6, 1865. JulvU 1862. July 13, 1862. May 15, 1862 \ug. 23, 1864. May 12, 1864. July 29, 1864. July 3, 1663. July 5, 1864. Nov. 30 1863. Aug. 30 1664. Mav 31 1864. May 15. 1863. May 10, 1864. Operation and Operator. Head and two inches of shaft of humerus removed through a straight incision, by Surgeon O. A Judson, U. 8. V. Removal of hoad and three inches oi tbe shaft o f humerus through an S-slmpcd incision, by Surg. Z. E. Bliss, U. R. V. Removal of tho head and three inches of shalt of humerus, by a Confederate surgeon, ot Richmond. Removal of tho head of the humerus, by A. A. Surgeon J. Pancoast. Head and one and a half inches of shaft of humerus removed, by Surgeon A. F. Sheldon U. S. V. Excision of tho head and four inches of the shaft of humerus through a straight incision, by Surg. E. Bentley, U. S. V. Head and two inches of shaft of humerus removed through an S-shnpcd incision, by Surg. D. W. Bliss U. S. V. Head and three inches of shaft of humerus excised through a straight incision, by Ass't Surg. J. C. McKee, U. S. A. Head and four inches of shaft of humerus removed through a V-shaped incision. Excision ot head and a portion of the shaft of. humerus, by Surg D. W. Bliss, U. S. V. Removal of the head and half an inch of shaft of humerus and det ;ched fragments of scapula, by Surgeon R. I-I. Coolidge, U. S. A., assisted by Surgeons J. H. Brinton and D. M. Rankin. Excision of the head and two and a half inches of shaft of humerus, bv Ass't Surg. H. S. Schell, U. S. A. Excision of the head and five inches of the shaft of humerus through a linear incision, by Surg. II. McLean, 2d NT York. Excision of the head and three inches of shaft of humorus, by A. A. Surg. C. T. Bullen. Excision of the head and two inches of shaft of humerus, by Surg. J. II. Thompson, I2th New York. Excision ofthe head and three inches of shaft of humerus through a straight incision, by A. A. Surg. E. G. White. Excision of the head and two inches of shaft of humerus, by Surg. J. Wilson, U. S. V. Head and one inch of shaft of humerus excised, by Surg. E. Bentley, U. S. V. Head and five inches of shaft of humerus excised, by Surg. A. P. Honker, 26th Mass. Excision of head and about two inches of shaft of liumerus thro' a longitudinal incision, by A. A. Surg. L. C. Do 'ge. Excision of tbe head and three inches of shaft of humerus, by SurgD. XV. Bliss, IT. 8. V. Excision of the head and three and a half inches of shaft of humerus through a linear in- cision, by Ass't Surgeon C. A. McCall, U. 8. A. Removal of tho head and two inches of shaft of humerus, and pieces of glenoid cavity and bo Iy of scapula, through a straight it.c;sion, by Ass't Surg. II. Allen, U. S' A, Result and Remarks. Disch'd June 10, 1865; pensioned. Sept.. 1873, arm useicss for manual labor. Dischd Jan. 7, 1865; pensioned. ■Sept., 1873, arm useless for labor. Disch'd July 25, 1665; pensioned. Sept., 1873, arm hangs useless. Disch'd Nov. 10,1862; pensioned. Oct., 1873, good movement ; fistulous opening discharging pus. Spec. 315, A. M. M. Disch'd Juno 6, 1865 ; pensioned. Disch'd Nov. 29,1864 ; pensioned. Sept., 1873, arm useicss. Spec. 2712, A. M. M. Disch'd Oct. 30,1862; pensioned. Sept., 1873, muscular atrophy; disability total, 3d grade. Spec. 185, A. M. M. Disch'd Oct. 10,1864; pensioned. Sept, 1873, disability total, 3d grade. Phot. 146, A. M. M. Furloughed July 27, 1864; re- covered. Disch'd July 21,1865; pensioned. Amp. of arm at shoulder, July 10. 1867. by Dr. McDemont. Spec. 3492, A. M. M. Disch'd Dec. 15, 1862; pensioned. Se->t, 1873, for purposes of man- ual labor the arm is almost en- tirely useless. Disch'd Oct 24, 1862; pens:oned. Sept., 1873, lossof ujo of shoul- der and limb. Disch'd Aug. 20,1862; pensioned Dec, 1873, indications'ofnecro- sis of bone ; arm perfectly usc- Disch'd October 18, 1G05. Had not been admitted to pension in August. 1874. Disch'd Nov. 22, 1865; pensioned. April, 1867, arm cannot be ex- tended without help from oppo- site arm. Disch'd Jan. 9, 1865; pensioned. Sept., 1873, only backward and forward motion possible ; three inches shortening and some atrophy. Disch'd Jan. 23,1864 ; pensioned. Sept., 1873, upper arm useless ; forearm comparatively so. Disch'd June 1,1865; pensioned. Spec. 2830, A. M. M., and Phot. 100. Disch'd May 18, 1864; pensioned. Oct., 1869. uses fore.irm to feed himself; handles light articles. Disch'd Dee, 3, 1864 ; pensioned. Sept., 1836, unable to use arm for any purpose. Spec. 3161, A. M M. Disch'd July 15,1835; pensioned. Sept., 1873, arm useless for man- ual labor. Spec. 2394, A. M. M. Disch'd Nov. 13,1863; pensioned. Dec, 1866, arm almost useless for labor. Spec. 1118, A. M. 51. Disch'd July 30,1865; pensioned. Sept., 187'.'.. arm totally useless for purposes of labor. Spec. 23J5, A. M. M. 580 INJURIES OF THE UPPER EXTREMITIES. [CHAP IX. In two of the ninety-one operations above tabulated, consecutive amputation at the shoulder was practised; and, in another case, intermediary hsemorrhage necessitated the ligation of the right axillary artery. Seven of the ninety-one were operations on Confed- erate, and eighty-four on Union soldiers; and eighty of the latter were pensioned. The method of operation was specified in only forty-four instances, and was described as by straight anterior incision, in thirty instances—by (J or V_shaped flaps, in seven—by a curvilinear or S-incision, in six—by a crucial incision, in one. Forty-seven operations were on the right, forty-two on the left, and two cases were undetermined. Five of the mutilated men died subsequently, at periods from six to ten years after operation. In thirty-four instances, pathological preparations wTere transmitted to the Museum: Case 1560.—Private E. H. Woods, Co. G, Cth Maine, was wounded at Chancellorsville, May 3, 1863, and was admitted to Mount Pleasant Hospital, Washington. Acting Assistant Surgeon E. Ooues reported: "The patient, a very robust, mus- cular man, aged 24 yours, was admitted May fc-th. A minie ball had entered the outer anterior aspect of the shoulder, passed backward and inward, and badly comminuted the upper poition of the humerus, the frac- ture extending up into the joint. Operation of resection of five and a half inches of the humerus with the head was performed, May loth, by Assistant Surgeon C. A. Mci all, U. S. A." The specimen (Fig. 454) consists of the head and three and a half inches of the right humerus. The anterior face of the shaft and posterior portion of the head are carried away, and the articular surface is split in two vertically. It was contributed bv the uprratur. The patient recovered and was discharged the service, and pensioned November 13, 1633. At that date, Examiner T. B Smith, of Wash- ington, reported: ''Ball entered the shoulder an inch below the cor- acoid process, aud passed backward, fracturing the humerus in the upper portion. Resection of the head and about three inches of the shaft in consequence. Hand motions perfect, but unavailable for labor by reason of uselessness of the arm; may improve much in a couple of years." In November, 1835, Dr. E. D. Hudson, of New York, furnished this man with an artificial limb, and reported that there had been an excision of five inches of the shaft and head of the humerus through a linear incision, posteriorly, of the deltoid, and that the arm was shortened three-fourths of an inch, with slight atrophy. The general condition ofthe arm was excellent, the interspace being mainly filled with new growth of the continuity. The usefulness c;f the apparatus while under observation was very satisfactory. Dr. Hud- son contributed a photograph, represented in the accompanying cut (Fig. 453), showing the mode of adaptation of the apparatus to the limb, and another giving a view of the patient, showing the cicatrix, wlik-h will be found on page 2, Vol. IX, Contributed Photographs, A. M. M. In June 1637, Examiner A. H. Agard, of Sandusky, Ohio, reported: '"The excised end or stump has not formed a joint, but plays all about, rendering the arm quite useless for purposes of manual labor." The pensioner was paid March 4,1674. Cask 1551.__Private \T. Vericker, Co. E, 9th Massachusetts, aged 25 years, was wounded at Malvern Hill, July 1, 1832, and was sent to Washington, and admitted to Epiphany Hospital on July 4th. Acting Assistant Surgeon D. N. Rankin reported: " Wounded by a minie" ball entering at the outer side of the upper third of the humerus, passing obliquely upward, and carrying awav one-third of the head of the humerus, also making a triangular fracture of the outer two-thirds of that part, the ball con- tinuing in its course upward, crushing the coracoid process of the scapula, comminuting the humeral end of the clavicle, and making its exit immediately above the inner side of the supra-spinatus fossa. On the 18th of July, the operation of resection of the upper third of the humerus was performed by Surgeon R. H. Coolidge, U. S. A., assisted by Surgeon J H. Brinton, U. S. V , and Acting Assistant Surgeon D. N. Rankin; he made the V-shaped incision, the point being upward; in dissecting up the flap large sinuses were discovered, especially one very large one, which was much more noticeable than the rest; it occupied the space between the ribs and clavicle, and when cut into discharged more than a pint of very unhealthy looking pus. All the pieces of comminuted bone were removed that could readily be taken away without complicating the operation, as it was sup- posed at that time that it would be impossible that the operation should prove successful, the system being in such a very bad condition, so much so that, in consultation, it was a very long time before it was fully decided upon to operate. The incisions were drawn together by sutures and adhesive plasters, with lint and a bandage over it, and a handkerchief sling to support the arm; themext day the cold-water dressing was commenced, and continued, though we found it necessary to put a felt splint on the elbow and forearm to assist in supporting the arm. Since the day the operation has beeu performed he has been improving rapidlv; he has been taking themost nutritious food that could be gotten for him, such as beef essence, eggs, chicken soup, chickens, mutton, etc. He has been taking as tonics quiniue, muriate tincture of iron, brandy, punch, porter, etc. His condition at this time the 2d dav of August, is certainly very cheering." The patient remained under treatment until December 15, 1832, when be was discharged the service and p- ■nsioned. Examiner (r. S. Jones, of Boston, July 2, 18 J J. in a special report says: " The Fig. 453.—Apparatus employed in case of excision at the shoulder. [From a photograph.] Fig. 454. —Upper extremity of right hu - merus excised for shot fracture. Spec. 1118. SECT. III.] EXCISIONS AT THE SHOULDER. 581 head of the humerus has been resected, and a fistulous opening now exists, from which matter is discharging. The arm is now powerless anil useless.'' In a letter dated December 25, 1835, Surgeon General Dale, of Massachusetts, reported that this man was employed as a farmer at Nort'i Bridgewater, Massachusetts; that there had been no fistulous openings or other incon venienecs since the operation; that the man could put his hand to bis hoad, and that the voluntary movements of the arm were otherwise eminently satisfactory. The South Abiagton Board, Drs. A. Millet and B. F. Hastings, report, September 6, 1873: " The ball entered the left shoulder joint and humerus of tho left arm, fracturing the scapula, and passed out above the inner end of the clavicle. The motion of tho shoulder joint is almost lust. The muscles about the shoulder and left arm are greatly atrophied and very adherent to the bone. For purposes of manual labor, the arm is almost entirely useless." A photograph of the specimen, shown as No. 121, Vol. Ill, Phot. Ser., A. M. M., represents the head and one-half inch of the shaft of the 1-ft humerus. The inner portion of the head is carrieil away and the articular surface is eroded. This pensioner was paid September 4. 1874. Cask 1562.—Captain D. G. Risley, Co E, 9th Colored Troops, aged 28 years, was wounded in the arm at Deep Bottom, September 29, 1634, and, on October 3d, was received into Chesapeake Hospital, Fort Monroe. Surgeon D G. Rush, 101st Pennsylvania, made the following special report of the case: "The missile entered the outer aspect of the arm, through the middle of the deltoid muscle, four inches below the head of the bone, producing unusual comminution, driving numerous frag- ments ot the bone into the axilla and beneath the scapula, under which it passed and effected a hidden lodgement, where it still remains. The wounded man was carried off the field and did not arrive here until the morning of October 3d, at which' time he was suffering from extreme pain and anxiety, having been told that he was not in a condition to boar amputation at the shoulder joint, which alone could save bis life. He was emaciated and anjemic from an attack of miasmatic fever, from which he hnd jast recov- ered. The coft parts were lacerated, swollen, everted, and painful; and the patient inclined to the belief that the wound was occasioned by a frag- ment of shell, but'the lodgement remaining innocuous, tends to prove that it was a musket ball On the afternoon of the day of his admission, I removed the head and fragments of the humerus, amounting to six inches, through a V-shaped incision, commencing immediately before and behind the acromion and terminating in the external wound The comminuted fragments were first removed, carefully separating them from any attached periosteum, which, even though in shreds, was not removed. The next step was to detach the periosteum from the remaining fragment of shaft of bone attached to the head, which had partly been effected by the missile. The condition of the patient improved immediately, and by cold-water irrigation, tonics, moderate use of stimulants, and a very nourishing diet, he made a good recovery, being convalescent in six weeks after the operation. A large amount of callus was developed by the periosteum, producing a good substitute for the head of the bone, enabling the patient to perform considerable motion at the time of his discharge from hospital, January 23, 1835, with a fair prospect of future usefulness of the limb." Captain Risley was discharged from service May 15, 1885, for disability, and pensioned. On October 5, 1853, he was again commissioned as Second Lieutenant 42d Veteran Reserves. The adjoining wood-cut (Fig. 455) was taken from a card photograph, shown in Vol. II, page 9, Card Photographs, A. M. M. upper extremity of the humerus. [Frtai a photograph.] The specimen, No. 3804, Surg. Sect, A. M. M., consists of the head and five inchss of the shattered shaft of the right humerus excised. The epiphyseal portion is uninjured, but the remainder of the specimen is much broken. Contributed by the operator. Examiner D. H. Henry, of Elkhart, Indiana, reported, February 16, 1835, that " the arm and forearm at present are totally disabled." Case 1563.—Private TV. H. Ricketts, Co. A, 13th Virginia, aged 22 years, was wounded at Gaines's Mills. June 27, 1852, and was admitted to Confederate Hospital No. 24, at Richmond, on tbe 28th. The case was recorded in Confederate Register^No. 100, as follows: "A conoidal ball passed through the right arm near the shoulder joint, lacerated the capsule, and split the humerus in many fragments for three inches below the surgical neck. The head of the humerus was attached to a mere fragment; the glenoid cavity was uninjured. Great depression followed the injury. On July Sth, chloroform was administered, and excision of the head of the right humerus and five inches of the shaft by a perpendicular incision, was performed by Surgeon Otis Frederic Manson, P. A. C. S. After carefully removing all spiculae, the wound was closed by sutures, the limb placed upon a pillow, and cold-water dressings applied. The cure of the case was delayed by three separate attacks of erysipelas, the last of which occurred about August 22d; these yielded, however, to quinia and iron. March, 1834, the patient has very good use of his arm ; (he functions of the forearm and hand tire nearly perfect; he writes well." A report of this case was published by the operator in the Confederate States Medical and Surgical Journal, Richmond, 1861, Vol I, No. 3, p. 40, with a wood-cut of the patient showing the resulting cicatrix, and of the pathological specimen. An enlarged copy ofthe latter is represented by the adjacent cut (Fig. 436). Dr. Manson, in this publication, dated March, 1884, states: "The patient has now very good use of his arm; the func- tions ofthe forearm and fingers being almost perfect. He writes a beautiful hand, and, altogether, presents another of tho many proofs of the value of this surgical expedient in preference to that formerly practised in such cases—amputation at the shoulder joint." Fig. 4C5. — Cicatrix after intermediary excision of the Tig. 43S.—Excised up- per extremity of right humerus. [Enlarged from a drawing in the Cor.f. States Med. and Surg. Jour., 1834, Vol: I p. 40. ] ()$■! INJURIES OF THE UPPER EXTREMITIES. Periostitis, osteitis, and osteomyelitis of a portion or the whole of the remaining part of the humerus were not very infrequent after intermediary excision of the upper extremity of the bone; such examples were more common, however, among the fatal cases. The following i* an instance of superficial caries ofthe diaphysis following periostitis: Cask 1"64.—Private R. B. Mason, Co. I, 7th Michigan, aged C5 years, was wounded at White Oak Swamp, June '.\(\ isf>2. and was sent to Washington, and admitted into Epiphany Hospital on July 4th. Acting Assistant Surgeon D. N. Rankin furnished the following report of the case : "Wounded by a minie hall, which entered at the outer side of the upper third of the humerus, passed obliquely upward, and through the posterior part ofthe head ofthe bone, causing several long fissures, extend- ing three inches downward. The posterior part of the bone is likewise crushed to pieces; three large fragments are connected with the head and extend to the body ofthe bone; the fissures do not quite extend to the place where the bone was sawn off, the latter being about one-quarter of an "inch farther down, the ball making its exit immediately below the acromion process. The patient having had pneumonia complicated with the wound, we were deterred from operating as soon as we wished. He was put on the best known treatment for pneumonia in order to get him in a better condition for operating; but we did not succeed very well in this particular, and finally concluded to operate notwithstanding his objectionable condition. We thought it was the only hope of saving his life, ns the wound was suppurating largely, so much so, that it was telling severely upon his system. On July 19th, I performed the operation of resection of the head of the humerus, with the assistance of Surgeons J. IT. Brinton, U. S. V., and R, IT. Coolidge, U. S. A. The form of the flap made was the semicircular; it was necessary to remove about four inches of the humerus. The operation over, the man did very well for some ten days, at the end of which tunc his pneumonic symptoms returned as prominently as ever, assuming the character of phthisis pulmonalis; so much so, that at present his case is considered a very unpromis- ing one." The specimen (FlG. 458) consists of the excised head and two inches ofthe shaft ofthe right humerus. A conoidal ball, enter- ing the base of the great tuberosity, has shattered the surg- ical neck and extensively fissured the articular surface. Contributed by the operator. The patient remained under treatment until November 20, 1852, when he was dis- charged from the service and pensioned. Examiner H. 0. Hitchcock, of Kalamazoo, reported, January 15,185:5: "There are now several fistulous openings along the humerus; there may be a necessity for amputation. The arm at any rate is more adapted for ornament than for use." On April 18, 1853, Dr. Hitchcock forwarded the photograph ofthe man, represented in the cut (FlG. 457), with the following notes : "' For a year and a half after his discharge there were fissures still open and discharging, leading down to diseased bone and periosteum. The periosteum and surface of the bone had become diseased nearly to the elbow joint. An operation for scraping the diseased surface of the bone was followed by a complete and sound closure of all the sinuses. There is now com- plete anchylosis of the elbow joint. There has been no reproduction of bone where the bone was exsected. No power exists to extend the arm upon the shoulder. There is a, little control and use of the hand, as the man can write when the forearm is laid upon the table and the paper moved instead of the hand; this, however, can be continued only a few minutes. The photograph represents the case at this date." On a subsequent examination, in 1874, it is reported that "there is atrophy of the muscles of the shoulder and arm ; anchylosis of the elbow joint, and that tliere are extensive cicatrices on the outer side of the arm from the shoulder to the elbow. The disability arising from the uselessness of the arm for the purpose of manual labor is rated total." Mason av:is paid March 4, 1874. Similar exfoliations from the sawn end of the shaft, especially in the shape of necrosed rings of bone, were quite common: Cask 1505.—Private J. M. Hall, Co. I, 27th Indiana, was wounded at Antietam, September 17, 1852, and was admitted to Ho.-pital No. 2, Frederick. Acting Assistant Surgeon J. H. Peabody transmits the following history: " Upon au examination of the wound it was discovered that the ball had entered between the first and second ribs, about three inches to the right of the sternum, passing obliquely backward and outward, and making its exit at the external edge of the scapula, about an inch and a half below the acromion, fracturing the head of the liumerus. Shoulder very much swollen and extremely painful at the time the patient was admitted; constitutional disturbance considerable; loss of appetite; pulse at 100. Waited until October 4th, hoping for a change; nene having taken place, concluded to operate. Resected the head and one inch of the shaft of the liumerus. Operation—straight incision. Patient did not lose an ounce of blood. Had to saw the bone twice, having found it denuded below the line of the first cut. October 28th, patient doing well; appetite good; wound entirely filled with healthy granulations. Treatment: wound kept open with lint; water dressing; granulations stimulated with basilicon ointment. The Via. 457.—Appeartlnceof cicatrix after intermediary rxeision of the head and portions of the 6haft of the humerus, four years after operation. [From a photo- graph 1 FlG. 458.—Upper ex- tremity of right humerus excised for shot fracture. Spec. 1, A. M. M. SEl'T. III.] EXCISIONS AT THE SHOULDER. 583 his rlischnrge. Fig. 459.—Appearance of cicatrix after intermediary excision of the head and three inchps of the shaft of the right liumerus. [From a photograph. J incision made in this operation had entirely healed six weeks after the operation. The patient now awaitin Tolerable use of arm and forearm." The patient was discharged the service December 17, 1H62, and pensioned. Examiner S. Hughes, of (ireoncastle, Indiana, reported, April 2, 1S5:>: "The condition of the applicant is such as to be unable to move his right arm, the ball passing from the inside, near the outer third of the clavicle, through the shoulder joint, and out just below the scapula, fracturing upper third of humerus 60 much as to be necessary to remove some three inches of that bone at the joint; general health good." Examiner John 8. Baker, of Osceola, Iowa. September 6, 1S75, reported : "A number of spicula) of bone have since come out; impos- sible to raise the arm: use of joint entirely lost, and at times is very painful." The pensioner was paid December 4, 1ST:!. The specimen, 451, Surg. S"ct, A. M. M., was contributed by the operator, and consists of "the head and one inch of the shaft of the right humerus excised. The inner half of the head was carried away by gunshot, and the specimen shows eight small fragments that were removed. The neck was sawn through in two places." Cask 1566.—Private 8. F. Thicker, Co. D, 20th Indiana, aged 34 years, was wounded at the Wilderness. May 5, 1864, in the right shoulder, and was admitted to a Second Corps hospital, and thence sent to Washington, entering Lincoln Hospital M;iy 30th. On June 1st, excision of the shoulder joint was performed by Assistant Surgeon J. C. McKee, U. S. A., who subsequently contributed the photograph represented by the cut (ElG. 45!)), and reported: "Bill entered the posterior surface of the head of the right humerus, passing forward, making its exit at the anterior surface, fracturing the head of the humerus and the anterior and posterior borders of the glenoid cavity. June 1st, excision of the head and three inches of the shaft of the right humerus through a straight incision, commencing at the coracoid process of the scapula and extending downward five inches. Ether was used as an anaesthetic. October 10th, parts entirely healed. Recovered." The patient was subsequently transferred to the Soldiers' Home, and was discharged the service January 24,1865. He is a pensioner, and wras paid June 4, Is? 4. His disa- bility is rated total. The photograph from which the cut is copied is No. 146 of the Surgical Section. When the joint is perforated' antero-posteriorly by a small projectile, the posterior opening is of utility for purposes of drainage, and such cases are peculiarly adapted to the operation by a single anterior incision. The following is an illustration of this: Case 1567.—Corporal J. Moncke, Co. C, 7th New York, aged 32 years, was wounded at Petersburg, April 2, 1885, and was admitted to the Second Corps hospital at City Point, where resection of the head and neck of the humerus was performed by Acting Assistant Surgeon W. J. Burr. The patient.was subsequently treated in Armory Square and Stanton Hospitals, Wash ington, and DeCamp Hospital, New York, and discharged the service January 9, 1883, and pensioned. In March, 1856, Assistant Surgeon Warren Webster, U. 8. A., contributed the photograph represented by the wood-cut (Fig. 460), with the follow- ing report: "The patient received a compound comminuted fracture of the right liumerus. A conoidal ball penetrated the anterior surface of the arm opposite the surgical neck of the humerus, traversed the bone in an antero-posterior direction, and emerged at the posterior fold of the axilla. He was twenty-fpur hours a pris- oner after receiving the wound, during which time he received no treatment. On the 9th of April, he reached the Second Corps hospital at City Point, where, on the 13th of the month, he was rendered insensible by chloroform, and four inches of the liumerus, including the head and upper portion ofthe shaft, were excised. The steps of the operation appear to have been those pursued by Langenbeck. The longitudinal incision was, however, commenced more internally than recommended by that operator, the surgeon having probably been influenced by the position of the wound, which occupied the line of the cut. Pasteboard appliances were used upon the patient until his transfer to Armory' Square Hospital, Washington, where he arrived May 11, 1855. After that time, the limb was maintained in a straight posi- tion, supported by oakum and pillows. He was admitted to DeCamp Hospital September 4, 1865, at which time the case was progressing favorably. The exist- ence of a posterior wound, permitting the free escape of pus in the recumbent posture, which, according to Esmarch,1 is paramountly desirable in the operation by anterior incision, is believed to have essentially promoted recovery in this case. On the 25th of December, 1865, the accompanying photograph was taken at DeCamp Hospital. Although the knife, it would seem, was carried wide of the long tendon of the biceps, the preservation of the latter, if accomplished, proved of little prac- tical value in this instance. An interval of nearly the extent of the removed bone exists between the humerus and the glenoid fossa. The member hangs like an inanimate mass at the man's side. He cannot raise the hand toward the mouth, nor does the deltoid enable him to abduct the arm in the slightest degree." Examiner James Neil, of Harlem, New York, August 16, 1866, reported: "The right arm hangs like a pendulum and is useless." The pensioner was paid March 4, 1874. 'Esmauch (F.), Vber Resectionen nach Schusswunden, Kiel, 1851, S. 4(1, and Statham, abridged English translation of Esmauch, London, 1856, p. 67. ^^SfPSSS!5^^ Fig. 460.—Appearance of the cicatrix eleven months after excision of the upper extremity ol the humerus. [From a photograph.] 534 INJURIES OF THE UPPER EXTREMITIES. [t'HAP. IX. § Intermediary Unsuccessful Operations.—Of the one hundred and fifty-five cases of intermediary excisions of the upper extremity of the humerus for shot injury, referred to on page 473, sixty-four had a fatal termination; a mortality rate of 41.2 per centum. Seven examples are detailed, and all the cases are summarized in the succeeding tabular statement: Case 1568.—Private T. McC------, Co. F, 2d New York Cavalry, aged 38 years, was wounded at Culpeper, September 15, 1855. He was sent to Washington, and on the following day admitted into Armory Square Hospital. Suigcon D. W. Bliss, U. S. V., reported the case as follows: '"'The patient is of a sanguine temperament, and was in good health up to the time of the injury. A mini6 baU entered about four inches above the left nipple and emerged one inch and a half below the acromion process of the left arm, fracturing the humerus at the surgical neck.- Wound quite painful. Lead wash was ordered to the shoulder, which was considerably swollen. The patient had the best diet possible, with wine thrice daily if he desired it. On September 17th, I resected the head and about three inches of the shaft of the h :merus, the iucision through the muscles being of an S-shape. Chloroform was used and a moderate amount of blood was lost. The muscles were considerably infiltrated with serum, and, after the removal of the bone, the inner part of the wound looked dark and unhealthy. The patient reacted well from the anaesthetic, and did not seem affected more than usual by the operation. The after treatment consisted in the administration of half-grain doses of opium with brandy every four hours. Lead and opium wash applied to wound, and best diet given. On the 18th, 19th, and 20th, a quarter of a grain of morphia was given at bed time, and the lead and opium wash continued. On the 21st he complained of a want of appetite; the wound presented a gangrenous appearance. One-half of an ounce of tincture of cinchona was given three times daily, and warm-water dressings applied to the wound. September 22d: Bowels constipated; has had no operation for seven days; pulse increased in frequency and weak; complaiued of being cold; well- developed moist gangrene covered the incision and a sanious discharge flowed from the wound. A purple color pervaded the skin for some distance from the wound, the lips of which were glued by fibrinous bands, giving evidence of reparative action. One ounce of sulphate of magnesia was ordered at once, and half an ounce of tincture of cinchona given before meals, with the best diet. A warm poultice, made of pulverized cinchona and charcoal, yeast, and carrots, was applied every three hours, and beef tea and milk punch were given. In the afternoon he was unable to retain the milk punch, and a half ounce of brandy with two grains of carbonate of ammonia was substituted. The patient failed rapidly, and died at six o'clock a. m. of the 23d." The excised portion of the humerus was contributed to the Army Medical Museum by the operator (Fig 461). The missile has perforated and almost entirely carried away the surgical neck. A number of fissures reach to, but do not transcend, the epiphyseal line. The fractures extend dowuward to the line of excision. In one-third of the cases, the fatal result was ascribed to the invasion of pysemia, and to exhaustion from burrowing of pus and profuse suppuration in fourteen instances: Case 1569.—Private Lyman C. B----, Co. E, 7th Maine, aged 23 years, was wounded at Ny River, May 18, 1864, and was admitted to a Sixth Corps hospital. On examination, a shot fracture near the neck of the humerus was diagnosticated; splints and water dressings were applied. The patient was then sent to Washington, and entered Emory Hospital May 25th. Surgeon N. R. Mosely, IT. S. V., noted: "Gun- shot wound of right arm; minie" ball passed from before backward, through the deltoid muscle just above the insertion, fracturing the upper third of the humerus, the fracture extending into the joint. The bone was comminuted at the surgical neck. The soft parts were somewhat lacerated, with a sinus extending down the inner edge of the triceps, discharging dark ichorous pus. The patient was weak aud debilitated from exposure on the field and during transportation. He was suffering much pain, and was desirous of having the limb amputated. On May 26th, the patient was placed under the influence of chloroform and ether, and Acting Assistant Surgeon S. W. H. Ensign exsected the head and two and a half inches of the shaft of the humerus. The incision made was carried from the acromial process to the point of insertion of the deltoid. Adhesive straps were applied, with lateral felt splints and cold-water dressings, and the patient did well until May 28th, when a sinus was discovered descending from the shoulder down to the seventh rib, and extending over the greater portion of the side. A valvular incision was made into the abscess, which discharged about one pint of pus each day. He died on June 7, 1864, from progressive emaciation consequent upon the excessive discharge from the abscess." The pathological specimen is rep- resented in the adjacent wood-cut (FlG. 462). It was contributed by Surgeon N. R. Mosely, U. S. V. It consists of the head and four and a half inches of the shaft of the right humerus excised for comminution of the upper third. A fracture occupies the anatomical neck in its outer half. Fig. 461 .—Excised head and three inches of shaft of humorus. Spec. 1730. Fig. 4i'0 —Excised upper third of right humerus. Spec. 23li0. In the succeeding summary (Table XXXIV) the sixty-four fatal intermediary cases are recorded alphabetically. Thirty-ei^ht of these cases, and thirty-four of the preceding series, furnished pathological specimens to the Museum, or seventy-two of the one hundred and fifty-five cases. Intermediary operations were, for the most part, practised in perm- anent hospitals, which accounts probably for this remarkable preservation of the specimens. SECT. III.] EXCISIONS AT THE SHOULDER. 585 Table XXXIV. Summary of Sixty-Four Fatal Cases of Intermediary Excisions of the Head and Portions of the Shaft of the Humerus for Shot Injury. Name, Age, and Military Description. Anderson, II., l't., II, 14th Indiana, age 22. Aumiller, J., Ft., C, 15th In- fantry, age 24. Becker, J. T., Ft., F, 4th Colored Troops, age 22. May 3, 1863. Aug. 7, 1864. July 24. 1864. Besse, L. C, in., E, 7th i May 12, Maine, age 23. I IbtU. Blair, S., Color Sergeant, C, May 31, 101 st Pennsylvania. Bond, J. S., Ft., H, 1st Mary- Aug. 18. land. ' 1BG4. Bowen, J., Pt., F, 1st Sharp- May 12, shooters, age 44. 1864. BrightbUl, S., Pt., K, 209th Mar. 25, Pennsylvania, age 30. 18G5, Britton, E., Sergeant, I, 69th Sept. 17, Xew York, age 32. 1802. Bullard, A., Pt., A, 37th N. Dec. 12. Carolina. 18G2, Burk, E., Pt., 1,81st Pennsyl- May 12, vania, age 20. 180'4. Butler, J. L., Pt., G, 45th June 3, Pennsylvania, age 22. Byrd, R., Pt., E, 28th North May 12, Carolina, age 22. 1864. Cadigan, M., Pt., G, 57th July 30, Massachusetts. 1864 Case, H. W., Serg't, H, 116th May 12, Pennsylvania, age 21. 1864. Clemm, C, Pt., K, 79th Ohio, Oct. 4, age 21. 1864. Crone, W., Pt., H, 15th Ohio, Dec. 31 age 22. 1862. Darby, John, Pt., C, 36th July 1, New York, age 25. 1862. Dormer, L., Pt., A, 5th Penn- June 15 sylvania Cavalry, age 30. 1864. Donaldson, W., Pt., C, Sth May 5, New Jersey. Douglas, J., Pt., B, 4th New May 19, York Artillery, age 25. 1864. Dow, 8. G., Pt,, E, 31st June 11 Maine, age 19. 1864 Nature ok Injury. Minio hall comminuted head of left humerus, driving one frag- ment into tho parietes of chest; missile lodged in scapula. Shot fracturo of upper third of the right humerus, extending into tlie joint, Musket ball split off two large pieces of the shaft of right hu- merus; lissurcs extended into shoulder joint. Minie hall comminuted the right humerus at anatomical neck; fracturo extended into joint. Musket ball shattered the neck and upper portion of shaft of humerus. Shot fracture of upper portion of right humerus. Portion of articulating surface of head of right humerus car- ried away by shot. Inner fifth of the head of right humerus broken off by a co- noidal ball; joint opened,ball impacted. A musket ball shattered the right humerus just below the surgical neck and lodged. Shot fracture of surgical neck of right humerus with exten- sive comminution of bone. Shot fracture of the head of left liumerus. Compound comminuted frac- ture of the head of right hu- merus by a conoidal ball. Shot fracture of left humerus, opening into the joint. Comminution of surgical neck of right humerus by a musket ball, which also fractured fifth and sixth ribs, and was found, post-mortem, in the abdomen. Shot fracture of the head of right humerus and acromial process of scapula. Head of right humerus badly comminuted by a conoidal ball. Shot fracture of upper portion of humerus. Comminuted fracture of the bones forming the right shoul- der joint by a musket ball. Comp'd comminuted shot frac- ture of the left humerus. Compound shot fracture of the head of left humerus; also ' shot fracture of middle third of right thigh. Shot fracture of the head of the left humerus. Wound of left shoulder joint; ball passed through head of humerus. Opera- tion. May 27, 1863. Aug. 21, 1864. July 30, 1864. May 26, 1864. June 6, 1862. Aug. 27, 1864. May 19, 1864. April 1, 1865. Sept. 28, 1802. Dee. 29, 1862. May 20, 1864. June 11, 1864. May 20, 1864. Aug. 4. 1864. May 29, 1864. Oct. 18, 1864. 'Jan. 23, 1863. July 5, 1862. July 1, 1864. May 12, 1862. May 26, 1864. June 19, 1864. Operation and Operator. Head and one inch of shaft of humerus removed through a U shaped incision, by Surg. O. A. Judson, U. S. V. Ball extracted. Four inches of upper extremity of humerus, including head, through incision over deltoid, by A. A. Surg. W. II. Matlock. Excision of tho head and two inches of the shaft of humerus through a V-shaped incision over deltoid, by Ass't Surgeon E. Curtis, U. S. A. Head and four and a half inches of shaft of humerus removed, by A. A. Surg. \V. II. Ensign. Head and three inches of shaft of humerus removed through a U-shaped incision, by A. A. Surg. J. M. Brown. Middle of head of humerus, with splinter of bone one and a half inches long attached, removed, by Surgeon A. A. White, 8th Maryland. Head and one inch of shaft cf humerusTemoved through an S-shaped incision, by Surg. Z. E. Bliss, U. S. V. Excision of the head and one inch of the shaft of humerus through a straight incision, by Surg. G. L. Pancoast, U. S. V. Head and three and a half inches of shaft of humerus through a linear incision, by A. A. Surgeon J. H. Bartholf. Excision of the head and three inches of the shaft of humerus, by Surg. H. Bryant, U. S. V. Excision of head and two inches cf shaft of humerus, by Ass't Surgeon A. Ingram, U. S. A. Excision of the head and f jur inches of the shaft of humerus through a V-shaped incision, by Surg. O.A. Judson, U.S.V. Head and three inches of the shaft of humerus removed, by Ass't Surg. A.Ingram, U. S.A. Excision of the head and three inches of the shaft of humerus, by Surgeon A. F. Sheldon, U. S. V. Head and four inches of shaft of humerus removed, by Surg. G. L. Pancoast, U. S. V. Removal of the head and two inches of the shaft of humerus through a single straight in- cision, by Ass't Surg. B. C. Brett, 21st Wisconsin. Removal of the upper part of humerus, including the head. Removal of tho head and one inch of the shaft of humerus and the shattered fragments of the clavicle and acromial process, bv Ass't Surg. J. S. Billings. II. S. A. Head and two and a half inches of shaft of humerus removed through a straight incision, by A. A. Surg. W. P. Moon. Head and two inches of shaft of humerus removed, by Surg. R. B. Bontecou, U. S. V. Head and one inch of shaft of liumerus removed, by A. A. Surg. F. W. Kelly. Excision of head and two inches of shaft of humerus through circular transverse incision across deltoid, by Surg. R. B. Bontecou, U. S. V. Result and Remarks. Died Juno 1, .1863, of pyaemia. Spec. 1207, A. JI. M. Died Sept. 23, 1864, of pyaemia. Died August 26,1864, of exhaus- tion. Died June 8,1864, of exhaustion. Spec. 2360, A. M. M. Died July 12, 1862. Died Aug. 30, 1864, from haemor- rhage from superior profunda. Spec. 129, A. M. M. Died June 15, 1864, of colic. Died April 10, 1865, of pyaemia. Spec. 4282, A. M. M. Died October 27, 1862, of symp- toms of pleuritis and pneumonia. Specs. 787 and 804, A. M. M. Died Jan. 10, 1863, of pyaemia. Spec. 582, A. M. M. May 28th, ligation cf subscapular. June 2, pyaemie chill. Died June 28, 1864, of pyaemia. Died August 16, 1864, of chronic diarrhoea. Spec. 2944, A. M. M. Died May 30, 1864. Died August 6, 1864. Spec. 2973, A. M. M. Died August 12,1864. Spec. 2468. A. M. M. Died April 21, 1865, of variela. Died Feb. 13, 1863, of secondary hoemorrhage. Died July 10, 1862, of gangrene. Died July 14,1864, of exhaustion. Spec. 3624, A. M. M. Died May 13, 1862. Died June 5, 1864, of pyaemia. Died July 7, 18G4, of exhaustion. Spec. 3038, A. M. M. 586 INJURIES OF THE UPPER EXTREMITIES. [CHAr. ix. 23 Name, Age, and Military Description. Date of Injury, Elliott, C. H., Corp'l, D, Gist May 31, Pennsylvania. lsu'2. Emmert, J. W., Ft., F, 63d May 14, Tennessee, age 31. 1864. Evans, J., Pt., G, 21st Wis- Sept. 1, cousin, age 22. 1864 Finn, M., Pt., A, 88th New Sept. 17, York. 18G2. Frecht, J., Serg't, B, 122d May 3, Pennsylvania, age 24. 1863. (lage, M., Corporal, K, 94th Mar. 31 New York, age 21. 1865. Gibbons, E., Pt., L, 112th June 23 Pennsylvania, age 31. 1864 Hankin, J., Pt., H, 1st Mich- June 17 igan Sharpshooters, age 17. 1864 Harrison, D. W., Pt.,H, 13th April 12, Tennessee Cavalry, age 31. 1864 Hill, J. A., Pt., A, 31st Maine, April 2, age 17. 1865. Houston, A. M., Pt., H, 12th May 3, New Hampshire, age 24. 1863. Hughes, J., Corp'l, F, 1st Aug. 23 Penn'a Cavalry, age 25. 1864 Hutchins, XV., Pt., D, G4th May 12 New York. 1864. Hutchinson, S.R., Corp'l, G, Aug. 30 95th Ohio. 1862. Kaskatter, L., Pt., G, 211th April 3, Pennsylvania. 1865. Killingsworth, J., Pt., 1,37th Dec. 16 Mississippi, age 35. 1864 Lambert, A., Pt., E, 4th Aug. 20, Maryland, age 45. 1864. Laskey, V. T., Pt., A, 7th Aug. 28, Wisconsin. 1862. Leonard, C. H., Pt., C, 10th May 7, New Hampshire, age 29. 1864 Leveriiur. J. F.. Pt.. A, Sth Nov. 27, Michigan, age 33. 1863. Lillie, D., Capt., I, 4th Ver- | May 5, mont, age 26. 1864. Liscomb, J. M.. Pt., C. 1st June 18, Maine Artillery, age 18. I 1864. McOloskey, D. L., Pt., K, May 10, 155th Pennsylvania, age 22. 1864. Nature of Injury. Minie ball entered right acro- mion and escaped at the inser- tion of deltoid, shattering the head of humerus; another ball fractured head < f femur. Shot fracture of the head of right humerus. Shot fracture of the head of left humerus. Comminution of the surgical neck of right humerus by a ball, which lodged and could not be found. Left humerus broken off at the surgical neck by shot; fissures running up into capsule. Ball fractured the head of the right humerus and was cut out from between the clavicle and scapula. Musket, ball passed through the head and upper portion of shaft of left humerus and lodged in deltoid. Fracture of the head of right humerus by a minie ball. Head of left humerus badly comminuted by a musket ball; surgical neck shattered; also wounds of left lung and abdo- men. Mini6 ball fractured the neck and shaft of left humerus and was extracted from wound of entrance. Fracture, with extensive com- minution of upper third of right liumerus, by an English conoidal ball. Shot fracture of the head of the right humerus. Complete comminution of the surgical neck of the right hu- merus by shot. Shot fracture of left humerus, involving shoulder joint. Musket ball passed transversely thro' anatomical neck of left humerus and emerged from middle of vertebral border of scapula. Mini6 ball fractured head and split shaft of right humerus for two and a half inches. Shot perforation of right shoul- der joint; anterior and inner portion of head of liumerus carried away. Musket ball comminuted head and upper portion of the shaft of right humerus; shoulder joint implicated. Comminution of surgical neck of right humerus by a minie ball; severe laceration of parts by bone fragments. Gunshot fracture of surgical neck of left humerus, not de- stroying continuity. Ball comminuted the head and neck of the left humerus and slightly fractured the glenoid cavity. Wound of right shoulder joint; ball fractured the head of the humerus. Shot fracture of left shoulder joint, involving head of the liumerus. Date of One it a. tion. June 14 1862. June 12 1864. Sept. 5, 1864. Sept, 28 1862. Mav 9, 1863. \pril21 18o5. Julv 20. 1864. June 25 1864. April 22, 1864. April 12, 1865. May 8, 1863. Sept. 5, 1864. May 27, 1864. Sept. 11, 1802. Ap'l 14, 1865. Dec. 20, 18G4. Aug. 31, 1864. Sept. 23, 1862. June 3, 1864. Dec. 14, 1863. June 1, 1864. July 18. 1664. Mav 14, 1864. Operation and Operator. Head and a portion of shaft of humerus excised, by Ass't Surg. H. L. Sheldon, U. S. A. Excision of head andfour inches of shaft of humerus through a vertical incision seven inches long; synovial membrane of glenoid cavity removed. Excision of the head and one and a half inches of the shaft of humerus. Excision of the head and four inches of shaft of humerus, by Ass't Surgeon A. K. Smith, U. S. A. Head and three inches of shaft of humerus removed, bv Sur- geon T. Antisell, U. S.V. Excision of the head and one and a half inches of shaft of humerus through a straight incision, by A. A. Surgeon W. P. Moon. Excision of the head and upper third of shaft of humerus, bv Ass't Surg. E. Curtis, U. S. A. Head and one and a half inches of shalf of liumerus removed, by Surgeon It. B. Bontecou, U. S. V. Head and three and a half inches of shaft of humerus removed through a V-shaped incision, by Surg. H. Wardner, U. S. V. Head and four inches of shaft of humerus removed through a vertical incision, by Surg. J. C. McKee, U. 8. A. Excision of the head and three and one-half inches of shaft of humerus, by Surg. H. Bryant, U. S. V. Head and four inches of shaft of liumerus removed through a T-shaped incision, by A. A. Surg. W. F. Moon. Removal of the head and four inches of shaft of humerus, by A. A. Surg. H. M. Dean. Removal of three inches of up- per extremity of humerus, in- cluding tho head, by Surgeon H. Z. Gill, U. S. V. Head and three inches of shaft of humerus removed, by Surg. D. W. Bliss, U. S. V. Removal of the head and three inches cf the shaft of humerus, by A. A. Surgeon P. B. Nof- singer. Removal of the head and one- half inch of shaft of humerus, by A. A. Surg. C. II. Bowen. Excision ofthe head and portion of shaft of humerus, by Surg. E. Bentley, U. S. V. Head and four inches of shaft of humerus removed through a straight incision, by Surg. B. A. Clements, U. S. A. Excision of head and neck of left liumerus thro' a straight incision, by Surg. D. P. Smith, U. S.V. Excision of the head and two inches ofthe shaft of humerus, by Surg. D. XV. Bliss. U. S. V. Head and one-half inch of shaft of liumerus removed through a straight incision over deltoid, by Surgeon R. B. Bontecou, V. S. V. Removal ofthe head and three inches of shaft of humerus thro' a straight incision, bv Ass't Surg. A. Dulancy. U.*R. V. Result and Remarks. Died June 17, 18G2, of pyemia. Died July 9, 18G4, of diarrhoea. Died February 3,18G5, of chronic diarrhoea. Died Oct. 9, 1862, of empyema. The missile was found, post- mortem, to have traversed the lung and lodged in it, against spine of 11th costo-vertebral ar- ticulation. Specs. 382 and 9G0. Died May 13, 1863, of pysemia. Died Slay 6,1865, of exhaustion. Died July 22, 1864, of exhaustion. July 23d, ligation of the axillary artery. Died July 24, 1864, of secondary haemorrhage. Spec. 3033. A. M. M. Died May 4, 1864, of empyema and. exhaustion. Spec. 3309, A. M. M. Died Sept. 11,1855, of exhaustion. Died May 15, 1863, of pleuro- pneumonia. 4. Fl :.463.-Headand small portion of shaft of left humerus ex- cised for shot injur}-. Spec. 2462. was the operation most frequently adopted, having been employed in seventeen of the twenty-seven operations in which the method of excision was specified: Case 1 "-70.—Captain S. R. Reynolds, Assistant Adjutant General, U. S. V., aged 26 years, was wounded at Cold Harbor, He was at once admitted to the Base Hospital, Eighteenth Corps, and, on June 6th, was sent to Washington, entering Armory Square Hospital June 8th. Surgeon D. W. Bliss, U. S. V., reported: "Gunshot wound; ball entered the left shoulder anteriorly and immediately below the acromial process. Another ball entered the right arm immediately below the shoulder joint, and passed outward and emerged externally, a little above the insertion of the deltoid muscle. Resection of the humerus was performed on the afternoon of his admission, chloroform being given; three vessels were tied. The ball had opened the joint and lodged in the head of the humerus, from which place it had been extracted. Simple dressings, nourishing diet, and stimu- lants were prescribed. July 1st, patient doing well; wound nearly healed." The patient was furloughed July 20th, and died, while at his home in New York, in the following August. The specimen represented in the wood-cut (FlG. 463) consists of "the head and three-fourths of an inch of the shaft of the left liumerus excised.. A conoidal ball striking between the tuberosities has gouged out a portion, and split the head and shaft vertically without fissures."—Cat. Surg. Sect., 1866, p. 101. It was contributed by the operator, Dr. Bliss. Case 1571.—Private G. D. Stannard, Co. F, 17th Vermont, was wounded at Poplar Grove Church, September 30, 1^1)4. Surgeon J. Harris, 7th Rhode Island, reported, from a Ninth Corps hospital: "Gunshot wound of left shoulder; application of splints." On October 11th, the patient was sent to Alexandria and admitted into King Street Hospital. Surgeon E. Bentlev, U. S. V., reported: "Admitted with a gunshot wound of the left arm; the ball entered the posterior surface of the ann at the upper part of the middle third, fracturing the humerus. The arm was badly swollen. There was an incision, three inches in length, extending each way from the entrance of the bullet. The lips of the wound were everted and unsupported, indurated, and discolored. The patient stated that he had been etherized and the wound examined, but did not know whether the bullet or any bone had been removed. October 16th, profuse hsemorrhage occurred from the wound, which reduced the patient nearly to a state of syncope; it took place so quietly that it was not discovered until the patient beheld the blood flowing out of his bed on the floor. He was etherized, the incision extended, and the upper part of the humerus removed. A battered minie" ball was found impacted iu the posterior and inner aspect of the shaft, just below the anatomical neck. He had become so weakened by loss of blood that his pulse failed very rapidly under the influence of the ether, and for a little while was imperceptible at the wrist Three ligatures were applied and the wound left open. Wine, ammonia, and mutton broth were given, and at five o'clock the wound was closed with sutures and adhesive plaster. The pulse increased, with hot skin, dry tongue, and great thirst. Cold water was applied to the wound, and one- half ounce of solution of morphia given every two hours until the patient slept. October 17th, severe chill, much thirst, hot and dry skin, quick and irritable pulse, lips pale, tongue glazed on centre, eyes of a pearly cast; he had hiccough, and the stomach rejected both food and stimulants except in very small quantities. The discharge from the wound was thin and offensive. Diluted chlorinated soda was applied. October 18th, patient felt rather more comfortable, otherwise much the same as the day before. October 19th, arm dressed in the morning; discharge thin and foetid. That portion of the wound marking the first incision was gan- grenous, but the diseased muscle was apparently separating near the margin of the wound. In the afternoon hsemorrhage again occurred, and considerable blood was lost before it was arrested. The whole wound became gangrenous, and at death the shoulder, as well as the wound, became much discolored. Hiccough was constantly present after the operation. He retained his senses till nearly the last, and died at six o'clock P. M., October 19, 1864." The specimen (FlG. 464) was contributed by the operator, Dr. Bentley, and '•consists of nearly the upper half of the left humerus excised for gunshot. A conoidal ball is firmly impacted just below the head; posteriorly the articular surface is eroded; a longitudinal fracture occupies the bicipital'groove, and the posterior portion of the shaft is shattered."— Cat. Surg. Sect, 1866, p. 111. Case 1572.—Private L. Domrer, Co. A, Sth Pennsylvania Cavalry, aged 30 years, was wounded at Petersburg, June 15. 1864. Surgeon J. J. Craven, U. S. V., reported from a Tenth Corps hospital: "Gun- shot wound of left arm; simple dressings applied." The patient was transferred to Hampton Hospital, Fort Monroe, and, on June 21st, to Mower Hospital, Philadelphia. Acting Assistant Surgeon W. P. Moon reported: "This man was wounded by a conoidal ball, which entered at the outer edge of the insertion of the deltoid muscle, four inches below the articulation of the shoulder, and, passing obliquely inward and backward, made its exit on the inner surface of the arm, causing a compound comminuted fracture of the left humerus. The wound suppurated freely for several days, and was quite healthy. On July 1st, I con- cluded to perform excision of the shoulder joint. I made an incision, six inches in extent, from below the acromion to the external wound, and thence toward the internal border of the deltoid, and removed two inches of the humerus with the head of the bone. The wound was partially closed with silver sutures and adhesive plaster. Chloroform was used, and there was prompt reaction. The after treatment consisted of dry dressings, liberal diet, stimulants, and tonics. July 4th, pus burrowing into the axilla; compress and bandage applied. Patient had some diarrhoea, which was controlled by injections of opium. The discharge of pus was immense and continued for ten days. Jtily 13th, the patient was unable to retain nutriment or stimulants. He died on July 14th, from exhaustion, the result of excessive discharge. No post-mortem." The specimen (FlG. 435) was contributed to the Museum by Dr. Moon, and consists of the "head and two and a half inches of the shaft of the left humerus, excised for an oblique fracture with comminution through the surgical neck. The margins <>f the fracture are necrosed, and a very thin deposit of callus on the shaft litis occurred."— Cat. Surg. Sect., 1866, p. 107. Fn;. 464.—Head and upper portion of shaft of the left humerus excised for shot in- jury. Spec. 3289. Flu. 465.—Head and portion of shaft of left humerus excised for shot injury. Spec. 3624. SECT. III. EXCISIONS AT THE SHOULDER. 589 Fig. 466.—Head and one and a half inches of shaft of right humerus excised for shot injury. Spec. 2363. Flfi. 467.—Upper ex- tremity of right hu- merus excised for shot injury. Spec. 3033. There is frequent occasion to observe that shot penetrations of the shoulder, with lodge- ment of tho missile, are far more dangerous than shot perforations: Case 1573.—Private D. B. W----, Co. V, 1st Maine Heavy Artillery, aged 33 years, was wounded at North Anna River, May 1(», 1864. He was sent to Washington, and admitted into Armory Square Hos- pital on May 23d. Surgeon D. W. Bliss, U. S. V., reported: "Gunshot wound of the shoulder; the ball entered about the anterior part of the right shoulder joint and fractured the liumerus. On May 2V.A, the patient was anaesthetized by chloroform, and I performed the operation of resection of the shoulder joint, haemorrhage being guarded against by an assistant pressing upon the subclavian artery. At the time of operation his constitutional condition was favorable. The after treatment consisted of simple dressings and tonics. He died June 8, 1861." The specimen (Fig. 466) was contributed to the Museum by the operator, and consists of "the head and one and a half inches of the shaft of the right humerus excised. A conoidal ball lodged behind the greater tuberosity and split off the laminated structure over a triangular surface of which each side is one and a half inches."—Cat. Surg. Sect, 1866, p. 104. The next and last of the seven detailed cases of unsuccessful intermediary excisions resulted fatally, from secondary haemorrhage from the right axillary artery: Case 1574.—Private J. II----, Co. H, 1st Michigan Sharpshooters, aged 17 years, was wounded at Petersburg, June 17, 1864. Surgeon P. A. O'Connell, U. S. V., reported the patient's admission into a Ninth Corps hospital. Simple dressings were applied. On June 21st, he was transferred to Washington and admitted into Harewood Hospital. Surgeon R. B. Bontecou, IT. S. V., reported: "Gunshot wound of right shoulder, the ball passing transversely from the outer to the inner surface, fracturing the head of the liumerus. The parts were considerably swollen and discharging freely, and the patient was somewhat debilitated. June 25th, sulphuric ether was administered, and the head of the humerus was removed. The patient did very- well, the wound healing finely, and the general health continuing good, until July 23, 1834, when ha?mor- rhage occurred from the axillary artery to the amount of ten ounces. The artery was ligated, but the patient sank, and died from exhaustion on July 24, 1834. The treatment was supporting throughout." The speci- men, represented by the wood-cut (Fig. 467), was contributed to the Museum by Dr. Bontecou. It consists of "the head and one and a half inches of the shaft of the right humerus excised. A battered conoidal ball is lodged in the anatomical neck within the bicipital groove. A vertical fracture divides the anterior third ofthe head."—Cat. Surg. Sect, p. 104. Secondary Excisions of the Upper Extremity of the Humerus for Shot Injury.— To this subdivision fifty cases are referred, of which twelve were fatal, a fatality of 24 per cent., a more favorable exhibit than is presented by the secondary decapitations of the humerus. § Successful Operations.—Thirty-eight patients of this, class survived. Of the eight detailed abstracts that will be introduced, the first and third are remarkable because of the alleged reproduction, to some extent, of the excised portions of the diaphyses: Case 1575.—Private D. C. Lewis, Co. E, llth Massachusetts, aged 21 years, was wounded at Bull Run, July 21,1861, taken prisoner, and sent to Richmond, thence to Fort Monroe, where he was admitted into Hygeia Hospital on January 17, 1862. Surgeon R. B. Bontecou, U. S. V., noted: "Patient was suffering from gunshot wound of the left shoulder, the ball passing through the head of the humerus. Several fistulous openings communicated with the joint, scapula, and clavicle, and the whole shoulder was much swollen and indurated, the arm and forearm were much emaciated, and the general health broken down. In the latter part of January, or early in February, his health was so much improved by liberal diet that an operation was deemed advisable; and the head with about three inches of the shaft was resected. The V-shaped incision was employed on account of tbe situation of the fistules. I found great vascularity, and a cheesy condition of the parts, rendering it difficult to secure the vessels; there was also considerable difficulty experienced in removing the large irregular mass of bone in which the dead head, in three pieces, was enclosed. Gangrene attacked the wound, nearly proving fatal. In March, 1862, the patient became able to travel, and was transferred to his home in Boston. A new shaft had, at that time, supplied the place of the part removed, and some motion ofthe shoulder joint, with good condition ofthe limb, promised a favorable result." Dr. Bontecou transmitted a photograph of tlie patient when convalescent, from which the annexed wood-cut (Fig. 468) is taken (Card. Phot. Surg. Sec, A. M. M., Vol. Ill, p. 9). This soldier was discharged October 23, 1862, and pensioned. Examiner G. S. Jones, of Boston, reported, August 10, 1863: "Anchylosis has taken place between the end of the humerus and the glenoid cavity of the scapula. The power and usefulness of the arm is impaired; disability is three-fourths." Mr. Lewis is now living in Nicaragua, Central America; his disability is reported to continue the same as formerly. His pension was paid March 4, 1S74. Fig. 468.—Cicatrix after a secondary ex- cision of the head of the humerus for shot fracture. 590 INJURIES OF THE UPPER EXTREMITIES. (CiiAi'.ix. The various results attending recovery after secondary excisions are well exemplified in the three following cases: Case 1576—Private M. Kelly, Co. A, 16th Infantry, aged 46 years, was wounded at the battle of Stone River, December 31, 1S,)2. Surgeon G. D. Beebe, U. S V., reported, from a Fourteenth Corps hospital, "a shot wound of the left shoulder." The patient was sent to Nashville and entered Hospital 14, January 6, ISC:?. Surgeon F. Seymour, U. S. V , reported that a minie ball passed through the surgical neck of the left humerus, causing extensive comminution. After a general sustaining treatment, with simple dressings, the patient was in a condition to undergo an operation, and, on March 7, 1883, an operation for excision was performed. The head and neck, with fragments of the shaft, constituting about six and a half inches of the upper extremity of the left humerus, were removed through a V-shaped incision, severing the deltoid muscle. After the operation the patient progressed uninterruptedly to convalescence, and was discharged April 29, 1863, and pensioned. Surgeon J. H. Phillips, U. S V., in charge of Nashville No. 14 Hospital, and Examiners J. Phillips and J. O. Stanton, of Washington, also reported the case substantially as above, Dr. Stanton adding, September 1G, 1873. that " there is some atrophy ofthe muscles of the injured arm and of the forearm and hand. He cannot raise the arm." In September, 1835, Kelly was supplied with an apparatus by Dr. E. D. Hudson. He complained of this as "heavy and oppressive " This pensioner has long been employed as a doorkeeper at the Treasury Department at Washington. According to the observation ofthe editor of this work, he scarcely gave a fair trial to the ingenious apparatus designed by Dr. Hudson. The appearance of the cicatrix in this case is shown in FlG. 1 of Plate XIII, opposite page 520, copied from a photograph furnished by Dr. Hudson. Case 1577.—Private J. H. K------, Co. B, 71st Pennsylvania, aged 21 years, was wounded at Gettysburg, July 3, 1863, and was treated in a field hospital until the 25th, when he was admitted into Camp Letterman. Surgeon Henry Janes, U. S. V., noted: " Wounded by a minie' ball, which passed through the middle third of the left arm, causing compound commi- nuted fracture of the humerus. Resection was performed on July 6th. Anterior and posterior splints and water dressings applied. August 21st, the patient was steadily improving, and he was transferred, convalescent, September 3d." On September 5th he was admitted into Satterlee Hospital, Philadelphia. Acting Assistant Surgeon T. G. Morton made the following special report of the case: " Kavanaugh was wounded by a piece of shell, which struck him on the outer edge of the deltoid and passed through the arm, splintering the bone, and was removed from the inside of the arm in close proximity to the axillary artery. A great many fragments of bone were removed at the corps hospital; some pieces were at least an inch in length. After his admission into this hospital the wound continued open. Necrosed bone was discharged and large portions were readily felt; the finger, passed in, could distinguish a cavity which seemed to be at or near the head of the bone. The wound was painful and the patient's constitution seemed to suffer. October 19th : The outer opening ofthe wound has an ugly appearance; it is about one inch in diameter and unhealthy in character; the finger can be passed up to the bone, which feels soft and rugged The patient suffers great pain, especially at night, so much so as to wear upon his general health, which, for some time past, has been failing. There is daily fever, night-sweats, and loss of appetite. October 21st, condition not improving, I concluded to remove the cause of irritation, and accordingly made an incision down upon the diseased bone, through the external wound. The head of the bone was found to be very soft and the cartilage abraded; the shaft also was much diseased. The incision was extended, and I removed the head of the bone, with the old fractured portion, about three and one-half inches in length, which had not united and was in an unhealthy state. The only vessel requiring ligature was the circumflex artery, which bled profusely. The parts were Fig.46"q.—Head and carefully washed out, the wound brought together by silver sutures, and cold-water dressings applied. part ot shaft of left yrom the time of the operation all pain left him, and he improved rapidly in general health, and had not an humerus excised lor r . r r J ° necrosis consequent unfavorable symptom. The head ofthe bone was in a broken-down condition and filled with pus. On tlie utto!01!?10*1116 Sl'eC' s^enth day after the operation the patient was dressed and was out of hi3 bed, and, on the tenth day, was walking about; at the end of six weeks the wound had entirely closed. The size of the arm has increased since the operation, being now, February 1, 1884, nearly as large as the other; he has good use of it, and can perform light d uty.v The specimen (Fig. 469), contributed by the operator, consists of the head and two inches of the shaft of the left humerus. It shows the diaphysis much necrosed and the lesser tuberosity fractured. A moderate degree of callus has been thrown out on the lower extremity. This soldier remained under treatment until April 11, 1834, when he was discharged and pensioned. Surgeon 1.1. Hayes, U. S. V., certified : " Total loss of use of the left arm, from resection of the shoulder joint for gunshot wound." Examiner F. F. Burmeister, of Philadelphia, reported, December 6, 1868: "A piece of shell having struck the left humerus near the head, caused the loss of about two inches aud a half of the bone, resection having been performed, with the entire loss ofthe use ofthe whole arm The applicant will never have use ofthe limb. The disability is permanent." This pensioner was paid December 4. 1-73. Cask 1178 —Sergeant Julius Sachse, Co. K. 2d Missouri, aged 24 years, was wounded at Chickamauga, September 19, 1S53, and on the 25th was admitted from a Twentieth Corps hospital to No. 1, Nashville The following report of the case was forwarded, with the specimen, by the operator, Assistant Surgeon Charles J. Kipp, U. S. V.. through Surgeon C. W. Hornor, C S. V.: "The ball entered at the posterior aspect of the right shoulder joint and made its exit anteriorly, about an inch and a half below the coracoid process, fracturing the head of the humerus and opening the joint. At the time of admission the shoulder was immensely swollen and very painful; the constitutional disturbance was comparatively slight. Ice was applied to the shoulder, and the intensity of the inflammation soon subsided. As statistics show that secondary excisions of this joint are followed by more favorable results than primary operations, it was decided to postpone exsection, and, in the meantime, to treat the wound with ice-water dressings, and to inject a weak solution of permanganate stilts into the joint thrice daily. Under this treatment the patient did well. On November 9th, I excised the head of the humerus and two inches of the shaft, making an iryiision four inches in length on the anterior tispect of the arm, using chloroform as an anaesthetic. The head of the humerus SECT. III.] EXCISIONS AT THE SHOULDER. 591 was found very much comminuted, with loose pieces of bone in the glenoid cavity. Reaction was prompt. The inflammation following the operation was severe, but soon yielded to ice applications. The discliarge from the wound was profuse and very foetid; the patient's general health was moderately good. Injection of a weak solution of permanganate salts in the wound, cold-water dressings to the shoulder, and tho administration of nutritious diet and stimulants constituted the treatment. About December 8th. the patient had a severe rigor followed by high febrile reaction; the entire shoulder and arm became tumefied, hot, and painful; this continued for about a week, when the inflammation subsided. January 15th: Wound has now closed and the patient can move his arm without suffering much pain ; he has considerable lateral motion, and can adduct his elbow about five inches from his body; there is but little deformity. The shoulder has the appearance of being luxated backward, and the shortening of the whole arm is about one inch and a half compared to its fellow." The specimen (FlG. 470) consists of a portion of the head and one inch of the shaft of the humerus. A segment one and a half inches in diameter remains of the head. The inner half of the shaft opposite the tuberosities has been absorbed. The patient was transferred to Louisville, May 5, 1881, and was admitted to Clay Hospital; he was sent to Jeffersonville on May Sth, and from there to No. 1, Madison, and was discharged July 8, 1884, and pensioned. Examiner J. B. Colgrovo; of St. Louis, July 18, 1864, reported: "Gunshot wound of right shoulder; ball fractured the humerus; bone badly shattered; joint destroyed; total loss of use of arm. This man's pension was increased from May 10, 1878, and he died August 9, 1873." The cause of death is unknown. Fig. 470.—Excised head of humerus. Spec. 2180. Table XXXV. Summary of Thirty-Eight Gases of Recovery after Secondary Excision of the Head and Portion of the Shaft of th.—Lieutenant Michael Dolan (retired), while 1st Sergeant of Co. E, 2d Infantry, and 25 years of age, was wounded at the battle of Fredericksburg, December 13, ISM. lie was carried to the hospital of the 2d division of the Fifth Corps, whence Assistant Surgeon W. R. Ramsey, U. S. A., reported that "a musket ball penetrated the left shoulder; simple cold-water dressings were applied, and the patient was sent to a base hospital." On December lGth, the patient entered Hammond Hospital, at Point Lookout, under the care of Acting Assistant Surgeon John Steams, jr., who trans- mitted the following report, and published a duplicate of it.1 "A minie ball entered left shoulder just inside acromial process of scapula and lodged just below the head of the humerus, splitting off about an inch of that bone at this place. Patient was much prostrated, and confined to bed long after entrance to hospital. When placed under ether for examination, the motion of joint was so good that it was pronounced uninjured. A second examination proved the extent of injury, but his condition did not warrant an operation until March 6, 1833, when the joint was exposed by flap-incision and about two inches of the humerus was removed, with the head. In a week after he was about as usual, and iu four weeks from time of operation the wound had healed, the patient progressing most favorably. An opening was made on the inner and posterior aspect ofthe arm to facilitate the escape of pus, which was slight and of perfectly healthy character. April 5th, everything progressing favorably." This operation was performed by Acting Assistant Surgeon John Stearns, jr., who contributed the specimen (FlG. 471) to the Museum. The catalogue of 1866, page 103, erroneously accredits the donation to Assistant Surgeon C. Wagner, U. S. A., who was in charge of the hospital. In February, 1863, Mr. Dolan was appointed "2(1 lieutenant of the 2d Infantry. July 23, 1853, he was transferred to the Annapolis General Hospital. Surgeon B. A. Vanderkeift, U. S. V., reports that he resumed duty August 11, 1833. He was promoted to a first lieutenancy January 31, 1803, and retired, "for incapacity resulting from wounds received in the line of duty," December 15, 1870. In January, 1838, Mr. Dolan visited the Museum and permitted a photograph of the injured shoulder to be made. The picture is numbered 192 of the Surgical Serv s of Photographs, Vol. IV, p. 42. A reduced copy of it is presented by Figure 472. At this date, the lieutenant had a very useful arm. Cast. 1580.—Private Freeman S------, Co. I, 37th Xew York, aged 21 years, was wounded in the right shoulder in one of the battles before Richmond, June 30, 1832, and the ball was excised on the field. He was captured and incarcerated for three weeks, and then exchanged and sent to the Fourth and George Streets Hospital, Philadelphia. He was treated by Professor S. D. Gross, who forwarded the specimen from the case, represented in the adjoining wood-cut (FlG. 473), with the following report: " The patient, a stout, muscular man, received a gunshot wound of the right arm and shoulder. A round ball entered the back behind the vertebral border of the scapula, passed beneath the scapula, through the neck of the humerus, aud emerged in front of the arm, four inches and a half below the head of the humerus. He was greatly debilitated when he arrived at our hospital on the 27th of July. On the 1st of August, I exsected the head of the humerus along with nearly four inches of the shaft of the bone, which was completely comminuted, some ofthe splinters being driven in among the muscles. The greater portion of the shaft adherent to the head was necrosed at the time of the operation. In this case I made a single perpendicular incision, which was afterward united by metallic sutures. A considerable portion of the wound healed by the first intention, but there was a great deal of discharge for several weeks from the lower angle. Not a really untoward symptom occurred, and Snow was discharged from the hospital, October 20, 1832, in excellent health and flesh. The parts were perfectly cicatrized, and lie had a very good use of the limb. A large amount of callus was thrown out from the extremity of the humerus." The specimen consists of the head and outer portion of the shaft of the right liumerus, three and a half inches in length, excised two months after the injury. The articular surface was not involved, but the ° ' •> J r 10. 4/J.—Excised surgical neck was comminuted by a round ball. The specimen shows only the head and the la'rge fragments head and part of the attached. (See Surgical Series of Photographs, Vol. Ill, p. 24.) On October 25,1832. Snow was discharged the service and pensioned. Examiner Nelson Peck, of Lyons, New York, reported, in 1333, that the upper arm was useless, but that "he had some use of the forearm and hand." The pensioner went to reside in Cambridge, Massachusetts, and his pension was successively increased, on January 6, 1836, and August 5, 1372, from $3 to §15, and then to 813 per month. He was paid on March 4, 1874. 1 STEARNS (J., jr.), A few Cases of Excision of the Elbow and Shoulder Joints, in Boston Med. and Surg. Jour., 1863, Vol. LXVIII, p. 252. 75 shaft of right hume- rus. Spec. 387. 59-1 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. Fio. 474.—Cicatrices six years after an ex- cision of the upper part cf the humerus, fol- lowed by necrosis of the shaft. [From a M useu m photograph. ] The two following cases are remarkable for the extent of consecutive removal of necrosed or carious portions of the shaft, with retention of the functions of the forearm. They may be compared, in regard to this feature, with the case of Cleghorn, described on page 568, where necrosis of the diaphysis and condyles followed a primary excision: Case 1581.—Private J. P. Kegerreis, Co. B, 2d Pennsylvania Heavy Artillery, aged 19 years, was wounded at Petersburg, June 17, 13G4, and was treated in the hospital of the Ninth Corps, at City Point, until July 3d, when he was transferred to the 1st Division hospital at Alexandria. Surgeon Edwin Bentley, U. S. V., recorded: " Shot through right shoulder, tlie ball entering in front ofthe clavicle two inches from the acromial end, passing through the surgical neck ofthe humerus, and out near the centre of the deltoid muscle. November 19th: Excision of the upper part of the humerus, under chloroform, by a perpendicular incision from the acromion, through the deltoid, five inches in length, exposing the shaft of the bone, and sawing through the latter with a chain saw, and then disarticulating the head of the bone; length of bone removed, four and a half inches; long head of biceps not divided. He recovered slowly. At the time of operation, there was anchylosis of the shoulder, with slight swelling laterally, and much swelling in front; pus was discharging freely through the openings made by the ball, and at an incision in the anterior surface. The patient's condition was not very good; his constitution had evidently suffered from the excessive dis- charge from the wound; tongue coated; pulse 70; appetite poor. November 21st: Slight chill in the morning; pulse 120; beef tea. November 23d: Chill at 5 a. m.; pulse 128; at 1 p. m., another chill; pulse 130. Five grains of sulphate of quinia wrere given every eight hours, and milk punch. November 24th: Pulse 116; milk punch, beef tea, chicken broth. November 23th: Locally, water dressings and poultices, when painful. Opiates have been given to relieve pain and procure sleep. There has been gradual improve- ment since last date, and now, January 1, 1S35, the patient sits up." On February 28th, this man was transferred to Sickel Barracks, and thence discharged, May 29, 1835, and pensioned. Dr. II. W. Sawtelle reported from the Pension Bureau, where the pensioner was then employed in clerical duty: "Pensioner states that, about one year after he left the service, nine fistulous openings discharged ; the arm from elbow to shoulder becoming greatly enlarged, and his general health rapidly failing. December 17, 1837, Dr. J. L. Suesserott, of Chambersburg, removed a sequestrum of about six inches by enlarging the orifice from which it pointed, extending from the point of resection to the elbow, the patient being under the influence of nitrous oxide gas. He returned to his home, a distance of twenty miles, on the same day, no untoward symptoms occurring, and is now enjoying excellent health. The sinuses were all healed by April 1, 1838, and never reopened. The elbow joint is anchylosed in a semi- flexed position, and firm ligamentous union has taken place in the arm, so that the subject is able to lift about 135 pounds with the injured limb. Eleven well-marked cicatrices appear on the arm and side. The temperature of the limb is normal." Tho excised head, with a sequestrum of the shaft,, is represented by the wood-cut (FlG. 475); it was presented to the Museum by Dr. Sawtelle. In April, 1838, Mr. Kegerreis called at the Museum, and a picture of the injured limb was made, and numbered 289 of the Surgical Series of Photographs, Vol. VI, page 39. (See FlG. 474.) This pensioner is still (May, 1875) employed as a clerk in the Pension Bureau, using his right arm with comparatively slight inconvenience. Case 1582.—Private George P------, Co. B, 44th Illinois, aged 27 years, wounded in the arm at Chickamauga, September 19, 1833, was treated in hospitals on the field, and at Nashville, Louisville, Jeffer- sonville, Madison, and Quincy, arriving at the latter place July 27, 1834. Surgeon D. P. Brinton, U. S. V., reported that " a conical bullet had passed directly through the right humerus, at the upper third, in front. On admission, there was erythematic inflammation about the shoulder; it appears as though the bone might have been split into the joint. Simple dressings were applied to the wound, and tincture of iodine to the integuments about the shoulder; special diet given. August Gth, an opening was made from which pus flowed freely; wound still suppurating." He was discharged the service September 29, 1834, for disability on account of " gunshot wound of the right arm," and pensioned. The subsequent history of the case was furnished by C. M. Clark, late surgeon 39th Illinois, who reported: "Parce entered the Soldiers' Home Hospital, Chicago, in January, 1865, with caries ofthe upper third of the humerus, involving the head ofthe bone, with free discharge of pus from distinct sinuses on the dorsal surface of the arm. An operation for excision of the head was performed, April 7, 1835, by Dr. E. Andrews, when the head of the bone and a portion of the shaft were removed measuring three and three-quarter inches in all. The wound did not heal l7y__Carious readily, erysipelas occurring, with considerable sloughing. I first saw the case June 13, 18,37, at the time I headandgreaterpart took surgical charge of the Home. The arm was then swollen and painful, with discharge of sanious pus; moved in three sue- denuded bone could be felt when the probe was introduced, and the patient was anxious for another operation, cessive operations. sayjng that he could not survive such torture as the limb constantly gave him. He was placed on full and FIG. 475.—Excised carious upper end of right humerus, with a tubular sequestrum from shaft. Spec. 5711. J. SECT. III.| EXCISIONS AT THE SHOULDER. 595 nutritious diet, with stimulus, receiving great benefit and gaining largely in flesh and strength. On August 2, 1867, he was placed under the influence of chloroform, and two and a half inches of the bone were removed by longitudinal incision on the outer surface of the arm. The bone removed was greatly diseased and shell-like in structure; the medullary cavity was greatly increased in diameter, and its contents bleeding very freely when section was made. The space occupied by bone prior to the previous operation was filled with cartilaginous matter, with some few points of ossific deposit. The wound was dressed after the usual manner, with sutures, adhesive strips, splint and bandage, and plenty of cold water. Several of the stitches were removed on August 7th, at which time the wound was doing nicely. By September 1st, the wound had nearly healed, and the man expressed himself as feeling first rate, and was able to use the arm to some extent. On September 15th, he had a chill, with subsequent fever, and from this date the arm became painful and commenced again to discharge. The probe detected more dead bone, and another operation was decided upon, which was performed (Ktober 3, 18(57, when three inches more of the bone were removed, tbe portion removed presenting the same characteristics as the former piece. The wound healed readily, and ceased entirely to trouble him. In March, 1868, he could use the arm to some advantage, feed himself with it, and take off his hat. He left the Home in the latter part of March and went to his residence, since which time I have not heard from him." The specimen (FlG. 476) consists of the head and a portion of the shaft of the right humerus, removed in three operations, and in all eight and three- quarter inches, and was contributed by Dr. Clark, who performed the last two operations. A Board of Examiners, composed of W. C. Lyman, F. A. Emmons, and E. O. F. Roler, of Chicago, reported, September 15, 1873: " Removal of entire shaft of the right humerus, including the head of the bone and the condyles below; slight use of fingers; disability total." The pensioner was paid to March 4, 1874. § Unsuccessful Operations.—The excisions of the head with adjacent portions of the shaft reported as secondary procedures, and resulting fatally, were twelve in number: Case 1583.—Private Frederick K------, 14th Infantry, aged 31 years, was wounded at Spottsylvania, May 12, 1864, and entered Lincoln Hospital, Washington, on May 26th. Acting Assistant Surgeon A. An'sell reported: " When admitted, his wounds were healing very kindly, and he continued to do well until June 22d, when the limb began to swell, the lips of the wound having a phagedenic appearance, and he complained of severe pain in the shoulder. June 24th : He was removed to the operating room and the injury was examined under ether, when the shaft of the humerus was found to be so fearfully comminuted that resection was at once performed, by Assistant Surgeon J. C. McKee, U. S. A. The head and three and a half inches ofthe shaft were removed, and the wound was dressed with water dressings. He continued to do well until June 28th, at noon, when severe rigors supervened, accompanied by pain in the limbs, cough, and vomiting of bilious matter. His countenance became dull; he was at times delirious; the pulse was quick, small, and thready. Ordered five grains of carbonate of ammonia and fifteen grains of chlorate of potash every two hours, alternated with ten grains of sulphate of quinia in half an ounce of brandy. His respiration was hurried, at 40 a minute; he had pain in the left thorax; there was loud, small, and large crepitation in this region. The patient continued in this way, gradually failing, and expired at noon, June 30,1864." The post-mortem examination was made by Acting Assistant Surgeon H. M. Dean, who forwarded the pathological specimen (Cat. Surg. Sect, 1863, p. 109, Spec. 2719), with the following report: "Examination eight hours after death: Body not much emaciated. Had been wounded through the upper third of the arm. From the looks of the wound the ball entered two inches below the joint on the posterior surface, and was cut out immediately above the insertion of the pectoralis major muscle. Five and a half inches of the upper part of the humerus had been excised. Ligatures were still attached. The wound was in a sloughing condition, and there was no appearance of granulation. The glenoid cavity was normal. The upper extremity of the lower part of the humerus was denuded of its periosteum for one and a quarter inches." Case 1584.—Private T. T. P------, Co. A, 3d Michigan, aged 20 years, was wounded at Fair Oaks, May 31, 1832. He was sent to Christian Street, and thence to Haddington Hospitals, Philadelphia, and transferred, March 31, 1863, to Satterlee Hospital. Acting Assistant Surgeon J. H. Packard reported: "Wounded by a ball of unknown character, passing through the left humerus from before backward, about four inches below the articulation of the shoulder. Several sinuses existed both in front of the arm and behind it, leading to dead bone. The orifice of exit of the ball had entirely closed. Pending arrangements for his removal to a Michigan hospital at Detroit, I proposed to him the extraction of the dead bona from his arm, and he readily consented. Accordingly, on the 9th of April, he was placed under the influence of chloroform, and the sinuses were laid open posteriorly so as to expose the affected portion of the bone. It was now found that the whole of the upper part of the humerus was so degenerated as to forbid all hope of its again becoming of use. The posterior incision was therefore continued transversely through the deltoid, so as to form an external flap, which, being raised up, the head of the liumerus was freed from its articular connections, and the bone cut through below with bone nippers. Very little bleeding ensued, only three vessels needing ligation. Cold water was applied locally, and opium given to allay pain and promote sleep. He did very well until the night following April 16th, when he had what was considered a chill, followed by fever, with delirium and sweats. These symptoms proved the next day to have been the precursors of inflammation of the right lung. April 17th, I saw him at 6.30 P. m., and ordered six cut cups over the lower part of the right lung, beef essence and milk punch, with a febrifuge and anodyne mixture. Wound doing very well. On the 18th, Dr. Da Costa saw him, in consultation with me, and advised a mixture containing carbonate of ammonia, acetate of morphia, syrup of senega, and tincture of veratrum viride. Pulse ranging above 120; some delirium con- stantly; aggravated at night. 20th, Drs. Da Costa and Page saw him with me. His pulse was 136; tongue moist; slightly coated white. Bowels confined, abdomen excessively tympanitic, interfering with respiration, already impeded by the inflam- mation of the lung. I ordered au injection of spirits of turpentine, sixty drops in two ounces of starch water, every two hours; the brandy and milk to be given every hour. After two of the enemata, he became decidedly more comfortable, and his bowels were three times moved quite freely. All this time, the wound continued to do well. At two o'clock P. M., by order of the surgeon in charge ofthe hospital, the treatment was changed; a mixture of tincture of ergot, one ounce, and tincture of camphor, half an ounce, being prescribed, one dracbm to be given every two hours. The brandy, etc., to be continued. April 21st, 596 INJURIES OF THE UPPER EXTREMITIES. [CHAP IX. some pain toward the base of the left chost; respiration more limited; pulse 136; countenance very unfavorable; delirium con- stant; no additional distention. No change in the treatment. 22d, Drs. Stille, Da Costa, and Halsey were ordered to consult with me in regard to the case. Upon examination, we found the pneumonia to have involved the left lung as well as the right. The physical signs of effusion into the pleura? were also present. The patient's general condition was very bad; his pulse rapid and windy; his respiration impeded; his countenance anxious; his restlessness constant. The following treatment was ordered: half an ounce of brandy, with one and a half ounces of milk, every two hours at least; two ounces of beef essence every two hours; half a grain of aquaeous extract of opium every three hours; the anterior surface of the chest to be painted with tincture of iodine. The patient, however, sank rapidly, and died the same day, at about five o'clock P. JI." The following report of the post-mortem examination was made by Professor Joseph Leidy: "No restoration of the bone existed. Diagnosis of case, pneu- monia; body large and rather fat; heart healthy; right pleural cavity contained about a quart of pus, the left about a pint of serum; right lung with comparatively recent pleurisy; the lower lobs covered with soft, yellowish, ragged pseudomembrane, and more or less adherent to the phrenic and costal pleurae. More moderate pleuritic inflammation, with thin pseudomembrane, and partial attachments of the upper and middle lobes. Pleurisy of the left lung in a large circumscribed patch on the convex surface, about the size of the hand; the patch being adherent by recent pseudomembrane to the costal pleura. Both lungs, but especially their lower lobes, were affected with lobular pneumonia. The indurated masses, about the size of hickory nuts, were cream colored and infiltrated with pus. Some of the masses had broken down into cavities filled with pus. The bronchial mucous membrane throughout was inflamed. The abdominal viscera were all healthy. The lobular pneumonia was most probably metastatic inflammations and embolical in their origin." The specimen, No. 1875 of the Surgical Section, con- tributed by the operator, consists of "the head and three and a half inches ofthe shaft ofthe left humerus excised ten and a half months after injury, for perforation by gunshot of the surgical neck, followed by necrosis of the internal structures and a decided deposit of new bone internally. The specimen shows a portion of the shaft to have been removed by a trephine, of which there is no .account in the history."—Cat. Surg. Sect., 1833, p. 109. Table XXXVI. Summary of Twelve Fatal Cases of Secondary Excisions of the Head and Portions of the Shaft of the Humerus for Shot Injury. NO Name, Agk, and Military Description. Bennett, 0. A., Sergeant, I, Ilth Virginia. Cashing, W., Pt., B., 40th New York, age 24. Kase, F. M., Pt., 14th In- fantry, nge 31. Henry, G., Sergeant, E, 35th Massachusetts. Merriman, J., Pt., E, 155th Pennsylvania, age 26. Minot. E.G., Pt., M, 1st Maine Artillery, age 25. Peterson, T. F., Pt., A, 3d Michigan, age 20. Robinson, L., Pt., E, 4th Col- ored Troops, age 29. Spitler, S., Pt., K, 49th Ohio, age 19. Stiles, L. H., Pt., G, 9th Mas- sachusetts, age 30. Sweat, J., Ft., B, 58th Illi- nois. Welch, J., Pt., C, 61st New York, age 20. Date of Injury May 16, 18*64. Mav 5, 18G4. May 12, 18G4. Sept. 17, 18C2. Mav o, 1864. June 1C. 1864. Mav 31, iao'2. Sept. 29. 1864. May 27 1864. Jan. 10, 1864. April 9, 1864. May 5, 1864. Nature of Injury. Mini§ ball grazed the head of the humerus and emerged near the spine of the scapula. Musket ball passed through the surgical neck of the right hu- merus, comminuting the head of the bone considerably. Comp'd comminuted shot frac- ture of the head and upper portion of shaft of the right humerus. Anterior portion of the surgical neck and lower portion cf both tuberosities cf right humerus carried away by shot. Shot wound of right shoulder, fracturing the scapula and in- volving the shoulder joint. Musket ball lodged in and frac- tured the head of left humerus and a part cf the shaft. Musket ball perforated the left arm from before backward, about two inches below the acromion. Shot fracture of the head cf left humerus; portion of shaft and coracoid process of scapula also fractured. Left humerus shattered below surgical neck without open- ing the joint; ball perforated left thorax. Comp'd comminuted fracture of surgical neck of the left humerus by miniG ball; same ball comminuted the lower maxilla. Shot fracture of left humerus by a mini6 ball. Conoidal ball passed through the head of the left humerus, deeply grooving it. Date of Opera- tion. June 29, 1864. June 11, 1864. June 24, 1864. Oct. 21, 1862. June 15, 1864. Aug. 10, 1864. Apr. 7, 1863. Nov. 10, 1864. July 19. 1864. Feb. 16. 1864. May 20, 1864. Aug. 27. 1864. Operation and Operator. Four inches of the humerus, including the head, removed through a vertical incision. Excision cf the head and three inches cf the shaft through a straightincision, byA. A.Surg. H. B. Knowles. Excision cf the head and three and a half inches of the shaft, by Asst. Surg. J. C. McKee, U. S. A. Excision of the head and one- half inch of the shaft, by Asst. Surg. C. A. McCall, U. S. A. Excision of the head and one inch of the shaft, by Asst. Surg. XV. F. Norris, U. S. A. Excision cf the head and two inches of the shaft through incision over joint, by A. A. Surg. W. C. Flowers. The head and three and a half inches of the shaft exsected, by A. A. Surg. J. H. Packard. Excision of the head and two inches of the shaft, by A. A. Surg. O. Warner. Head and four inches of shaft resected, by A. A. Surg. II. C. May. Excision cf the head and two and a half inches cf the shaft through a V-shaped incision, by Surgeon O. A. Judson, U. S.V. Excision of the head and one inch of the shaft through a vertical incision, by Surgeon J. a. Keenon, V. S. V. Excision of the head and one inch of the shaft, by A. A. Surg. YvT. P. Moon. Result and Remarks. Died July 6, 1864. Died July 16, 1864. Did well until June 28. Rigors, vomiting, delirium. Died June 30,1864, of pysemia. Spec. 2719, A. M. M. Died November 3, 1862, of pyae- mia. Spec. 330, A. M. M.1 Died July 14, 1864; asthenia. Spec. 3559, A. M. M. Died September 17, 1864, from pyajmia. Died April 22, 1863, of pneumo- nia. Spec. 1875, A. M. M. Died November 14, 1864. Spic. 4003, A. M. M. Died July 26, 1864, of exhaus- tion. Spec. 3369, A. M. M. Died February 27, 1864; pyaB- mia. Spec. 2112, A. M. M. Died May 24,1864, of pneumonia Died Mar. 4, 1865, cf pneumonia. Spec. 3618, A. M. M. In seven of eleven cases in which the point was referred to, the operations were on the 1 COUKS (E.), Excision of Head of Humerus, in The Med. and Surg. Reporter, Philadelphia. 1862-3, Vol. TX. p. 231. sect. III.] EXCISIONS AT THE SHOULDER. 597 left side. Pyrjemic infection appears to have been the most frequent cause of death. In eight of the cases, pathological preparations of the injured bones were transmitted to the Museum. Excisions ofthe Upper Part ofthe Humerus for Shot Injury of Undetermined Date.— In nineteen of the five hundred and seventeen eases of excisions of the head with adjacent portions of the shaft of the humerus, after shot fracture, it was impracticable to ascertain the intervals between the dates of injury and of operation, either by the operators' or hospital reports, the pension examiners' reports, or by any other accessible sources of infor- mation. The recoveries, and the fatal cases, of which there were two only, will be summed up in a single tabular statement: Table XXXVII. Summary of JVineteen Cases of Excision of the Head and Portions of the Shaft of the Humerus for Shot Injury, in which the Intervals between the Injuries and Operations ivere not ascertained. Name, Ace, and Military Description. Nature of Injury. Opera- tion. Operation and Operator. Result and Remarks. Cromie, J., Captain, F, 12th New York, age 30. De Bank, XV., Ft., D, 20th Connecticut, age 31. Enbank, J. N., Sergeant, C. S. Artillery. Faunce, P. C, Pt., I, Cth Ohio Cavalry, age 20. Fleming, J. A., Ft., G, 21st Illinois. Gill, R. C., Ft., H, 13th Ala- bama, age 24. Hunter, N., Pt., C, 22d Mich- consin, age 23. Knot, F. R„ Ft., G, 7th Vir- ginia Cavalry. Qnarier, M., Sergeant Major, 22d Virginia, age 26. Ruggles, J., Pt., D, 121st Ohio, age 21. Saulsburg, J. L., Sergeant, 1). 66th Georgia, age 19. Scott, J. F., Ft., A, 21st North Carolina, age 24. Sidney. A., l't., I, 18th Mas- sachusetts, age 33. Shinn, W., Ft., K, 30th Hli- nois, age 39. Smith, T. B., Corporal, B, 93d Illinois, age 20. Taylor, G. W., Ft., B, 53d North Carolina, age 24. Taylor, J. D., Pt., I, 3d Ala- bama Cavalry, age 19. Williford, J. W., Pt., A, 43d North Carolina. June! 1862, May 3, 1863. Sept.14, 1863. May 4, 1864. Dec. 31, 1862. May 12, 1864. Sept. 19, 1863. July 21, 1861. May 15, 1864. Sept. 20, 1863. Aug. 28, 1862. Aug. 30, 1862. May 16, 1863. May 16, 18*63. Mav 30, 1864. July 3, 1864. May 23, 1864. Shot fracture of right shoulder joint. Comp'd comminuted fracture of head of the left humerus by a conoidal ball, which also wounded the lung and inter- costal artery; aneurism. Gunshot wound of the right shoulder. Shot fracture of left shoulder joint. Comminuted shot fracture of the head and neck of right humerus. Musket ball passed through the left shoulder joint. Shot fracture of right humerus; also wound of chest. Shot fracture of left shoulder, involving head of humerus. Shot fracture of the head and neck of the humerus. Shot fracture of the shoulder joint. Fracture of the head of left hu- merus by a mini§ ball. Shot fracture of upper portion of humerus. Fracture of upper portion of left humerus by a minife ball. Shot fracture of left shoulder joint. Shot fracture of right humerus. Shot fracture of upper third of left humerus. Gunshot wound of shoulder, with fracture of upper portion of humerus. Shot fracture of left humerus. Shot wound and fracture of the right arm. 1863. 1861. May 31, 1864. 1862. 1863. Upper half of the humerus re- sected, by a Confederate sur- geon, while a prisoner. Head and more than one-third of the shaft removed while a prisoner at Richmond. Excision of three inches of the upper extremity of humerus, including the head. Head and about three inches of the shaft of humerus excised. Head and a portion of the shaft, about three inches in all, re- moved, by Surg. It. G. Bogue, 19th Illinois. Head and three inches of shaft of humerus excised. Excision of the upper third of the humerus. Excision of the head and four inches of shaft, by Surgeon R. B. Bontecou, U. S. V. Excision of the head and four inches of shaft, by Surgeon C. B. Gibson, C. S. A. Excision of the head and upper part of shaft of humerus. Removal of the head and one inch of shaft of humerus. Excision of the head and five inches of shaft of humerus. Excision of the head and two inches of shaft of humerus. Excision of the head and three inches of shaft of humerus. Excision of the head and a por- tion of the shaft of humerus. Excision ofthe head and a por- tion of the shaft of humerus through a straight incision. E xcision of the head and three inches of the shaft of humerus. Excision of head and upper ex- extremity of shaft of humerus. Excision of the upper half of the humerus. Disch'd April 7,1863; pensioned. "Arm almost useless." Died August 9, 1870. Disch'd Nov. 11,1863; pensioned. Died January 30, 1864. Recovered; furloughed January 12, 1864. Disch'd Dec. 9, 1864; pensioned. Disch'd May 23,1863; pensioned. Recovered; retired Feb. 13,1865. Died October 8, 1863. Disch'd Feb. 4, 1862; pensioned. Never rallied. Died May 31,1864. Recovered; retired Dec. 3, 1864. Disch'd Oct. 28,1864; pensioned. Recovered; retired Dec. 3, 1864. Retired Feb. 18, 1865. Anchy- losis of joint. Disch'd Dec. 24,1862; pensioned. Disch'd Oct. 15,1863; pensioned. Disch'd Oct. 7, 1864; pensioned. Furloughed July 16,1864, cured. Recovered; retired Feb. 3, 1865. Retired March 14, 1865. Excisions at the Shouldek; Paets not definitely distinguished.—In thirty-nine of the eight hundred and eighty-live excisions at the shoulder for shot injury, the extent of bone removed was not precisely specified, and this and other imperfections in the reports precluded their distribution in the foregoing subdivisions. It is possible to state, however, that such dates were furnished as proved that twenty-seven of these operations were primary, and for the most part fi'eld cases. The recoveries and fatal cases will be tabulated together on the following page. 508 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. Table XXXVIII. Summary of Thirty-Xine Cases of Excisions after Shot Injury involving the Shoulder, in which the precise Portions of Pone removed have not been ascertained. NO. 1 Name, Ace, and Military Description. Date oe Injury. Nature of Injury. Date of Opera-tion. Operation and Operator. Result and Remarks. Allen, E., Ft., A, 59th New July 3, Shot wound of right shoulder.. July 3, Resection ofthe shoulder joint. Died July 15, 1863. York. 1863. 1863. o Anderson, M., Pt., E, 19th Sept. 19, Shot wound cf the left upper Sept. 19. Resection cf the shoulder joint. Died Sept. 29, 1863. Illinois. 1863. extremity. 1863. 3 Baroruft, L. S., Pt., B, 18th Ohio. Dec. 31, 1862. Shot wound of the shoulder. -.. Dec. 31, 1862. Excision..................... Died February 5, 1863. 4 Barr, H., Ft., K, 117th Xew Sept. 29, 1864. Gunshot wound.............. 1864. Excision ofthe shoulder j jint.. Died October 1, 1864, while a Vork, age 45. prisoner at Richmond. 5 Baufman, G., Pt., 1,73dOhio, Mar. 19, Shot wound of right shoulder Mar. 19, Excision at the shoulder....... Died March 28, 1865. age 32. 1865. joint. 1865. 6 Bennett, D., Pt., G, 8th Penn-sylvania Cavalry, age 34. 1864. Shot wound of the shoulder___ 1664. Resection of the shoulder joint. Died May 22, 1864, while a prisoner at Richmond. 7 Day, A., Ft., C, 23d Massa-chusetts, age 22. 1864. Shot fracture................ 1804. Resection ofthe shoulder joint. Died May 31, 1864, while in the hands cf the enemy. 8 Day, W. 11., Ft,, F, 17th Maine. July 3, 1863. Shot fracture cf right shoulder joint. 1833. Resection ofthe shoulder joint Died August 31, 1863. 9 Day, W. H., Pt., 4th New July 3, Fracture cf left shoulder joint July 3, Excision of the shoulder joint.. (?)* York Battery. 1863. by a shell fragment. 1863. 10 Douglas, E., Ft., B, 93d Illi- Nov. 25, Fracture of suoulder by a con- Nov. 25, Excision, by Surg. J. R. Mohr, Died December 20, 1863. nois. 1863. oidal ball; also wound of chest. 1863. 10th Iowa. 11 Eaton, \V., Ft., C, 4th Massa- June 14, Shot wouud through left arm June 17, Resection ofthe shoulder joint. Died June 21, 1863. chusetts. 1863. and left lung. 1G53. 12 Edel, E., Pt., M, 13th Penn-sylvania Cavalry. Oct. 12. 1863. Shot wound of the left shoulder. 1863. Resection of the left shoulder.. Died November 3, 1863. 13 Ellis, J., Pt, D., 81st Illinois May 22, 1863. Fracture of right shoulder by musket ball. May 22, 1863. Resection of shoulder......... Died June 19, 1863. 14 Fay, E., Pt., I, 5th North Carolina. July 3, 1863. Shot fracture of left shoulder joint. 1863. Resection at the shoulder...... (?) 15 Fussel, J. P., Pt., I, 9th Georgia. Aug. 30, 1862. Shot wounds involving right shoulder joint. 1862. Resection of right shoulder___ Died September 11, 1862. 16 Gray, W., Pt., D, ICth Ala-bama. Gunshot wound of the right shoulder joint. Resection of joint-............ ( ») 17 Green, C. B., Pt., A, 26th Massachusetts, age 25. 1854. Wound of left shoulder joint. . 1804. Died June 24, 1864. 18 Hains, A., Pt., D, 91st New June 14, Severe buckshot wound of left June 18, Resection of shoulder joint, by Died June 24, 1863. York. 1863. shoulder. 1863. Surgeon W. G. Provost. 159th New York. 19 James, J., Pt., D, 0th Vir-ginia. 1864. Gunshot wound of right shoul-der. 1854. Resection of the right shoulder joint. Died August 6, 2864. 20 Kelly, J., Pt., K, 18th Wis-consin. May 14, 1863. Wound of left upper extremity. May 16, 1863. Excision ofthe left shoulder.. Died May 20, 1863. 21 Lamb, J., Pt., D, 30th Ohio. June 17 Wound of left shoulder June 17, Resection of shoulder......... Died August 13, 1863. 1863. 1863. 22 Lynch, J. B., Lieutenant, G, May 3, Wound of left shoulder j jint... May 3, Resection of shoulder joint by Died June 1,1863, of haemorrhage. 58th Virginia, age 33. 1863. 1863. deltoid flap. 23 Mitchell, C. T., Ft., 19th In-diana Battery. Oct. 8, 1862. Shot wound of the shoulder___ Oct. 8, 1852. Resection of the shoulder joint. DiedOct. 15,1862, of haemorrhage. 24 Narigan, J., Pt,, E, 80th Ohio, Nov. 25, Shot wound of the chest, in- ilov. 25, Excision of the shoulder joint, Discharged September 24, 1864; age 22. 1863. volving the shoulder joint. 1863. by Surgeon E. J. Buck, 18th pensioned. Wisconsin. 25 Pitt, L. N., Lieutenant, B, 2d North Carolina. 1863. Gunshot wound of left shoulder. 1863. Excision of the shoulder joint.. Transferred to general hospital, November 2, 1863. 26 Ream, B., Lieutenant, C, 7th Nov. 7, Wound of right shoulder joint; Nov. 7, Excision ofthe shoulder joint.. Died November 21, 1861. Iowa. 1861. also wound through lung. 1861. 27 Riley, V., Pt., C, 90th New June 14, Gunshot wound of the right June 14, Resection of the shoulder joint. Died June 24, 1863. York. 1863. shoulder. 1863. 28 Ritchie, P., Corporal, K, 99th Oct. 28. Shot fracture of left shoulder; Nov. 13, Shoulder joint excised; thirty Disch'd July 1,1865; pensioned. Pennsylvania. 1864. ball lodged in the dorsum of scapula. Wound of right shoulder joint. 1864. pieces of bone removed. 29 Scoggins, J. B., Pt., K, 56th Resection ofthe shoulder joint. (?) Georgia. 30 Simmons, W. T, Pt., B, Pal- Oct. 7, Shot wound of right shoulder Oct. 8, Resection of the right shoulder Furloughed November 1, 1864. metto Sharpshooters, age 22. 1864. joint. 1864. joint. 31 Stansil, I., .Sergeant, U, 8th South Carolina. July 3, 1863. Gunshot wound of left shoulder. July 3, 1863. Resection ofthe shoulder joint. Died July 18, 1863. 32 Thoman, M. A., Lieut. Col., July 2, Wound of right shoulder...... July 2, Resection ofthe shoulder joint, Died July 11, 1863. 59th Xew Vork, age 33. 1863. 1863. by Surg. N. Hayward, 20th Massachusetts. 33 Wagner, J., Pt.. G, 93d Illi- Nov. 25, Shot fracture of right shoulder. Nov. 25, Excision of the shoulder joint, Died November 29, 1863. nois. 1863. 1863. by Surgeon E. J. Buck, 18th Wisconsin. 34 Watson, W., Pt.,F, 5thSouth Oct, 29, Shot fracture of humerus and Oct. 29, Resection ofthe shoulder joint, Died January 9, 1864. Carolina. 1863. scapula. 1863. by Surgeon A. K. Fifield, 29th Ohio. Resection ofthe shoulder joint, 35 White, W. P., Pt., A, 36th Nov. 25, Gunshot wound of left shoulder. Nov. 25, (?) Alabama. 1863. 1863. by Surgeon A. T. Hudson, 26th Iowa. 36 Winnacht, A., Pt., D, 32d Jan.'l, Gunshot wound of left shoulder Jan. 1, Resection of left shoulder joint. Died February 24, 18C3. Indiana. 1863. joint. 1863. 37 Winningham, J. W., Cor-poral, Hart's Battery. Wound of left shoulder joint Excision of the left shoulder... ( ?) 38 Wright, W.. Pt., G, 184th June 22, Shot fracture of left shoulder June 22, Excision ofthe joint on the field, Died July 10, 1864. Pennsylvania. 1864. joint. 1864. by Surgeon G. Chaddock, 7th Michigan. 39 Wykert, E., Pt., B, 18th Ohio. Dec. 31, 1862. Wound of shoulder........... 1863. Resection ofthe shoulder joint. Died March 28, 1863. : The interrogation marks denote those cases in which the ulterior results were not learned. SECT. III.] EXCISIONS AT THE SHOULDER. 599 There were three recoveries after primary operations, and twenty-two fatal results; in two primary cases the terminations are unknown. There were seven cases with fatal results, and five with undetermined results, among the operations of unknown date. Concluding Observations on Exoislons at the Shoulder after Shot Injury.— The opinions regarding this operation expressed in the preliminary surgical report,1 derived from the results of five hundred and eight determined cases, require some serious corrections, and other very slight modifications, since the additions made to the statistical data, and the more exhaustive analysis the entire material has undergone. The following consolidation will facilitate a review of the subject: Tahlb XXXIX. General Numerical Summary of the Fight Hundred and Eighty-five Excisions at the Shoulder, after Shot Injury, enumerated in the Seventeen preceding Tables. Parts of Shoulder Joint Excised. Primary. Intermediary. Secondary. Undetermined. Totals. >> > o « o V to 1 20 3 175 293 27 > o 0) « 5 3 21 91 6 11 3 55 155 8 6 13 38 * o S J5 "3 "o 10 6 26 50 1 1 12 17 3 -g *a o a 31 13 165 359 3 571 *C3 10 1 107 158 29 305 1 1 7 9 to to to < 42 14 273 517 39 885 Head, or Head and Shaft, with portions of either Scapula or Clavicle, or of both. 17 3 119 213 3 O 1 0 1 4 2 7 14 56 80 22 2 34 64 13 12 I 1 17 5 6 19 12 51 E xcisions of Shoulder joint; bones not stated........ 120 104 224 65 27 92 31 355 160 3 518 In eight hundred and seventy-six cases the results as to fatality are known; in eight hundred and thirty-one of them, the stages at which the operation succeeded the injury are also determined. In three instances, the period of operation was stated, but not the final result; and, in six, both factors were wanting. The ratio of mortality in five hundred and fifteen primary excisions,2 in which the results were ascertained, was 31.06 per cent., or more than 7 per cent, higher than indicated by the preliminary report. The terminations of each of the two hundred and twenty-four intermediary3 operations were traced, and the death-rate amounted to 46.4 per cent., a sufficiently significant indication of the hazard attending operative interference during the inflammatory stage. The results of ninety-two 1 Circular 6, S. G. 0., 1865, p. 55. In this report, 575 excisions at the shoulder were reported, 252 primary, and 323 consecutive. The results, how- ever, of 42 of the former, and of 25 of the latter, were undetermined; and the mortality rates of 23.8 for primary, and of 38.5 for consecutive, operations was deduced from 210 primary and 298 consecutive excisions, or 508 operations with ascertained results. Further investigation has disclosed that a large proportion of the 67 then undetermined cases eventually had a fatal result. The ratios of mortality now given may be regarded as near approximations to precise truth, inasmuch as the results as regards recovery or fatality are known in all save 9 of the 885 operations. 2 There were 518 cases in the five groups into which the operations of this order were subdivided; the result was not ascertained in 3 instances. See Tables XXI to XXV inclusive, and Tables XXXI and XXXII. In the five groups, the fatality was distributed as follows: In the true excisions at the shoulder, in which portions of the scapula or clavicle were removed with the upper extremity of the humerus, there were but 2 deaths in 19 operations, or 10.5 per cent.; the partial primary excisions of the head were successful. Of 175 decapitations, 56 were fatal, or 33 per cent.; in 293 primary excisions of the head and portions of the shaft, the mortality rate was 27.3; in 25 primary cases in which the extent of exsected bone was not specified, the fatality reached the formidable ratio of 88 per cent. 3 A slight deviation was made, in tabulating the excisions, from the practice heretofore pursued by the editor in former publications in regard to the classification of amputations. Excisions practised on the day of injury, on the next, day, and also on the third day. were rated as primary, whereas primary amputations were limited to these done within 48 hours from the reception of the injury. The distinction was made because the stage of reaction appeared to be longer delayed in the cases selected for excision than in the graver instances of injury demanding the ablation of the limb. In the four subor- dinate groups of intermediary operations the mortality rates were: For 11 shoulder joint incisions, 54.5; three partial excisions of the head without fatality; 55 decapitations, 61.8; for 155 excisions of head and portions of shaft, 41.3 per cent. These cases were likewise subdivided into four groups. The excisions of head with portions of clavicle or scapula had a mortality of 20; all 6 of the partial excisions were successful; 26 decapitations gave a fatality of 50; in 50 secondary operations of unknown extent, the ratio of mortality was 24 per cent. 600 INJURIES OF THE UPPER EXTREMITIES. (CHAP. IX. secondary operations were also determined in every instance, and furnished a ratio of mortality of 29.3. Uniting the two groups of cases of consecutive operations, the mortality- rate was 41.4, instead of 38.5, per cent, as computed in Circular 6, from a series of cases numerically inferior to the present by almost one-third, and comprising nearly 12 per cent. of cases with unknown results. Of fifty-one excisions after shot fracture at the shoulder, enumerated in the foregoing table, some of the essential dates could not be ascertained,1 although the final results were verified in forty-five cases, the latter series giving a ratio of mortality of 31.1 per cent. Grouping the eight hundred and seventy-six excisions in which the results as to fatality were established,—for this point was determined in all save nine of the eight hun- dred and eighty-five operations,—the aggregate mortality was three hundred and five, or 34.8 per cent.2 in the eight hundred and seventy-six determined cases. Even assuming that these nine cases all terminated fatally, the general numerical result would be but very slightly modified. A more exhaustive analysis of these cases would be instructive, and, indeed, impera- tive, could it be accomplished without excluding the consideration of other kindred topics of equal importance. It would be interesting to inquire, for example, into the causes of a greater mortality after primary decapitations of the humerus after shot injury, than in excisions involving portions of the shaft as well as the head of the bone; and many similar questions might be profitably examined if there was space for their discussion. It cannot be denied that the foregoing statistics give a very extended view of the merits of the operation of excision at the shoulder after shot injury, as compared with expectant treatment and with ablation at the joint, yet they do not comprise all the information on the subject that has been accumulated. In addition to the foregoing examples which occurred either to Union soldiers or to Confederate soldiers treated in Union hospitals, the editor has been enabled to consult the record of a large number of Confederate cases, compiled by Dr. Howell L. Thomas, of Richmond, who, with great kindness, has contributed the register containing these obser- vations to the archives of the Office of the Surgeon-General of the Army, at Washington. Access to many of the larger military hospitals of the Confederacy, and to the files of the Surgeon-General's Office, at Richmond, afforded Dr. Thomas unusual facilities for accumulating these data, yet he regretfully records, as quoted in a preceding volume of this work (Part I, Vol. 2, page 456, Note 2), the manifold imperfections of the reports, and meagreness of the record.3 It is impracticable, from the facts detailed in these returns, to segregate, to any large extent, the primary and consecutive operations; and, in nearly half of the cases, the results are left to conjecture. Under these circumstances, it has been deemed inexpedient to attempt to group this series with those derived mainly from the reports of the Union surgeons. The total number of cases of excisions at the shoulder for shot fracture, recorded by Dr. Thomas, is two hundred and seventy-four; but seventy-three of these refer to cases treated at Union hospitals, and have been included in the preceding 1 In mest of these cases the dates either of the injury or of the operation were specified, one or the other being omitted, thus rendering it imprac- ticable to determine the interval between the two. The single operation in this category involving the scapula was successful; 1 of the 2 partial excisions was fatal; 16 determined decapitations had a death-rate of 25 per cent.; 19 excisions of the upper extremity of the humerus had a mortality-rate of 10.5; the 7 determined cases in which the parts of bone removed were unspecified, all proved fatal. 3 The mortality was distributed, in the five subdivisions, as follows: Excisions of head or head and shaft, with parts of clavicle or scapula, 40 deter- mined cases, death-rate 24.3; in 14 partial excisions there was but 1 fatal case, or 7.14 per cent.; 272 decapitations gave a death-rate of 39.33; 517 excisions of head with upper part of shaft had a death-rate of 30.56; and 32 excisions of unspecified parts of the shoulder joint had a mortality cf 90.6 per cent. 9 "Brevity is a very commendable feature in clinical reports," says Dr. THOMAS; but conciseness must not be insisted on at the expense of com- pleteness, else the cases may be robbed of all interest and the greater part of their value. SECT. III.] EXCISIONS AT THE SHOULDER. 601 tabular statements.1 There remain two hundred and one cases, of which the results have been definitely traced in seventy-five, a group including forty-three fatal cases and thirty- two recoveries. Twenty-three cases are returned as "furloughed," and probably a large proportion of these eventually survived, although some very grave cases were allowed to leave the hospitals for treatment at home. In one hundred and three cases, no satisfactory account of the results of the operations is afforded; hence it is not feasible to estimate the ratio of mortality in this interesting series. It is unnecessary to recapitulate the seventy-three instances already tabulated; they presented a very favorable percentage of recoveries. Of the remainder, a descriptive tabular statement is appended: Table XL. Summary of Two Hundred and One Gases of Excision at the Shoulder, after Shot Injury, practised in the Confederate Army. Name, Age, and Military Description. Ahrens, H., Pt., I, 1st Ar- kansas, age 35. Alfxinder, M. Ii., Ft., A, 5th Tennessee, age 25. Allen, A. A., Pt., D, 8th Georgia. A lien, R.D., Pt., C, Ashcraft's command. Alli.-on, C. E. L., Lieut., A, 6th Florida. Ander-on, A. C, Sergt., G, 7th Texas, age 26. Antry, D , Pt., I, 51st North Carolina, age 110. AppUbtrry. F, Pt,, C, 51st Tennessee. Arrington, J. W., Pt., I, 12th North Carolina, age 20. Asbell.W., Pt., C, 1st Del- aware. Beam, B. if., Pt., H, 33d Virginia, age 19. Bean, T. J., Lieut., K, 16th Mississippi. Beardin. W. P., Pt., C, 44th Georgia, age 23. Bell, E., Pt., H, 21st North Carolina, age 37. Belter, S. H., Pt., G, Sth Texas, age 30. Biackwell, G., Pt., C, 57th North Carolina, age 25. lilevins, S., Pt., G, 30th North Carolina, age 17. Bostick, J L., Lieut., 19th Arkansas, age 35. Bowlin, S. C., Pt., Corbett's Battery, age 29. Boyd, J. B., Lieut., E, 9th Tennessee, age 27. Brandon, C. C, Pt., K, 13th Mississippi. Brantley, J. M., Pt., A, 48th North Carolina, age 22. Breeden, J.H, I, 59th Vir- ginia, age 18. Brown, J. R., Sergt., Wyatt's Artillerv, at fracture of the head of left liumerus. Head of right humerus and por- tion of glenoid cavity. Head cf the right humerus, by minie ball. Wound of shoulder joint....... Ball split head of right humerus and chipped off portion of the glenoid cavity. Comminuted fracture of the left shoulder joint within capsule. Fracture of head of the left hu- merus ; ball penetrated chest. Wound of left shoulder joint, followed by anchylosis. Head of humerus fractured___ Fracture of head of the right humerus. Head of right humerus frac- tured; joint involved. Shot fracture of upper portion of right humerus. Shot fracture of humerus, in- volving head of bone. Musket ball chipped off head of right humerus and articular facet of scapula and lodged in joint. Shot fracture of head and two inches of right humerus. Shot wound of head of right humerus. Ball passed thro' shoulder joint, fracturing head of humerus. Fracture of right humerus at anatomical neck, extending into joint, by grapeshot. Shot fracture of upper portion of left humerus. Shot fracture of head of the humerus. Wound through right shoulder joint; fracture of head of bone. Fracture of head of humerus.. Head and shaft of the right humerus fractured; erysipelas and diarrhoea. Head of right humerus pene- trated. Head of the humerus fractured; flesh wound of elbow. Head and shaft of the humerus fractured. Head of humerus fractured___ Left humerus fractured........ Fracture of head and anatomi- cal neck of left humerus. Wound of right shoulder joint. Right humerus fractured at the neck. Upper third of the left humerus fractured. Date of Opera- tion. Aug. 20, 1802. ' 1864. May 9, 1804. June 29 1862. 1864. July 1, 1802. June 14 1864. June 16, 1804. Aug. 7, 1804. May 11, 1804. May 16, 1864. May 5, 1863. June 18, 1864. Oct. 19, 1864. Sept, 28, 1804. 1804. Sept. 14, 1863. Feb. 15, 1803. On field Aug. 4, 1864. Primary- Mar. 9, 1864. May 3, 1863. June 15, 1864. July 22, 1864. July 30, 1864. May 10, 1864. May 13, 1863. 1864. June 22, 1664. June 20, 18G-. June 22, 1864. Sept. 21, 1862. July -, 1863. Nov. 24, 1864. May 24, 18*64. May 6, 1864. July 23. 18*64. ' Julv 28, 1864. Nov. 29, 1863. July 23. 18*64. May 21, 1864. Operation and Operator. Two and a half inches, includ- ing head, by Surg. W. Hay, C. S. A. Head of bone excised...... Shoulder joint excised. Excision of the head.., Head and three inches of shaft removed. Excision of shoulder joint___ Head and neck and four inches of shaft removed. Head and two inches of shaft removed. Excision of the shoulder joint.. Broken fragments removed by resection. Head and three inches of shaft removed. Head and humerus, and portion of cavity. Two and a half inches, includ- ing head, excised. Shoulder joint excised......... Head excised through surgical neck. Three inches of bone from artic- ulation. Portion of anatomical neck.___ Head of humerus excised---- Head excised through straight incision through deltoid. Head, through straight incision. Three and a half inches of bone. Head and two inches of shaft removed. Four inches of upper extremity removed by posterior external flap. (Lisfranc.) Head excised through linear Removal of four inches of bone. Headandthree inches of bonere- moved through linear incision. Excision of head and one inch of shaft by White's method. Head excised through straight incision; posterior circumflex ligated. Primary excision of head and three and a half inches of shaft. Excision of head............. Head removed through single vertical incision. Head excised................. Head and two inches of shaft. Head and surgical neck through V-shaped incision. Head excised through linear incision. Head and three inches of shaft through V-shaped incision. Head excised................. Head and two and a half inches of shaft excised. Head and neck through straight incision, posteriorly. Resection................... Result and Reporter. Head excised. Head and four inches of shaft excised. December 16, 1862, considerable motion of limb. Surg. W. G. McKenzie, C. S. A. Died May 16, 1864. Surg. J. A. Bizzell, C. S. A. Recovered. Surg. J. A. S. Milli- gan, C. S. A. Died, June 25, 1864, from erysip- elas. Surg. J. R. Page, C. S. A. Recovered. Surg. J. M. Hallo- way, C. S. A. July 18,1864, furloughed. Surg. E. H. Smith, C. S. A. October 26, 1864, furloughed; motion of hand and forearm per- fect. Surg. J. L. Cabell, C. S. A. October 30th; improving. Surg. A. H. Snead, C. S. A. Secondary haemorrhage; died May 28, 1834. Surg. G. G. Crawford, C. S. A. Surgeon J. H. K. Monmonier, C. S. A. Furloughed in July, 1864. Surg. S. E. Chaill6, C.S. A. December 1st, doing well. Surg. A. R. Meun, C. S. A. Doing well October 1,1864. Surg. J. H. Murray, C. S. A. Surgeon A. R. Erstine. Surgeon J. H. K. Monmonier, 8th Louisiana. Returned to duty May 4, 1863. Surgeon P. F. Eve, C. S. A. Surgeon R. J. Hicks, 23d North Carolina. Surgeon W. E. Cochran, C. S. A. Furloughed Julv 30,1864. Surg. J. S. Brint, C.*S. A. Died March 29,1864 ; erysipelas. Surg. G. G. Crawford, C. S. A. Surg. L. G. Capers, C. S. A. Haemorrhage from circumflex ar- tery. Surgeon H. M. Darling, Stovell's Brigade. August 1st, doing well. Surgeon M. H. Nash, C. S. A. Gangrene; Sept. 30, 1864, not doing well. Surg. A. H. Snead, C. S. A. July 10,1864, doing well. Surg. M. Bellinger, C. S. A. Typhoid symptoms; died May 16, 1803. A. A. Surg. E. H. Wood, C. S. A. Julyl6th,furloughed. Asst. Surg. F. B. Shuford, C. S. A. Surg. J. M. Douglas, 2d Georgia. Doing well August 1st. Sing. W. E. Bickell, 19th Arkansas. Surg. W. E. Brock, 34th Georgia. Arm amputated; died next day. Surg. J. L. Cabell, C. S. A. Died, July 26,1863, from second ary haemorrhage. Surg. J. L. Cabell, C. S. A. Erysipelas. Surg. D. Herndon, C. S. A. Surgeon F. B. Henderson, 14th Georgia. Surgeon H. J. Parramore, 50th Georgia. August 31st, doing well. Surg. C. L. Herbert, C. S. A. Died August 14, 1864. Surgeon S. V. D. Hill, C. S. A. Asst. Surg. J. B. Clifton, C. S. A. Surg. W. H. Cooper, 16th South Carolina. June 2d, secondary haemorrhage. Surg. A. G. Lane, C. S. A. SECT. III.] EXCISIONS AT THE SHOULDER. 603 Name, Ac.f., and Military desciuption. Gray, A. A"., Ft., K, 21st Mississippi, aire 20. Gray, J. F., l't., G, 3d Ar- kansas, age 23. Green, C. A'., Ft., K, 32d Georgia, age 20. Green, I'., Lieut , F, Kith Tenucssee, ago 28. Grcctt, /*., Pt., B, 25th Texas, age 28. Green, P., Ft., 1st Ohio Bat- tery, age 27. GriffUli, R. 11'.. Ft., B, 45th Georgia, age X>. Haire, J. C, Sergt., D, 17th Georgia, age 20. Hall, T. it. Sergt., A, 37th Mississippi, age 30. Hanlcins, J. C, Pt., B, 38th Virginia, age 21. Hart, J., Pt., E, 63d Virginia, age 67. Head, W. S., Ft., T, 17th Alabama, age 35. Heywood, T. F., Pt,, F, 44th North Carolina, age 33. Hill, W. G., Lieut., I, 28th Alabama, age 28. Hobard, J. H, Capt,, Hum- phrey's Brigade, age 30. Hogwood, A.. It., G, 41st Virginia, age 28. Holton, A. J., Sergt., A, 6th Alabama, age 24. Horn, J. A.. Ft.. B, 19th South Carolina, age 21. House, E. G., Pt., C, Cobb's Legion, age 19. Howell, W., Pt.,H, 15th South Carolina, age 37. Hudson, B. F., Sergt., A, 4th Florida, age 28. Hudson, L., Lieut, K, ISth Alabama, age 36. Huff, J. 1., Sergt., H, 53d Georgia, age 27. Jenkins, J. A., Lieut., C, 51st Tennessee, age 39. Johnston, H. H, Sergt., B, 7th Texas. Jones, J., Ft., B, 121st New York, age 28. Johns, J. B., Pt., C, 18th Tennessee. Johnson, W. A., Pt., I, 44th Georgia, age 24. Reams, "P. J., Corporal, F, 114th Illinois, age 33. Key, D. L., Pt., D, 25th Ar- kansas, age 25. Kidd, C. H............. King, E. T, Pt., I, 47th Ten- nessee, age 22. Kinsey, E. T., Sergt., B, 3d Mississippi, age 40. Knight, IF., Pt., C, 28th Ten- nessee, age 38. Lawson, J., Ft., A, Palmetto Sharpshooters, age 16. Lee, G. W., Pt., H, 29th Ala- bama, age 27. Leslie, L, Pt,, B, 14th Geor- gia, age 18. Libbett, G. W., Pt., C, 35th North Carolina, age 19. Long, H., Lieutenant, B, 6th Louisiana, age 28. Long, W., Pt., C, 13th Geor- gia, age 22. Mav 6, I8ul. Mav 6, 1864. Feb. 20 1804. lulv 20, 1804. Mav -7, 180-1. Mav 28, 180-1. Mav 3, 1803. Sept. 19, 1803. July 28. 1864. Mav 10, 1804. !>cpt. 20, 1803. Sept. 8, 1863. Oct. 14, 1803. Julv 28, 1804. Mav 6. 1864. Mav 6, 18*04. May 2, 1803. Julv 22, 18*64. May 23, 1864. June 24, 1864. Sept. 20, 1863. July 22, 1864. July 21, 1864. July 20, 18o4. Sept. 19, 1803. May 10, 1864. May 26, 1864. May 10, 1864. July 14 1864. June 28 186-. Nature of Injury. Ball passed through surgical neck. Wound of left shoulder joint.. Shot in head of left liumerus . Comp'd comminuted fracturo of upper third of humerus. Fracture of humerus, head and neck of scapula. Compound fracture of right hu- merus, high up. Upper third of humerus frac- tured. Fracturo of head of humerus.. Wound in right shoulder joint Shot fracture of surgical neck of right humerus. Ball completely crushed head of humerus. Shot wound of left shoulder.... Neck of right humerus badly broken by shot. Shot wound of shoulder, involv- ing head of humerus. Shot wound of shoulder....... Shot wound of the shoulder and hand. Shot fracture of head of right humerus. Shot wound involving shoulder joint. Shot fracture of head of the humerus. Comp'd comminuted fracture of humerus and scapula. Fracture of head of the left humerus. Fracture of head of humerus.. Wound through shoulder joint Comminuted fracture of head and neck of right humerus. Wound of right shoulder joint. Fracture of head and surgical neck of humerus. Compound fracture of humerus. Ball passed through head of humerus, split bone for three inches, and shattered glenoid cavity. Opera- tion. July 20, 1804. July 20, 1804. July 7, 1864. May 10, 1864. July 22 1864. May 3, 1863. May 19, 18*64. Sept. 19 1864. Sept, 19 1864. Shot fracture of left humerus.. Shot fracture of head of the humerus. Comp'd comminuted fracture of head and surgical neck of right humerus by conoidal ball. Head of the humerus badly fractured by shot; tissues lacerated. Compound shot fracture of the head of right humerus. Shot wound implicating shoul- der joint. Comp'd comminuted shot frac- ture of head of right humerus. Musket ball lodged in head of humerus. Shot fracture of the humerus near shoulder. Compound shot fracture of right humerus near surgical neck. Fracture of head of the right humerus. May 7, 1804. May 7, 18(14. Mar. 4, 1864. July 20, 1864. 186-. May 20, 1804. On field Oct. 9, 1863. July 28, 1864. May 17, 1864. Oct. 16, 1863. Sept. 8, 1863. Oct. 20, 1863. July 28, 1864. May 6, 1864. May 7, 1864. On field July 22, 1864. May 23, 1864. June 24, 1864. Sept. 25, 1863. July 23, 1864. Juno 21, 1864. July 20, 1864. Oct. 14, 1863. June 30, 1864. Mav 26, 18*64. June 29, 1864. July 14 1864. 186-. July 20, 1854. July 25, 1864. July 8, 1864. May 10, 18*04. Operation and Operator. Upper three inches of bone ex- cised. Head oxcised through a V- shaped incision. Head excised................ Head through straight incision through deltoid. Head of liumerus and head and neck of scapula. Upper two-thirds, including the head. Head through straight incision through deltoid. Four inches of bone, including head, removed. Head of humerus excised...... Head and five inches of shaft removed through perpendic- ular incision through deltoid. Two inches of bone removed... Head of humerus removed, to- gether with fragments of bone. Removal of the head through a V-shaped incision. Removal of head thro' straight incision. Resection of head of humerus.. Head of humerus excised. Head excised Removal of injured head thro' straight incision. Head excised at surgical neck. Head of humerus and spicula? of scapula. Head excised................ Head excised. Joint resected. Head and surgical neck excised thro' straight incision. Head through perpendicular incision through deltoid. Excision of four inches of bone. Head and six inches of shaft excised. Three inches of humerus and de- tached fragments of scapula. Shoulder joint excised......... Primary excision of shoulder joint and upper third of the shaft. Head removed.............. Head and neck removed thro' a straight incision posteriorly. Head and upper third of shaft removed by vertical incision through centre of deltoid. Head removed through straight incision. Excision of shoulder joint by straight incision thro' deltoid. Result and Reporter. Died May 12,1864. Snrg. G. II. Pects, 21st Mississippi. Furloughed Julv 28,1864. Surg. B. M. Lcbby, C. S. A. Died March 17, 1864. Surgeon J. S. Morel, C. S. A. November 1 st, doing well. Surg. T. W. Leak, 10th Tennessee. Surgeon A. A. Lawrence, 25th Texas. Died July 5, 1864. Asst. Surg. G. G. Roy, C. S. A. Erj'sipclas; died of pyaemia, June 1,1863. Surgeon J. Chambliss, P. A. C. S. Doing well. Surg. S. E. Chaill6, C. 8. A. Died. Surg. J. A. Groves, C.S.A. Died from exhausting suppura- tion. Surg. S. E. Habersham, C. S. A. Jan. 1, 1864, complete recovery. Asst. Surg. T. J. McFarland, C. S. A. Nearly well, and promises to have a useful arm. Surgeon D. L. Darden, C. S. A. Furloughed Dec. 11,1863, nearly well. Surg. J. L. Cabell, C.S.A. Asst, Surg. J. W. Graham, 28th Alabama. May 31st, improving. June 30th, nearly healed; perfect use of forearm. Surgeon P. B. Baker, 41st Virginia; Died, July 27, 1853, of exhaus- tion. Surg. C.J. Clark, C.S. A. Furloughed Sept. 28,1804. Sur- geon W. H. Rankins, l'Jth South Carolina. Asst. Surg. H. S. Bradley, Cobb's Legion. Doing well; "have some fear of necrosis of scapula." Surg. J. A. James, 15th South Carolina. Died November 29, 1863. Surg. C. E. Michel, C. S. A. August 31st, doing well. Surg. C. Foxey, 19th Alabama. Died August 9, 1864. August 1st, doing well. Surg. S. V. D. Hill, C. S. A. Died Oct. 31, 1863, of pysemia. Surg. W. P. Harden, C. S. A. Julylst.conditionnotgood. Sur- geon H. C. Chalmers, C. S. A. August 31st, doing well. Surg. J. F. Grant, C. S. A. July 31st, pretty good use of arm. Surg. J. L. Cabell, C. S. A. Died of pysemia, Aug. 9, 1864. Surg. W. C. Cavenaugh, C. S. A. Asst, Surg. A. M. Walls, 25th Arkansas. July 26, Head and four inches of shaft 1864. excised. Head and one and a half inches of shaft removed thro' straight incision. Head excised through straight incision. Head and two inches of shaft re- moved thro' vertical incision. Shoulder j oint excised........ June 1, 1864. On field Sept, 29, 1864. Recovered. Surg. S. V. D. Hill, C. S. A. Sept. 11th, doing well. Surgeon W. T. McAllister, C. S. A. Oct. 31st, doing well. Surg. C. R. Wilson, 28th Tennessee. June 1st, doing well; furloughed June 6, 1864. Surgeon A. G. Lane, C. S. A. August 1st, doing well; Sept. 5, 1864, furloughed. Surg. G. G. Crawford, C. S. A. May 9th, doing well: healthy granulations. Surg. J. Cham- bliss, C. S. A. Recovered. Surg. A. G. Lane, C. S. A. February 1, 1865, recovering; arm rapidly improving. October 30th, can use arm without trouble; furloughed Nov. 30, 1804. Surg.T. H. Fisher.C. S.A. 604 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. Name, Aoe, and Military Description. 110 111 112 113 114 115 110 117 118 119 120 121 122 123 124 125 126 127 129 130 131 132 133 134 135 136 137 139 140 141 142 144 145 !l46 Lynch, D., Pt., D, 65th Geor- gia, ago 10. McCornuedale, N., Lieut., H, i;th Georgia. McDamel, W. IL, A, 55th Tennessee, age 3.1. McDonald, D., Sergeant, F, Jeff. Davis's Legion. McDonald, J., It, I, 33d Alabama. McElroy, J., Sergt., D, 2Sth North Carolina. Mclnnis, S. J., Pt., G, 8th South Carolina, age 21. Mchwil, N, Pt., A, 29th Alabama, age 18. Mc Kinney, W., Co. C, 24th Georgia, age 23. McMinn, F., Ft., K, 60th Illinois, age 25. McRce, G. IF., Corporal, F, 32d Mississippi, age 32. Maddison, W. B., Private, Pongue's Battery, age 34. Manning, G., Pt., F, 1st Tennessee, age 23. Massey, E. W., Pt., D, 2d Georgia Sharpshooters, age 22. Mayben, S. S., Corporal, G, 19th Arkansas. Mayfield, T. J., Corporal, B, 32d Tennessee, age 34. Merrick, J. T., Pt., B, 4th Virginia, age 23. Miller, J., Pt., G, 12th Vir- ginia, age 31. Mills, G. W., Pt,, K, 39th Georgia, age 21. Mitchie, T. E., Pt., I, 33d North Carolina, age 23. Mixon, J., Pt., H, 7th Florida, age 22. Montgomery, T. F., Pt., G, 38th Tennessee, age 25. Moore, A., Pt., G, 3d Vir- ginia, age 19. Moore, M. L., Pt., A, 58th North Carolina, age 26. Morphis, F., Pt., E, 61st North Carolina, age 19. Moses. J. H., l't., D, 28th Alabama, age 21. O'Neil, G. W., Sergt., G, 31st Georgia, age 22. On; G. F., Corp 1, I, 37th North Carolina, age 28. Pack, W., Pt., I, 54th North Carolina, age 18. Padgett, J., Pt., E, 24th South Carolina, age 33. Parton, T., Pt., D, 7th Ar- kansas, age 21. Perry, W. J., Sergt., C, 42d Georgia, age 30. Peterson, A., Pt., D, 10th Georgia. Phillips, J. N, Sergt., B, 10th Georgia, age 21. Pierson, J., Pt., E, 1st Ala- bama, age 16. PinkUy, M., Pt., C, 46th Tennessee. Powell, J., Pt., I, 3d Geor- gia, age 28. Ptolifino, J. U., Pt., H, 4th Texas. Aug. 3, 1804. Nov. 22, 1864. July 28. lbo4. Aug.], 1803. May 27. Sept. 19, 1803. June 5, 1804. Date OF Injury July 22, 1803. Jan. 23, 1804. July 8, 1804. July 17, 1864. June 27, 1804. May 27, 1864. Juue 30, 186-. May 15, 1804. 1862. June 28, 1864. May 15. 1864. May 3, 1803. Sept. 2, 1S04. June 30, 1864. July 3, 1803. July 24, 1864. Sept. 30 1804. July 28 1804. May 6, 1804. May 2, 1803. June 7. 1864. Sept. 19, 1863. July 22, 1864. May 15, 1864. Nov. 22, 1864. May 3, 1863. Julv 28 180-. July 28, 18ti4. June 11 1864. Sept. 20, 1863. Nature of Injury. Ball passed through head cf humerus. Head of left humerus fractured. Compound fracture of neck of right humerus. Pistol ball through shoulder joint. Wound cf left shoulder ...... Compound fracture of head and neck of humerus. Head of right humerus commi- nuted. Head cf left humerus fractured Upper part of humerus commi- nuted. Shot wound in right shoulder.. Shot fracture cf head of the humerus. Shot fracture of head, neck, and upper part of shaft of the left humerus. Shot fracture of head of the humerus. Shot fracture cf head of the left humerus through capsule, and down the shaft four inches. Shot fracture of head of the humerus. Comp'd comminuted shot frac- ture of head of left humerus. Shot wound of shoulder....... Shot fracture of head of the left humerus, glenoid cavity, and neck of scapula. Compound shot fracture of head of left humerus. Wound of left shoulder joint.. Wound of shoulder joint....... Fracture of head of the left humerus. Fracture of head of the left humerus. Fracture of head of humerus ; ball entered pleural cavity. Head of humerus fractured___ Fracture of neck of humerus; joint involved. Wound of right shoulder...... Shell divided right humerus and all except a small portion of soft parts. Wound of shoulder joint....... Musket ball passed through surgical neck of humerus. Shot fracture of right shoulder joint. Compound shot fracture of the head of left humerus. Shot fracture of head of the left humerus. Shot fracture of head of the humerus. Shot wound of right arm. Compound shot fracture of the head of humerus. Shot fracture of left shoulder joint; also wound of the left lung. Shot fracture of the upper por- tion of the humerus. Date of Opera- tion. Aug. 3, 1;:„4. 1864. 1864. On field Oct. 7, 1863. June 5, 1864. July 23, 1863. On field On field July -, 1804. June 28, 1804. 1864. July 1, 180-. Mav 16, 18*64. June 2, 1862. June 29, 1864. Mav 16, 1804. May 8, 1803. Sept. -, 1864. June 30, 1864. On field July 24, 1804. Oct. 2, 1864. July 28, 1864. May 7, 1804. On field June 7, 1864. Oct. 3, 1863. July 22, 1864. May 16, 1864. 1864. On field July 28 18*6-. July 28 1864. June 12 1864. Oct. 12, 1863. Operation and Operator. Head excised . Head and two inches of shaft through linear incision. Head and four iuches cf shaft excised thro' linear incision. Shoulder joint excised......... Head and part of shaft........ Head excised............... Shoulder joint excised......... Head excised................ Upper part excised through straight incision. Excision of shoulder joint...... Head and portion of shaft re- moved through linear incision. Primary excision of the head, neck, and about five inches of shaft. Removal of the head through a straight incision. Removal of the head and four inches of shaft by single in- cision through deltoid. Removal of the head.......... Head and three inches of shaft removed. Excision of shoulder joint...... Head and one inch of shaft and a portion of scapula excised through straight incision. Removal of the head and two inches through a V incision. Shoulder joint excised......... Joint excised................. The superior extremity excised through vertical incision. Head excised................. Head and four inches of shaft through longitudinal incision. Head and three inches of shaft excised. Head and neck excised thro' straight incision. Head and two inches of shaft of humerus. Shoulder by a V-shaped in- cision. Two inches of bone excised... Excision of the head and four inches of shaft. Head removed through a V- shaped incision. Head and three inches of shaft removed by straight incision through deltoid, and another on posterior aspect. Head and one quarter of an inch of shaft removed thro' linear Head removed by straight In- cision through deltoid. June 26th, amputation two inches from glenoid cavity. Excision ofthe shoulder joint.. Excision of head............. Result and Reporter. Removal of three inches ofthe upper extremity of humerus. Excision of the head and three inches of shaft. Furloughed. Asst. Surg. W. H. Nardin, C. S. A. Died December 18, 1864. Surg. D. Herndon, C. S. A. Sept. 21, 1804, doing well. Surg. H. W.Brown, C. S. A. Died Aug. 27, 1803. Surg. T. M. Palmer, C. S. A. July 1st, doing badly. Surg. F. Hawthorne. November 1,, 1803, doing well. Surg. W. F. Westmoreland. June 30th, ball caused good deal of irritation about the lungs; recovered. Surg. J. F. Pierce, 8th South Carolina. July 1st, improving. Surg. J. A. Groves, C. S. A. August 31st, rather profuse sup- puration. Surg. Lebby, C. S. A. Died of exhaustion. Asst. Surg. G. G. Roy, C. S. A. Gangrene; Aug. 31st, no visible improvement. Surgeon E. J. Roach, C. S. A. August 27, 1804, wound entirely healed. Surg. E. H. Smith, C. S. A. Surgeon J. R. Buist, Maney's Brigade. Died, June 18, 1864, from pneu- monia. Surg. G. G. Crawford, C. S. A. In hospital, July 8th. Surg. J. A. Groves. C. S. A. Died, May 28, 1804, of typhoid fever. Surg. G. G. Crawford, C. S. A. Recovery. Surg. E. H. Smith, C. S. A. August 30th, condition favorable; furloughed. Surgeon P. F. Browne, C. S. A. May 20th, haemorrhage; doing well June 1; died June 7,1864. Surg. G. G. Crawford, C. S. A. Recovered. Surg. J. B. Strachan, C. S. A. Furloughed Sept. 24,1864. Surg. J. A. Groves, C. S. A. Asst. Surg. J. W. Beale, 38th Tennessee. Recovered. Surg. J. H. Pottin- ger, C. S. A. August 1,1864, doing well. Surg. M. H. Nash, C. S. A. Profuse suppuration. Surg. S. Meredith, C. S. A. Recovered. Asst. Surg. J. W. Graham, 28th Alabama. June 30th, wound healed. Surg. J. R. Page, C. S. A. Transferred. Surg. C. Witsell, C. S. A. June 8th, considerable venous haemorrhage; August 1st, im- proving. Asst, Surg. R.O'Leary, C. S. A. November 1st, general condition improving. Surg.H.W.Brown, C. S. A. Surg. S. F. Turner, 7th Arkansas. May 29th, rigors; died June 2, 1804. Surg. G. G. Crawford, C. S. A. Surgeon D. Herndou, C. S. A. July 13th, haemorrhage from ax- illary ; ligated; Aug. 3d, stump healed. Surgeon C. J. Clark, C. S. A. Died. Surgeon J. A. Groves, C. S. A. Asst. Surg. B. S. Barnes, 46th Tennessee. "Doing well when last heard from. Surg. E. B. Lewes, 3d Georgia. Secoiid'y haemorrhage; rocovered completely, with good useof fore- arm. Stirg.F.Hawthorne.C.S.A. sect, iu.] EXCISIONS AT THE SHOULDER. 605 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 Name, Aoe, and Military Description. Pullim, J. P., Pt., H, 44th G eorgia, age 22. Pultz, H., Ft., D, 7th Vir- ginia Cavalry. Rains, M. W., It., 6Cth Georgia. Rainwater. J. A., Capt., F, 2S'tli Mississippi, age 25. Ramsey, T. J., Ft., A, 19th Tennessee, age 23. Ready, It'., Pt., 1), 50th Vir- ginia, age 23. Rcinbert, J., Ft,, 3d South Carolina Battery. Rice, T„ Sergt., 12th Ten- nessee, age -.:2. Richardson, C, Pt., D, 58th Virginia, age 43. Richardson, J. P., Lieut., A, 10th South Carolina, age 23. Rogeis, R. R., It., D, 26th North Carolina, age 20. Rose, D. A., Corp 1, K, 47th North Carolina. Rowe, C. T., Pt., Sample's Battalion, age 28. Rushing, E„ Lieut., I, 37th Mississippi, age 21. Rushing, J. R., Pt., E, 18th Tennessee. Sco«. A. A., Corp'l, H, 57th North Carolina. Serratt, D. J., Pt., H, 55th Alabama, age 25. Shaggard, A., It., E. 44th North Carolina, age 24. Simons, H., Pt., K, 2d Ar- kansas, age 43. Smith, B. F., Pt., B, 37th Virginia Cavalry, age 27. Smith, F. H, Corp'l, B, 3d and Sth Miss uri. Smith, J., Pt., F, 29th Ala- bama, age 25. Sorter. S. H., Pt., F, 18th Georgia, age 24. Stanton, A. J., Pt., B, 24th South Carolina, age 21. Starton, A. J., Pt., F, 18th Georgia, age 24. Summers, G. W., Pt., F, 32d Tennessee, age 30. Summers, J. C, Sergeant- Major, 5th Louisiana, Sweet, S. L., Pt., C, 9th Ten- nessee. Tanner, E. J., Pt., B, Phillips' Legion, age 27. Taylor, J., Sergeant, A, 9th Arkansas, age 32. Taylor, H. P., Pt., G, 1st Tennessee, age 27. Thomas, J., Pt., 7th South Carolina. Thomas, J. P............. Thompson, J. J., Pt., G, 28th Georgia. Thompson, T. J., C, 3d South Carolina, age 30. Toland, W. T., Pt., D, 22d Alabama, age 27. Turner, J., Pt., 61st Virginia. Vanderwoot, W., H, 23d North Carolina, age 24. Varnador, T., Pt., 15th Ala- bama, age 36. Walker, J. H, Pt,, F, 1st Georgia, age 20. Walsh, J., Sergt., 15th Lou- isiana, age 35. May 10, 1804. May 0, 1804. Mav 0, 18*04. Aug. 31, 1804. July 22, 1804. 186-. Sept. 14, 1802. July 22, 1864. May 12, 18*0-1. Julv 28. 1804. Julv 3, 1803. 1864. Nov. 25, 1863. Julv 28, 1804. Mav 26, 1864. Dec. 13, 1862. July 20, 1804. Oct. 14. 1803. Dec. 31, 1862. June 17, 1864. June 27, 1864. June 20, 1864. Mav 6, 18*64. Nature of Injury. Shot fracture of head of the humerus. Upper third of humerus commi- nuted. Fracture of neck of humerus, extending into tho joint. Head of humerus fractured___ Wound of right shoulder joint Surgical neck of humerus com- minuted. Wound of shoulder joint....... Ball penetrated right shoulder joint, fracturing humerus. Wound of shoulder joint....... Wound of shoulder joint....... Ball passed through the right shoulder joint. Wound of shoulder joint....... May 6, 1864. Aug. 18, 1864. June 15, 1863. Sept. 19, 1803. Nov. 29, 1863. July 28, 1864. July 22, 1864. July 10, 1863. Sept. 20, 1862. Dec. 13, 1662. May 6, 18*64. July 28, 1864. June 22, 1864. May 3, 1863. June 4, 1864. June 15, 186-. Aug. 29, 1862. Wound of left shoulder joint. Wound through left shoulder; head of humerus fractured. Compound fracture of humerus. Fracture of humerus j ust below shoulder joint. Fracture of head of the right humerus. Comminuted fracture of three inches of the upper part of the humerus. Comminuted fracture of head and one inch of shaft of right humerus. Conical ball through head of humerus. Wound of left shoulder........ Shot wound in left shoulder joint, Wounded severely in shoulder by shot. Head of the humerus and the glenoid cavity crushed by a ball. Shot wound of the left shoulder joint. Shot fracture of left humerus.. Shot wound of shoulder joint.. Shot fracture of head of right humerus; same ball fractured superior maxilla. Shot wound of shoulder joint.. Shot fracture of head of the left humerus. Comp'd comminuted shot frac- ture of head of right humerus. Extensive destruction of tissue of head of humerus by shell. Head of humerus fractured___ Fracture of upper third of the humerus. Compound fracture of the head of humerus and the whole of the scapula. Compound fracture of head and surgical neck of humerus. Head and upper part of shaft of humerus. Head of humerus and glenoid cavity fractured. Wound of head of left humerus. Ball lodged in shoulder joint, chipping head of humerus and fracturing acromion. Fracture of shoulder.......... Opera- tion. May 11, 1804. Mav 9, 1801. Mav 7, 1804. Aug.31, 1804. July 23, 1864. 186-. Sept.28, 1862. July 22 1804. May 25, 1864. July 28, 1864. July 19, 1863. 1864 Dec. 1, 1863. July 28, 1864. May 26, 1864. Dec. 14 1802. July 21 1864. Oct. 29, 1863. Jan. 13, 1863. June 17 1864. June 27 1864. June 20, 1864. May 7, 1864. Operation and Operator. Result and Reporter. Excision of head............, Four inches of bone, including head, excised. Head and four inches of shaft excised thro' straight incision. Head excised................ May -, 1864. Aug. 18, 1864. June 18, 1863. Oct. 20, 1863. Nov. 29, 1863. July 28, 1864. July 23, 1864. Sept. 23, 1863. Aug. 11, 1864. June 23, 1864. June 28, 1863. June 5, 1864. June 15, 186-. 1862. II ead and two and a half inches of humerus excised. Four and three-quarter inches of upper end excised. Excised..................... Head excised to the anatomical neck. Head of humerus excised. ... Shoulder joint excised through straight incision. Head of humerus excised, by Dr. Peachy, of Richmond. Shoulder joint excised....... Shoulder excised through ver- tical incision. Articulation excised........... Head and four inches of shaft excised. Head and two and a half inches of shaft. Head excised................ Head and three inches of shaft through incision along the in- ner edge of deltoid. Head and one inch of shaft through straight incision. Head through straight incision. Scapula taken out; head of humerus resected. Excision of shoulder joint..... Excision of shoulder joint___ Fragments and two inches of shaft of humerus and a portion of glenoid cavity removed by perpendicularincision through deltoid. Head removed through straight incision. Head and two inches of shaft removed. Shoulder joint excised by Lar- rey's operation. Anatomical head removed thro' deltoid flap. Shoulder joint excised......... Removal of head.............. Head excised through straight incision. Head by linear method....... Shoulder joint................ Head and two inches of shaft.. Head of humerus and glenoid cavity. Head and five inches of shaft removed by curved incision. Headand one-half inch of shaft. Two and a half inches of shaft and fragments of head ot the humerus. Four inches of bone excised .. Head of humerus and acromial process thro' curved incision. Upper third of humerus..... Surgeon A. Taylor, C. S. A. Surg. W. H. Benton, 7th Virginia Cavalry. Surgeon R. A. Lewis, C. S. A. Surgeon A. S. McKay, C. S. A. August 31st, doing well. Surg. B. Franklin, C. S. A. Surgeon O. F. Baxter, C. S. A. Died October 5, 1862. Surgeon F. P. Lovcrett, C. S. A. Surgeon B. F. Dickinson, 12th Tennessee. Died June 7, 1864. Surgeon A. G. Lane, C. S. A. Surgeon T. P. Bailey, 10th South Carolina. Died Aug. 2,1863, from erysipelas. Surgeon W. C. Dixon, C. S. A. Died June 2(1, 1864, from exten- sive suppuration. Surgeon D. W. Thomas, C. S. A. Dec. 19th, secondary haemor- rhage ; died December 23, 1863. Surg. W. p. Harden, C. S. A. Surgeon II. Estes, C. S. A. May 27th, doing well. Surgeon J. F. Grant, C. S. A. Died. Surgeon C. S. Morton, C. S. A. Ass't Surgeon L. D. McReynolds, C. S. A. Furloughed Dec. 14,1863; acquir- ing considerable use of arm. Surg. J. L. Cabell, C. S. A. Mar. 4, 1863, wound granulating. Surg. H. W. Brown, C. S. A. August 1st, doing well. Surgeon J. J. Terrell, C. S. A. Surgeon B. G. Dysort. Died July 4, 1864, of pyaemia. Surg. G. W. McDade, C. S. A. Surg. J. B. Brown, 18th Georgia. Doing well. Surgeon XV. P. Har- den, C. S. A. May 31st, doing well; stump healed. Surg. M. W. Houston, C. S. A. Nov. 18,1864, doing well. Surg. J. A. Groves, C. S. A. Recovered. Ass't Surg. T. S. Latimer, C. S. A. Nov. 30th, wound nearly healed. Surg. C. E. Michel, C. S. A. Died. Surgeon R. N. Price, C. S. A. Surgeon J. R. Buist, C. S. A. Sept. 29th, profuse haemorrhage; the posterior circumflex ligated. Surg. W. C. Hoilbeck, C. S. A. Died Nov. 1, 1862. Surgeon F. Hawthorne, C. S. A. Sloughing. April 1st, improved. Surg. J. A. Milligan, C. S. A. Surg. J. Evans, 3d South Caro- lina. Furloughed Oct. 13, 1864. Surg. H. XV. Brown, C. S. A. June 30th, doing well. Surgeon Powell. 01st Virginia. Aug. 1, 1863, improving rapidly. Surg. F. B. Henderson, C. S. A. Furloughed Nov. 10,1864. Surg. T. M. Palmer, C. S. A. Surg. H. M. Darling, StoveU's Brigade. Died September 12, 1862, of sec- ondary haemorrhage. Surgeon J. P. Chazell, C. S. A. 606 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. NO. Name. Aoe. and Military Date of Injury Description. 189 Waring, M. H., Sergt., G, 3d Florida. May 28. 190 Waterman, P., It., D, 20th Sept. 14, North Carolina. 1862. 191 Webb, B., Pt., E, 4th Missis- July 9, sippi, age 34. 1864. 192 Westwood, IF., Pt., Carter's Sept, 14, Artillery, age 28. 1863. 193 Wholey, I., Corp'l, H, 54th July 28, Alabama. 1864. 194 White, A. L., Pt., I, 7th Oct, 7, Georgia, age 22. 1864. 195 White, J. W., Lieut., I, 14th May 6, Alabama. 1804. 196 Williams, G. W., Pt., G, May 27, 10th Texas, age 27. 1864. 197 Williams, J. IF, Pt., B, 19th April 5, Mississippi, age 24. 1862. 198 Wilson, E. T., Pt., A, 6th May 27, Texas, age 28. 1864. 199 200 Wilson, J.H............... 186-. Workman, W. J., Pt., G, June 1, 44th North Carolina, acre 21. 1864. 201 j Youngblood, C. S., Pt., H, 2d May 3, Louisiana. 1863. Nature of Injury. Shot fracture of head of right humerus. Shot comminution of head of liumerus. Fracturo of head of right hu- merus and scapula by a mini6 ball. Extensive comminution of up- per part of left liumerus. Comminuted fracture of right humerus, splitting head from lessertuberosityupward; frac- ture and comminution cf the scapula one and a half inches above inferior angle. Shot wound of right shoulder joint. Shot wound of shoulder joint.. Comp'd shot fracture of right hu- merus involv'g shoulder joint. Shot fracture of neck of the hu- merus; necrosis. Shot fracture of surgical neck of humerus. Fracture of head of humerus... Wound through shoulder joint antero-posteriorly. Fracture of upper third of right humerus. Date of Opera- tion. May 29. Sept. 14, 1862. On field Sept. 15 1863. 1864. Oct. 8, 1864. May 6, 1864. 1864. Feb. 18, 1863. May 28, 1864. Sec'd'y June 2, 1864. On field Operation and Operator. Head removed. Three inches of upper extremity of humerus removed. Head of humerus and fractured portion of scapula removed. Portion of head through a curvi- linear incision from coracoid to insertion of deltoid. Head and three inches of shaft and spiculae removed. Excision of shoulder joint. Excision of the head...... Excision of head andfour inches of shaft. Thirteen pieces of bone with the articular head removed. Head and portion of shaft re- moved; two small muscular arteries divided and ligated. Head excised................ Shoulder joint excised......... Head excised................ Result and Reporter. Surgeon J. T. Holden, C. S. A. Surgeon R. J. Hicks, C. S. A. Doing well. Aug. 1st, still in hospital. Surgeon C. A. Rice, 4th Mississippi. Sept. 27th, haemorrhage. Febru- ary, 1864, recovered. Surgeon B. F. Browne, C. S. A. Aug. 11th, haemorrhage from del- toid branch. Aug. 12th, vessel ligated. Aug. 29th, prognosis favorable. Surgeon P. H. Otey, C. S. A. Dec. 30, 1864, still in hospital. Surg. B. F. Browne, C. S. A. Furloughed June 2, 1864. Ass't Surg. T. C. Foster, 10th Texas. Duty. March 16, 1863, wound entirely healed. "Thinks he will ultimately regain the entire use of arm." Surg. J. Cham- bliss, C. S. A. May 30th, doing well. Assistant Surg. R. A. Smith, 6th Texas. Recovered. Furloughed July 26, 1864. Sur- geon R. A. Lewis, C. S. A. Died May 10, 1863. Surgeon J. A. Milligan, C. S. A. The two hundred and one operations above enumerated may be summed up as one hundred and thirty-four primary, twenty-eight intermediary, and ten secondary excisions at the shoulder for shot injury, together with twenty-nine cases of the same subdivision, although of uncertain date. The undetermined results are in large proportion, as the cases appear in the tabulation;1 but many of the reports, especially those of the field cases, indicate that the patients were "doing well" when last accounted for; and the series tends to corroborate the evidence in favor of primary excisions at the shoulder for shot injury derived from the experience of other wars.2 The numerical statement of Dr. Chisolm3 is 1 The figures are as follows: Primary, 134; recovered, 21—furloughed, 17—fatal, 25—unknown, 71. Intermediary, 28; recovered, 4—furloughed, 5—fatal, 9—unknown, 10. Secondary, 10; recovered, 4—fatal, 2—unknown, 4. Operations of Undetermined Date, 29; recovered, 3—furloughed, 1— fatal, 7—unknown, 18. 2Thus LOffler (F.) (General-Bcricht, u. s. w., 1867, S. 288) observes: "From a statistical point of view, it is undoubtedly the duty of the field surgeon, in cases of shot wounds of the shoulder joint, to excise the joint during the first forty-eight hours after the reception of the injury. Has this period passed, operative interference should be deferred until the end of the period of inflammatory reaction. But statistical results are hardly necessary to convince the field surgeon cf the advantages cf primary resection. If resections of the joints are acknowledged to be a means of diminishing the ratio of mortality notoriously following abstention from operative treatment, it is difficult to see why the operation should be delayed until the aspect of the case has really become threatening. * * More astonishing still is the assertion that nothing is gained by a primary resection. Less danger to life and shortening ofthe period of confinement by disease are certainly advantages worthy of consideration. Uncertainty regarding the diagnosis and accumulation of labor during the first days following a battle, already encroach sufficiently upon the time for primary resection." STROMEYER (L.) (Maximen der Kricgshcilkunst, 1855. S. 694) remarks: "According to my view, in every well-attested case of injury of the bone with opening of the shoulder joint, resection is indicated as the only method which will prevent the threatening danger of a suppurative inflammation." SCHWARTZ (H.) (Beitrage zur Lehre von den Schuss- wunden, 1854, S. 205), treating of shot fractures involving the shoulder joint, and illustrating the subject by his experience in the Schleswig-Holstein war, emphatically declares (the italics are his own): "All require theprimary resection; the secondary should only be performed when the injury was overlooked in the first place, or if there was not time to resect during the first twenty-four hours." And, on page 207, he continues, after citing several excisions: " The last two cases teach obviously not only that anywise important cases of fractures of the humerus, extending within the capsular ligament, should be resected, but should he primarily resected." MACLEOD (G. II. B.), referring to excisions of the joints for shot injury (Notes on the Surgery of the War in the Crimea. 1858), avers: "So far as my observation went, primary excisions were much more successful than those done at a later date, both as regards the final results and the length of the period of convalescence.'' And DEMME (Studien, u. s. v.. 1861, B. LI, S. 224) argued to the same effect, and denies that excisions are more prejudicial to the transport of the wounded than unmolested shattered limbs: " The condition of the soft parts more than any- thing else speaks in favor of primary resection. There is no considerable infiltration, no carious destruction of the joint, no burrowing of pus nor softening of the fibrous tissues, no fatty degeneration cf muscles,—complications that are likely to follow expectant treatment, directed to symptoms, complications that sometimes persist after secondary resection, rendering the complete restoration of the functions of the arm impossible. * * The advocates of second- ary operations lay great stress upon the fact, that it is difficult to estimate the extent of operative interference requisite in recent shot injuries; that there is danger < f too much or too little being removed. This objection may have some foundation; but to say.that the transport of the wounded after the opera- ticu is mere dangerous to patients, and more difficult, is an error, and I am convinced that the contrary is the fact." 3 CllISOLM (J. J.) (A Manual of Military Surgery, Columbia, 1864, p. 377), in a " Consolidated table of Resections, collated from records in the Surgeon-General's Office from June 1, 1862, to February 1, 1864,—prepared by Surgeon H. EAER, P. A. C. S.," accounting for 41 primary and 27 second- ary excisions at the shoulder, after shot injury, with a percentage of fatality of 31.7 and 25.9, respectively. SECT. III.] EXCISIONS AT THE SHOULDER. ^ 607 at variance with this conclusion, representing the secondary excisions at the shoulder as the practice to be most advantageously followed. Before discussing this question, it is proper to refer to the excisions at the shoulder for shot injury done elsewhere. Of these, more than four hundred well-authenticated examples have been published, besides several score of analogous operations, described by some authors as excisions or resections at the shoulder; but not thus recognized by other writers. Only in the last thirty or forty years has the operation come to be regarded as one of the legitimate regular procedures of military surgery. The cases belonging to this period are classified in the following tabular statement: Table XLI. Showing the Xumber of Excisions of the Upper Extremity of the Humerus for Shot Injury on the Occasions named, and from the Authorities quoted, with the Ratio of Mortality. Actions and Authorities. Algeria and other occasions prior to 1855 {BAUDEXS)i............................ Austrians in Lombardy id 1848 (Beck)......................................... Sleswig Holstein, 1848-51 (ESMARCH and STROMEYER).......................... French in Algeria iBertheranp), 1854-56..................................... Crimean War, 1854-56, Russians (HObbexet).................................. Crimean War, 1854-55, French (ClIEXU)....................................... Crimein War, 1S54-50, British (Matthkw).................................... Italian War, 1859-60, French (Chenu)......................................... Italian War, 1859-60, Austrians (DEMME)...................................... New Zealand War, 1863-65 (Mouat)............................................ Danish War, 1864 (Lcefflei:)................................................., Prussians in Six Weeks' War, I860 (Stromeyer, BECK, BlEFEL, and MAAS.)___ Army of the United States. 1865-70 (Circular 3)................................ Franco-German War, 1870-71, Germans (H. Fischer, Socix, Beck, Billroth, Rupprecht, Lucre, Schullf.r, G. Fischer, Lossen, Steinberg, Mayer, cestehlex. Kirchxer, Koch, Schixzixger, Stumpf, mosetig, and Graf). Franco-German War, 1870-71, French (Pasas, COUSIN, Christian, PoNCET, Hergott, F. Gross, Tachard, Sedillot, Chipault, and Vaslix). Franco-German War, 1870-71 (McCoitMAC, etc.)................................ Cases. 14 1 19 1 20 42 16 19 26 9 35 13 2 126 Recov- eries. Results undeter- MIXED. Ratio of mortality. 84.fi 57.1 18.7 47.3 34.6 51.4 46.1 62.5 45.4 42.0 ■Baudexs (Mem. sur la resection, de la tele de t'humerus, in Rec. de mem. de med., de chir., 1855, 2° sgr., Vol. XV, p. 184); BECK (B.) (Die Schusswunden, 1850); Esmarch (F.) (Uber Resectionen nach Schusswunden, 185], S. 41); STROMEYER (L) (Maximen, 1855, S. 750); Bertherand (A.) (Camp, de Kabylie, 1802); HCbbenet (C. v.) (Die Sanitdts Verhaltnisse der Russischen Venoundeten wdhrend des Krimkrieges in den Jahren, 1854-56, Berlin, 1871); Chenu (J. C.) (Camp, d Orient, p. 677); MATTHEW (T. P.) (Op. cit, p. 376); CHENU (J. C.) (Camp, d'ltalie, 1809, T. II, pp. 544-597); Demme (H.) (Miliidr-Chirurgische Studien in den Iialienischen Lazarethen von 1859, B. II, S. 225); MOUAT (Med. and Surgical History of New Zealand War, in Army Med. Dept. Report for 1865, Vol. VII, pp. 476-8); L02FFLER (F.) (Generalbericht, u. s. w., 1864, S. 280-301); STROMEYER (L.) (Erfahrungen uber Schusswunden, Hannover, 1867); BECK (B.) (Kriegschir. Erf. wdhrend des Feldzuges, 1866); BlEFEL (R.) (Kriegs- chir. Aphor., von 1866, in Arch, fiir Klin. Chir., Berlin, 1869, Vol. XI, S. 426 and 474); Maas (H.) (Kriegschir. Beitrage, Breslau, 1870, S. 73); Circular 3, War Department, S. G. O., Washington, 1871, p. 226; FISCHER (II.) (Kriegschir. Erf, Vor Metz., 1872, S. 146); SocrN (A.) (Op. cit, S. 153;; Beck (B.) (Chir. der Schussverletzungen, 1872, S. 583); Billroth (Th.) (Chir. Briefe, 1872, S. 213); RUPPRECHT (L.) (Militdrdrztlichc Erf, Wiirz- bnrg, 1871, S. 15 and 61); LUCKE (A.) (Kriegschir. Frngen und Bemerk, Bern, 1871, S. 105); SCHtJLLER (M.) (Kriegschir. Skizzen, Hannover, 1871, 8. 11 and 10); Fischer (G.) (Dorf Floing und Schloss Versailles, in Deutsche Zeitsehrift fur Chir., 1872, B. I, S. 187); LOSSEN (H.) (Kriegschir. Erf. u. s. w., in Deutsche Zeitsehrift fiir Chirurgie, 1873, B. II, S.40); Steinberg (Die Kriegslazarethe und Barackenvon Berlin, 1872, S. 148); Mayer (L.') (Kriegschir. Mittheil., u. s. w., in Deutsche Zeitsehrift fur Chir., 1873, B. Ill, S. 49); CEsterlen (Ott, CEsterlen, und Romberg) (Kriegschir. Mittheilungen aus dem Ludwigsburger Reserve Spilal, * * 1870-71); KlRCHNER (C.) (jErztlicher Bericht uber das Koniglich Preussische Feldlaz- areth im Palast zu Versailles, Erlangen, 1872); KOCH (XV.) (Notizen uber Schussverletzungen, in Laxgexbeck'S Archiv fiir Klin. Chir., 1872); Schinzixger (A.) (Das Reservelazareth Schwetzingen, Freiburg, 1873); Stumpf (L.) (Bericht uber das Kriegsspilal des St Georg-Ritter Or dens zu Neuberghausen im Jahre 1070-71, in Bayerisches AVrztl. Intelligenzblatt, 1872, Nos. 617, 655); Mosetig (V.) (Erinnerungen aus dem drutsch-fran- zosischen Kriege, in Der Militdrarzt, 1872); GRAF (E.) (Die Konigl. Feservelazarethe zu Dusseldorf wdhrend des Krieges, Elberfield, 1872); Faxas (F.) (Mem. sur le traitement des blessures, etc., in Gaz. hebdom. de med. et de chir., 1872, p. 389); Cousin (A.) (Hist. chir. de I'ambulance de Vecole cesponts tt chaussees, in L' Union mid., 1872); CHRISTIAN (J.) (Relation sur les plaies de guerre observies d. I'ambulance de Bitschwiller, 1870-71, in Gaz. mid. . de Strassbourg, 1871, p. 279); Poncet (F.) (Contribution it la resection med. de la guerre de 1870-71, in Montpellier midical, 1872); HERRGOTT (Am- bulance du Petit el du Grand-Seminaire pendant le sitge de Strassbourg, in Gaz. med. de Strassbourg, 1870); GROSS (F.) (Notice sur Ihopital civil pendant le siege et le bombardement de Strassbourg, in Gaz. med. de Strassbourg, 1872); Tachard (E.) (Reflexionspour servir a I'histoire de la chirurgie en campage, in Gaz. des Hop, 1871); Sedillot (Du traitement des fractures des membres par armes de guerre, in Arch gen. de med., 1871, We s6r., T. 17, p. 393); Chipault (A.) (Fractures par armes d. feu, 1872, p. 104); Vaslin (L.) (ttude sur les plaies par armes d.feu, 1872, p. 76); MacCormac (W ) (Notes and Recollections of an Ambulance Surgeon, l£7l, p. 130). 608 INJURIES OF THE UPPER EXTREMITIES (riiAp. ix Apart from the references here tabulated, there have been published accounts, for the most part isolated, of particular instances of excisions at the shoulder for shot injury. Thirty-four of these, of which twenty-seven at least resulted favorably, are mentioned in the subjoined historical note.1 An aggregate of four hundred and twelve cases is obtained by adding those included in the numerical statement on the preceding page. Or, laying 1 Authors frequently mention Thomas, of Pezenas, as the first who excised, in 1740, the head of the humerus; but it appears (Sap.atier, Mim. sur un moyen de supplier A l'amputation du bras dans l'article, in Mem. de I'Institut National des Sci. et Arts, Paris, An. XII (1804), p. 367) that Thomas simply successfully extracted, for caries, in a girl, aged 4 years, a portion of the cylindrical part of the upper extremity of the humerus, about an inch and a half in length, and, the following day, the epiphysis forming the head of the humerus. The next case referred to is that of Vigarous, of Montpellier, said to have excised, in 1767 (Guthrie, G. J., Gunshot Wounds, 3d ed., 1827, p. 471, and Pean, J. E., De la scapulalgie et de la rejection scapulo-humi- rale, Thfise, Paris, 1860, p. 45), the head of the humerus, for caries, in a lad of 17, who died shortly afterward; but, in a letter to M. Sabatier, an extract of which is published by the latter (1. c, p. 373), M. VlGAROUS remarks: " Je n'ai point retranch6 la t£te de l'os du bras." In 1768, Charles White, of Manchester (Cases in Surgery, with Remarks, London, 1770, p. 57, and Phil. Transactions, 1770, Vol. LIX, p. 39), excised, for caries, the head of the humerus in a boy of 14; good motion of the limb being preserved. Three years later, in 1771, Dr. LENTIX (Med. Chir. Bemerkungen, 1771) successfully removed, for caries, the head and shaft of the humerus, with the exception of the lower two inches-of the bone. From this time the operation was repeat- edly and successfully performed by J. BENT, in 1771 (Hunter, Account of a Woman enjoying the Use of her right Arm after the Head of theos humeri was cut away, in Phil. Transact, 1774, Vol. LXIV, Part I, p. 353), who excised the head ofthe right humerus for caries, in a young girl, retaining perfect use of forearm;—by Daniel Orred, in 1778 (Percival (T.), A Case in which the head of the os humeri was sawn off and yet the motion of the limb preserved, in Phil. Trans., 1779, Vol. LXIX, Part I, p. 6);—by MOREAU, the elder, in 1786 (Mokeau (P. F.), Essai sur I'emploi de la resection des os, Obs. I, 1816), in the case of a woman, aged 45, for caries; arm shortened two inches; good motion of forearm; and, by the same operator, in 1794 (/. c, Obs., IV), in a widow, Moulin, aged 43, removing the head and shaft, 5J inches in all; abscesses and fistulae remained until her death, 10 years after the operation;—by the surgeon of the Cavalry regiment Berri, in 1789 (PERCY et Laurent, Art. Riseclion, in Diet, des Sci. Med., 1820, T. 47, p. 546), in a boy, aged 13, for caries. Several other cases are mentioned by the last named authors (PERCY and Laurent), but it is impossible to reconcile their state- ments in the above article with others made by them in the article Humerus, Diet des Sci., Med., 1818, T. XXII, pp. 36, 37, a fact that, in a measure, may account for M. Sauatier's silence regarding them. Percy et Laurent (Diet. des. Sci. Med., 1818, T. 22, p. 26) further declare: "Des Fan 1794 nous presentames a feu notre collegue Sabatier, neuf exemples vivans de cette cure." [M. Legouest (De la Chirurgie mil. contemporaine, in Arch, gen de med., 0e ser., 1859, T. XIII, p. 463) and Dr. R. M. Hodges (The Excision of Joints, 1861, p. 23) inadvertently cite nineteen operations, all accredited to Percy.] Percy complains that Sabatier, "le chirurgien, si justement celebre fit dans la suite le sujet d'un memoire oil il nejugeapas a propos d'en nom- mer l'auteur." But it is doubtful whether these cases were excisions, or mere removal of fragments; it would seem that at least some of them would have been reported in detail, especially as prior to that period no cases of excisions of the head of the humerus for shot injury are on record. The first case of excision for shot injury (the only series to be referred to hereafter in this note) that is reported in detail, is adduced by L. Grosbois (Diss, sur l'amputation du bras dans l'article avec des remarques et observations sur la risection de Vexiremiti superieure de I'humerus, etc., Paris, 1803, p. 34): Corporal Gache, 18th regiment of the line, was shot through the right shoulder joint, at Roveredo, September 4, 1796; two days later he was admitted to the hospital at Verona. The head and a portion of the shaft were successfully excised by the author's brother, a noted surgeon in the French army. Sabatier, who is reported to have performed the operation of excision of the head quite frequently, describes, in his memoir to the Institute, the mode of operation, but does not claim to have practised it, although he carefully cites all authentic cases known to him. LARREY (D. J.), alleged to have operated in ten instances, remarks (Relation hist, et chir. del'expedition de I'armie d'Orient, 1803, p. 314, and Mem. de Chir. mil. et camp., 1812, T. II, p. 174): "I'ai eu la bonheur de prevenir dix fois ces accidens, et deviter l'amputation qu'ils aurarient necessitee, en fesant I'extraction entiere de la tete de l'hum§rus, ou des ses frag- mens;" but his cases were, undoubtedly, not cases of excisions, but removal of fragments, etc., as he remarks elsewhere (Mem. de Chir. mil. et camp., 1812, T. II, p. 172): "Mais je n'ai point a m'occuper do la resection de la tete de I'humerus que je n'ai pas eu occasion de pratiquer; il me suffira d'avoir fait sentir la difference qui exist entre cette op6ration et I'extraction de la tete de I'humerus, separ€e par une fracture de son col, ou rtjduite en fragmens.'' The second authentic excision for shot injury was reported by M. Poret (06s. sur la risection de la moitii superieure de Vhumirus, apres un coup defeu pris I'articulation, in Jour, de mid. chir. phar., T. XXII, Juillet, 1811, p. 425), who excised the head of the humerus in the case of a soldier of the 95th regiment, who had been shot through the upper third of the humerus. The operation was performed on March 12, 1809, by M. PORET, in the presence of MM. LlXON, Mantel, and Fayet. The patient recovered "toutes les fonctions se faisaient parfaitement bien." 3. According to J^GER (Operatio resec- tionis, Erlangae, 1832), WlLLAUME, in 1812, successfully excised the head of the humerus. 4. MOREAU (P. F.) (op. cit, 1816, Obs. 3) performed the operation on December 22,1812, in the case of Sebastian Vilain, 65th of the line, who had been wounded in Spain, July 22, 1812; the head and four inches of the shaft were removed for caries; the patient recovered, with considerable use of the arm. 5. Dr. R. M. HODGES (The Excision of Joints, 1861, p. 24) records, on the authority of an eye-witness of this operation, that "In the United States it was first practised for gunshot wounds by Dr. Wm. Ingalls, of Boston, in the winter of 1812-13. The patient was a soldier in the United States Army, and he recovered with a tolerably useful limb. 6. Naval Surgeon Brown, in 1814, excised the head of the humerus of Lieutenant Duncan of the Navy, wounded a few days before the battle of Plattsburgh, September 11, 1814, the patient recovering, with good use of the forearm. The case is detailed by Dr. H. Hunt (Am. Med. Recorder, 1818, Vol. I, p. 365). 7. 8. Mann (J.) (Med. Sketches of the Campaign of 1812, '13, '14, Dedham, 1816, p. 208) cites the cases of two seamen of Commodore McDonough's fleet, wounded at the battle of Plattsburgh, September 11,1814, by cannon balls; the fractured heads of the humeri were excised. 9. 10. Legrand (de Brege) (Diss, sur la risection de la tete de Vhumirus, 1814) twice resected the head of the humerus for shot wounds, in 1814. 11. MOREAU (P. F.) (op. cit., 1810, Obs. 5) excised the head of the left humerus in the case of Gautier, aged 24, wounded June 16, 1815; little use of the arm was retained. 12. W. R. MOREL, as reported by Sir J. McGrigor (Case of Gunshot Wound of the Shoulder joint, in Med. Chir. Trans., 1816, Vol. VU, p. 161), resected the head of the humerus, in the case of Th. Ellard, 18th Hussars, wounded at Waterloo, June 18, 1815. Recovery, with "little motion in the shoulder, but all the variety of motion of which the forearm and hand are capable." Guthrie (G. J.) (A Treatise on Gunshot Wounds, 1827, p. 470), in his chapter on "Excision of the Head of the Humerus," cites various cases from the British campaigns, 1810-1815, but, with the exception of the case of Ellard, above cited, they are all cases of removal of loose fragments. While the conservative treatment, as carried out by THOMAS, BOUCHER, and others, was practised extensively by military surgeons, the excision of the bone, as performed by White, Moreau, and others, was little favored by the former, and, as late as 1820, the eminent Hennen (op. cit, 3d ed., 1829, p. 30) remarked, that it was "not generally adopted;" and added: "I have never seen it performed on the field, and, in hospital practice, I have only seen one case of it. * * Upon the whole, I am inclined to think that the excision of the head of the humerus will be found to be an operation more imposing in the closet than generally applicable in the field." 13.14.15. BRIOT (Histoire de I'etat et de progres de la chir. mil. en France, 1817, p. 16) remarks: " M. Bottin a op6r6 une cure semblable a Barcelonne; M. Cou RVILLE une a Mayence; MM. Peret et LAFAYE ont egalement rehssi, dans un cas extiemement complique, a conserver le bras a une jeune soldat qui 6tait a l'hopital de St. S6bastien." 16. VERXET (Letter autograph, Bayeux, 1819) resected the shoulder joint for shot injury, but I have not been able to determine the result. 17. ReynaUD (YVAN) (Risection de Vextremiti superieure de Vhumirus & Voccasion d'un coup defeu, in Arch. gen. de med., 1827, T. XV, p. 464) excised the head of the humerus in the case of a marine, at Toulon, who had received two balls in the shoulder: "La une nouvelle articulation s'est formfee en 8 ou 9 mois. et aryourd'hui le malade peut executer des mouvemens dans tous les sens." 18. Bryce (Ch.) (Three cases of Surgical Operations, in Lancet, 1831, Vol. II, p. 742) relates the case of a soldier wounded at Phalerus, Greece, in May, 1827; resection of the head of the humerus was performed, but the patient died. 19. ROFX (J. X.), a Brignoles (Gaz. me'd de Paris, 1836, T. IV, p. 72), in 1836, excised the head of the humerus for shot injury, and the patient recovered, SECT. III.] EXCISIONS AT THE SHOULDEB. 609 aside fourteen instances in which the results were unknown or only partially determined, a series of three hundred and ninety-eight excisions at the shoulder for shot injury is collected, with two hundred and forty-two, or somewhat more than sixty per cent, of recoveries. Operations by Larrey, Percy, Guthrie, and others, referred by many writers to this category, have not been added to it, either because the operators explicitly declared that tho cases could not be considered examples of formal excisions, or on account of some ambiguity in the records, or hazard of duplicating identical instances.1 Although the period of opera- tion in this series could not be determined with precision in more than half of the cases, the imperfect analysis was very favorable to primary excision. Of the nine hundred and fifty-one completed observations of this operation reported from the American war,2 there were six hundred and three recoveries, a percentage of 63.4. The distribution of these cases according to the period of operation is minutely explained on page 599, and it clearly appears that the mortality of the consecutive operations exceeded that of the primary in a proportion greater than ten per cent. The concurrent testimony of two such large bodies of facts affords a strong presumption in favor of primary excisions, although many surgeons entertain an opposite view.3 There would probably be less differ- ence of opinion if a ternary, instead of a binary, classification of operations4 were more with good use of forearm and some use of arm. 20. Baudely (P. T. II.) (Proceedings of Surgical Society of Ireland, in Dublin Med. Press, Dec. 14, 1042) relates the case of a Hindoo soldier, aged 21, who had shot himself in the shoulder; secondary excision of the head of the humerus; recoverj-, with complete use of forearm and hand; can elevate the arm utmost to a right angle with the body. 21. Leriche (Mem. de la Soc. d'emulatiou de Lyon, 1842) successfully performed the operation. 22. Siratton" (Til) (Case of Gunshot Wound and Excision of the Head of the Humerus, in Edinb. Med. and Surg. Jour., 1846, p. 30) successfully excised the head of the humerus in a Chippewa Indian boy, aged 6, shot in the shoulder, in 1844; an intermediary operation. 23. Williamson (G.) (Notes on Gunslwi Injuries, etc., in Dublin Quart Journal, 1859, Vol. XXVIII, p. 81) cites the case of John Morgan, shot at Idaliff, September, 1842; the head of the humerus was excised on Juno 22, 1844; patient "gradually regained power of motion in the arm." 24. Dr. Beith, of the Royal Navy (Gunshot Wound through the Shoulder Joint. Excision of the Head of the Humerus; Recovery, with Hinge-like Move- ment of the Articulation, in Lancet, lS'y.'i, Vol. I, p. 207). 25. 26. Williamson (G.) (loc. cit, p. 81) cites two successful cases from the Indian mutiny, 1858, one a primary, the other a secondary operation. 27. Dyas (W. G.) (Resection of the Head of the Humerus for Gunshot Wounds, in Chic. Med. Jour., 1859, Vol. XVI, p. 704) removed the head of the humerus, shattered by gunshot, in the case of XV. B----; the result is not stated. 28. Matthew (T. P.) (Stat San. and Med. Reports of the Army Med. Department, London, 1861, p. 309), in 1859, successfully excised the head of the humerus in the case of Eraser, 9"d regiment. 29. Eve (P. F.) (Nashville Jour, of Med. and Surg., July, 1800), the case of a young man, aged 16, accidentally shot in the shoulder; head cf the humerus excised; recovery, with good use of limb, being able to raise the arm to a level with the clavicle. 30. v. Pitha (PODRAZKI, ffeber Schusswunden. in (Ester Zeitsehrift fiir prakt. Heilkunde, B. VII, If 61) removed the head and portion of the shaft cf tie right humerus for shot injury; patient "does, with the fingers of this arm, the finest carving." 31. Chief Surgeon Riedl (Allgeme.ine Militararztl. Zeitung, 1864, Nos. 17, 18) removed the head of the humerus in tbe case of a soldier who had attempted to commit suicide; recovery, with good use of forearm and tolerable good use of arm. 32. Surgeon RL'DGE, Sth Bengal Artillery (Brit. Army MM. Dept. * * Reports, 1866, Vol. VI, p. 520), in 1865, excised the head of the humerus cf a sapper shot through the axilla. The patient recovered, with good use of the forearm, and, "in fact, with very little exception, the entire use of the arm had been restored." 33. Fitzgerald (J. W.) (Western Jour, of Med , 1869, Vol. IV, p. 112), in 1868, successfully reu/ved the head of the left humerus, in a girl of nineteen, for comminuted shot fracture. 34. Miner (XV. XV.) (Excisions Involving the Joints cf the Upper Extremity, in Buffalo Med. and Surg. Jour., 1871, Vol. XI, p. 82) excised "the head, with the upper and middle two-thirds of the humerus," for gunshot injury of the shoulder; recovery, with perfect use of foreann, but very little motion of arm. I have endeavored in this note to refer only to isolated cases of excisions of the upper extremity of the humerus for shot injury, and the large number of cases collected from publications on special campaigns have been grouped in tabular form, see Table XLI. p. 607. 1 All this is explained, at as great length as space will allow, in the preceding note. I must say. however, that notwithstanding the disclaimer of the illustrious Larrey, several of his operations appear to me to have been excisions at the shoulder for shot injury, in the strictest sense. I cannot find, in. either of PERCY'S three articles, that he ever practised this operation after injury, although he collected a number of cases of excision for disease, and presented some of the recovered patients to the institute, and deserves much credit for his earnest advocacy of resections. The operations attributed by some writers to Sahatier, refer simply to those cases collected by PERCY. Tliere are many other well known, authenticated cases, which, at first sight, might appear to be omitted in Taisle XLI; but are, for the most part, grouped under the heads of the different campaigns, as the operations by Professcr Laxgenheck, Stromeyer. Schwartz, etc., in the Dutchios, those of MM. Baudexs and LEGOUEST, in the Crimea. 2 The gn >ss aggregate is one thousand and eighty-six operations, of which in one hundred and thirty-five instances the ultimate results were unknown or only partially known. While regarding the importance of such naked numerical statements and comparisons as vastly overrated, they appear to afford the only feasible mode of presenting in a small compass the results of such large numbers of cases. 'Thus SOCIN (A.) (Kriegschir. Erf, 1872, S. 155), treating of excisions at the shoulder after shot fracture, while admitting that he has had no personal experience on the subject, opines that "primary resection should be confined to those cases in which extensive splintering of the bone can be diagnosticated;" but adds: "Should the considerably more favorable mortality-rate, observed in the American War (Circular fi), be confirmed, the field of primary resection should be extended, as, as a matter of course, the vital prognosis should be preferred to the functional." And BILLROTH (T.) (Chir. Briefe aus den Kriegs Lazarethen, u. s. w., 1872, S. 210) contends that "primary resection is only to be practised when the splintering in the joint is very extensive." HODGES (R. M.) (Exc. of Joints, 1861, p. 29) strongly presents the arguments of the advocates cf deferred operations. Fcr the views of the writers on the other side, see the note on page 000. 13 Something further will be adduced regarding the indications and comparative value of expectant measures, excisions, and amputations, for shot injuries near the shoulder, at the close of the Section. AMPUTATIONS AT THE SHOULDER. Eight hundred and sixty-six examples of amputations for shot injury, by exarticula- tion at the shoulder joint, were reported. Fourteen of these, practised on account of com- plications attending injuries of the soft parts, have been enumerated in Table XIV, on page 468. in the first Section of this Chapter. Eight hundred and fifty-two cases will be referred to here, the results having been ascertained in all but twenty-eight. Scapulo-Humeral Amputations after Shot Fracture.—A large proportion of these cases were primary operations, practised on account of shot fractures of the upper part of the humerus, generally with implication of the joint, and with such lesions of the soft parts as precluded a resort to excision. Others were performed on account of consec- utive disease involving the upper arm. 1 Amputation at this joint fur gangrene was advised by Hiri'OCRATRS, IIELIODORUS, Galen, AliUL KASEM, PARE, HILDANUS, and others. In 1642, Figray (P.) (Epitome desprec. de mid., 1642, p. 130, Chap. IX, de la curationde sphacele ou sideration) observes: " Aucuns sont difficult6 de couper dans la jointure ou pr6s d'icelle, il cause des parties nerveuses: toutefois d'autant que l'on les coupe du tout et promptement, les accidents n'cn sont pas si prands, j'en ay veu plusieurs qui ont bien suecede." Barhette (P.) (Thesaurus Chifurgise, 3d Eng. ed., London, 1676), while speaking of the point of amputation, remarks: "Except the mortification hath extended itself to the uppermost parts ofthe arms or thighs; for then we are forced to take the joint itself;" but there is no evidence that he knew of any instance of scapulohumeral amputation. Purjiann (M. G.) (Lorbeer-Krantz, 1692, B. Ill, 8. 229) relates a case cf amputation ofthe arm and adds: "Some say, the amputation can be most readily, and should be, performed in the joint nearest above the injun-," but adds: "I have never performed this operation." In the Jour, de mid. de M. DE LA ROQUE, an 1686, Juin, p. 3, is related a case of gangrene of the arm. treated by Surg. La Gareine. and subsequently by another surgeon: "Qui prit une petite scie pour emporter l'os du bras; mais s'etant appercu qu'il brnnloit vers son articulation avec l'epaule, il y donna quelques legeres seeousses, et l'os sortit facilement de sa boete." The patient, a boy, recovered. Moisaxd (F. S.: (Opuscules de Chirurgie, 1768, T. II, p. 212) claims that his father first performed amputation at the shoulder joint: "C'est mon pere qui a fait le premier cette operation aux 1•.ealides, et c'est & tort que quclquesur.s ont cru devoir l'attribuer a M. LEDliAN le pere qui avait ete Chirunrien-major des Gardes Fruncaises. 11 est vray que M. LeDran fit cette operation ensuitc avec succfis, mail il en accordant lui meme la priorite a mon p6re." And La Fa ye. in his notes to DlONTS, Cours d'operat. de Chir., 1750, p. 758, ascribes the first operation to Salvador Morax [i. e., SAUYtxii FRANCOIS Moraxd], LeDuan (II. F.) (Observations de Chirurgie, 1731, T. I, p. 315) relates that his father (in 1715) exarticulated the arm i f M. Comadeux fur caries, in the presence if JIM. Ar.naud, PETIT, and others, and that the patient recovered. GARENGEOT (Traite des op. de chir., IT"8. 2ded., T. III. p. 455) describes the operation at length, and, on page 465. remarks that "le jeune Marquis de Coetmadeu, gentilhomme dc Bretagnc ievidently Le Dkan's patient) s-iit peri en six mois aprds la cure de cette amputation, quoique tres-parfaitement gu6ri, mais par une abondanee de sang." Mm le.- (S.) (The Elements of Surgery, London, 1746, p. 178) states that Du VEUXEY successfully exarticulated the arm, at Paris, on September 24, 1730, iu the presence of BOerhaave. Ravaton (Chir. d'armee, 1768, 06s. LVI, p. 26.;) amputated the arm at the shoulder joint in a soldier wounded May 13, 1734, the case terminating fatally; and on page 266 (Obs. LVH) records a case of shot wound of the head of the humerus in 1744, and of successful exarticu- lation by a surgeon whose name he could not ascertain. Heister (L.) (Instituliones chirurgicse, 173!). P. I, p. 510) describes the operation although he never performed it. SHARP (S.) (A Treatise on the Op. of Surgery. 1740, p. 220) observes: " There are in armies a great many instances of gunshot wounds of the arm near the scapula, which require amputation at the shoulder; but the apprehension of losing their patients on the spot by the haemorrhage has deterred surgeons from undertaking it." La Faye (Nouvelle method pour faire Voperation de l'amputation dans Iarticulation du bras avec l'omoplate, In Jilem. de I'Acad, de Chir., 1753, T. II, p. 242): " Depuis 1740, que j'ai lu ces reflexions a I'Acadcmie, plusieurs celebres chirurgiens ont adopt6 cette m&hode et Font pratique H 1'armSe avec success." FAURE (V. M.) (Mem. in Prix de I'Acad. de Chir., 1819, T. Ill, p. 337) and BOUCHER (06s. sur des playes d'armes a. feu, etc., in Mem. de I'Acad. de Chir., 1753, T. II, p. 463) exarticulated the arm of an English soldier, aged 25, shot through the shoulder joint, at Fontenoy, in 1745; the operation was performed 29 days after the injury; the man recovered. BEAUSSIEU (Sur une non.fe.lle maniere de faire l'amputation du bras dans l'article, in Jour, de Med., chir., phar., Janvier, 17CS. T. XXVIII, p. 530) observes: "J'ai vu faire deux fois l'amputation de I'humerus dans l'article; je I'aifaite une fois A I'armie, apris un coup defeu, qui ne laissait que ce moyen de sauver le blessi." Daiil (I'. II.) (De humeri amputationi ex articulo, in Sandifort, Thesaurus dissertalionvm,17G8, Vol. I, p. 37) exarticulated the arm ai the shoulder). BROJIFIELU (XV.) (Chirur- gical Observations and Cases, 1773, p. 209) performed the operation several times prior to his publication, and remarks: "I must acknowledge 1 had but little encouragement to do it at first, from those who had seen it performed repeatedly in tho army." ALAXSON (E.) (Practical Observations on Amputa- tions, 1782, 2d ed., p. 180) records a successful case of exarticulation at the shoulder joint for shot injury, arm being blown off at the insertion of the deltoid. Mich^lis (Briefe aus New York, in Richter's Chir. Bibliothek, Gottingen, 1782, B. VI, S. 125) saw, at Charleston, South Carolina, in 1778, a French soldier, wounded during Count Estaing's expedition against Savannah; the arm had been amputated at the shoulder joint and the patient recovered. Dr. John Warren performed the earliest exarticulation at the shoulder in this country, at the Boston Military Hospital, in 1781 (E. Warren", in Boston Med. and Surg. Jour.. 1839, Vol. XX, p. 210); the patient recovered. Dr. R. Bayley (Tiiacher (J.), American Medical Biography, 1828, Vol. I, p. 164), in 1782, successfully exarticulatad the arm at the shoulder. Surgeon XV. BURD, of the British Navy (Annals of Med. for the year 1797, Edinburgh, 1798, Vol. H. p. 282), exarticulated, on May 3, 1796, the arm of J. Moirieton, a French officer, shot in the right shoulder; the patient was discharged, cured, August 17, 1796. Larrey (D.J.) (Mem. de chir. mil., 1812, T. II, 167) remarks: " II s'en est presente dix-neuf, qui ont n6cessit6 l'amputation du membre a son articulation scapulo-humerale. Cette operation a eu un succes complet chez treize blesses; les Six autres ont peri de la peste, oudeseffets de la com- motion portSe par la cause vulnfirante sur les organes intfcrieurs." FI.EURY (Observation sur une amputation du bras dans l'article, in Jour, de med., chir., phar., 1806, T. XII, p. 437) exarticulated the arm for shot wound in a boy of 12 ; the patient recovered after consecutive ligation of the axillary artery and vein. Larrey (D. J.) (Mem. de chir. mil., 1812, T. Ill, p. 3G1) states that after the battles of Wagram and Eslingen he performed fourteen exarticu- lations at the shoulder, of which twelve were successful; and (I. c, T. IV, p. 432) remarks that, of a hundred and odd of his exarticulations at the joint, over ninety were successful. Trowbridge (A.) (Report of Extraordinary Cases of Amputation, read before the Med. Soc. of Jefferson County, New Tork, in The Medical Repository, 1818, N. S., Vol. IV, p. 20) records two successful cases of exarticulation at the shoulder joint for shot injury. WHIT- RIDGE (J. B.) (Case of Amputation nt the Shoulder Joint, in The Xew England Jour, of Med. and Surg., 1816, Vol V, p. £1) exarticulated the arm at the 611 INJITRIKS OF THE UPPER EXTREMITIES. [CHAP, ix Table XLII Numerical Statement of Eight Hundred and Fifty-two Cases of Amputations at the Shoulder Joint after Shot Fracture. Operations. Total cases. Recoveries. Fatal cases. Results not specified. Mortality rate, deter-mined cases. Primary.................. 499 157 66 130 368 85 47 91 117 72 19 28 14 24.1 45.8 28.7 23.5 Intermediary............. Secondary................. OF UNSPECIFIED DATE..... 11 . 852 591 236 25 28.5 Primary Amputations at the Shoulder Joint.—Only operations practised within forty- eight hours from the reception of the injury are included in this category. The results, ascertained in all but fourteen of the four hundred and ninety-nine cases, are remarkably good, more than three-fourths of the patients having recovered. Undiscriminating oppo- nents of conservative measures might seek to found on this datum a serious argument. The series is large, yet less numerous,"by one-third, than the primary excisions. It would appear that the well-known indications for primary exarticulation,—viz: a shot fracture of the upper extremity of the humerus, with lesion of the vessels or nerves; or, secondly, a fracture high up, with splintering extending below the insertions of the latissimus dorsi and great pectoral,—were not invariably respected; but, for the most part, the cases were well chosen, were such, in fact, as admitted of no alternative but ablation of the -limb. shoulder joint in a soldier of the 2d Artillery, wounded at Stoney Creek, Upper Canada, June 6, 1813; the patient died five weeks after the operation. GUTHRIE (G. J.) (A Treatise on Gunshot Wounds, 1827, 3d ed., p. 469) tabulates thirty-eight cases of amputation at the shoulder joint—nineteen primary and nineteen secondary; sixteen fatal and twenty-two recoveries. LAROCHE (Ret chirurg. des ivenemens qui se sont passis a Lyon, etc., in Rec. de mim, de med., 1835, T. XXXVII, pp. 102, 108) records two cases of amputation at the shoulder fjr shot injury; one patient recovered—the other perished. PlXKXEY (N.) (Report of some Operations performed during the late Cruise in the Pacific, in Am. Jour. Med. Sci., 184G, N. S., Vol. XII, p. 332) reports a fatal case of amputation at the shoulder joint for shot injury, at Callao, in June, 1843. Peaslee (E. R.) (New York Jour, of Med., 1853, Vol. X, p. 297) reports the case of a man who shot himself accidentally in 1845; Dr. Peaslee amputated at the shoulder; reovcry. Dr. E. Jexxixgs (see letter tu the editor of the Annalist, 1847, Vol. I, No. XXILI, p. 538) amputated the arm at the shoulder joint in a case of shot wound of the axilla; secondary haemor- rhage and death ensued. Dr. Jons Watson (Amputation at the Shoulder Joint, in the Annalist, 1847, Vol. I, Xo. XVI. p. 371) exarticulated the arm at the shoulder joint, in 1847, iu a case of injury cf the right arm and hand, caused by the premature discharge of a cannon; the patient died. TRIPLER (Cu. S.) (Case of Secondary Hsemorrhage after Amputation at the Shoulder, in New York Jour, of Med., 1849, X. S., Vol. HI, p. 41) exarticulated the arm of a private of the 2d Infantry, wounded at Cherubusco, August 20, 1847—recovery. Eve (P. F.) (Southern Med. and Surg. Jour., 1848, Vol. IV, X". S., p. 663) amputated, for shot injury, the arm of a black boy at the shoulder joint—recovered. HusuiHR (Des plaies d'armes a feu. Communications faites * * par MM. les Docteurs BAUDEXS, ROUX, etc., 1849, p. 143), in 1848, twice removed the arm at the shoulder joint for shot wounds; both patients recovered. Massarexti (MrxELLI, Frattura comminutiva dell'omero. Disarticolazione scapula-omeral, in Bullelino dell science mediche, Bologna, 1850, Ser. 3, Vol. XVHI, p. 191) exarticulated at the shoulder joint, in the case of a soldier, aged 31, shot through the shoulder; the patient recovered. May (J. T.) (Cases of Amputation, in Am. Jour. Med. Sci., 1851, X. S., Vol. XXII. p. 327) records a fatal case of amputation at the shoulder in a man accidentally shot by a fowling piece, in December, 1850. Mr. COCK (Lancet, 1852, Vol. II, p. 84), at Guy's Hospital, in 1851, exarticulated the arm at the shoulder joint, in the case of a leather-dresser, accidentally shot in the shoulder; the man recovered. BOLIXG (Western Jour, of Med. and Sci., Vol. XHI, and New York Jour, of Med., 1853, N. S., Vol. X, p. 21) exarticulated the arm for shot injury; patient died in six hours. COCHRAN (J.) (A Case of Amputation at the Shoulder Joint, in The New York Jour, of Med., 1854, X. S., Vol. XITI, p. 43) successfully exarticulated the arm for shot injury, in the case of a young gentleman of South Brooklyn. Heyfelder (J. F.) (Deutsche Klinik, 1855, B, VII, S. 495) exarticulated the arm at the shoulder for shot wound of the right forearm, in the case of Wasili Rilkoff, aged 27, wounded April 29, 1855; the case terminated fatally. HEYFELDER (J. F.) (Deutsche Klinik, 1858, B. X, S. 226) removed the arm at the joint in the case of A. Baum, accidentally shot in the shoulder, while hunting; the patient died. Sanborx (E. K.) (Surgical Clinique at Castleton Med. College, in Boston Med. and Surg. Jour., 1859, Vol. LX, p. 35) exarticulated at the shoulder joint, in the case of a young man accidentally shot through the shoulder; the case terminated fatally. IRWLN (B. J. D.) (Amputation at the Shoul- der Joint in Am. Jour. Med. Sci., 1859, X. S.. Vol. XXXVHI, p. 350), in September, 1858, succpssfully exarticulated the arm cf S. St. John, aged 24, shot in the shoulder by Mexicans. DUFFEE (W. J.) (Amputation at the Shoulder Joint; Gunshot Wound, in Philadelphia University Jour, of Med. and Surg., Vol. XII, 1869, p. 394), in 1859, successfully exarticulated the arm at the shoulder for shot injury. IRWIX (B. J. D.) (Gunshot Wound of Arm; Ampu- tation at the Shoulder Joint, in Am. Jour. Med. Sci., 1861, X. S., Vol. XLH, p. 337) cites a case of exarticulation at the shoulder for shot injury; the patient died. MIXER (J. F.) (Clinical Remarks upon Surgical Cases in the Buffalo General Hospital—Gunshot Wound—Amputation at the Slunddtr Joint, in Buffalo Med. and Surg. Jour., August, 1864, Vol. TV, p. 378): a young lad, shot through the upper portion of the right arm; recovery without accident. In Circular 3. S. G. O., 1871, pp. 188-189, are reported three cases of amputations at the shoulder joint for shot injury, by Assistant Surgeons D. L. Huntington and C. Smart, U. S. A., and Dr. Owens, cf Lynchburg. The two former were successful; tho latter terminated fatally. Black (J. J f (Notes of some Surgical Cases, in The Western Lancet, 1874, Vol. Ill, p. 291) exarticulated, in 1873, the arm at the shoulder foraccidental shot injury; thfl [uiticnt recovered. SECT. III.| AMPUTATIONS AT THE SHOULDKR JOINT. 615 § Successful Operations.—-The details recorded regarding the three hundred and sixty- eio-ht cases of this group are very scanty, consisting, for the most part, of little more than minutes of the injury and operation at field stations, notes of entrance and discharge from general hospitals, and reiterations of the facts by pension examiners. A few illustra- tions will precede tlie tabular enumeration of the cases: Case 1585.—Captain E. L. Severn. Co. K, 96th Pennsylvania, aged 27 years, was wounded at Spottsylvania, May 10, 1331. Amputation at the shoulder joint was performed by Surgeon D. W. Bland, 93th Pennsylvania, who reported: "The wound was caused by the explosion of a case-shot, fired from the guns of the enemy while the command were resting in line of battle. Tlie shot wounded seven men, four of whom died in a few hours. The captain was brought to the rear immediately, and expressed a desire to have me sent for, and if an operation was to be performed I should do it. I had been detailed as Medical Inspector ofthe Corps, and felt some hesitancy in leaving my regular duties to perform an operation; however, I examined the wound and found the entire humerus completely comminuted, involving the elbow joint. A portion of the shell had passed through the top of the shoulder, carrying with it a considerable portion of the clavicle and superior part of the scapula. The subject was all that could be desired for a capital operation—young, perfect health,' and strictly temperate. After consulting with several medical oflBcers of the corps, the unanimous conclusion was for immediate removal of the arm at the shoulder joint, and as much of the clavicle and scapula as was seriously involved. Assistants were selected and assigned their respective duties; the patient was placed under the influence of chloroform, and I proceeded to remove the arm at the shoulder joint by making the superior flap from the body of the deltoid muscle, disarticulating the head of the bone, and cutting the lower flap from the muscle and integument on the inner side of the arm; ligatures were applied and all haemorrhage arrested. I then enlarged the wound over the clavicle by cutting in the direction of the bone, and after care- fully removing the loose spiculae of bone I sawed off either end ofthe clavicle, there remain- ing about four inches of this bone. I then removed the fragments ofthe superior part of tlie scapula, cutting away all loose and damaged integument. I closed the wound over the clavicle and scapula by the interrupted suture. The removal of so large a quantity of bone and integument above the shoulder joint offered a fine opportunity for the escape of all secretions through the joint and at the most dependent portion of the flaps, thus very materially favoring a speedy and successful cure. At the completion of the operation, I administered one ounce of brandy with one grain of morphia. The operation took place in the midst of a dense wood, at five o'clock P. M., with the light from a half dozen candles. At midnight the wounded were loaded for Fredericksburg, and this patient, with hundreds of others seriously wounded, was sent twenty miles over corduroy roads, before the wound was examined or his condition inquired about. The discouraging circumstances under which the first instalment of wounded were sent to Fredericksburg" are too fresh in the memory of every one to recount them. In sixty hours after the operation, the wound was dressed, and tlie subject made as comfortable as circumstances would permit; everything went favorably from this time on, and at the end of three weeks he was sent to Washington and placed in the Officers' Hospital, at Georgetown, under the care of the late Dr. Ducachet. This gen- tleman told the captain that he would get well, but assured him that he was one case out of t:n thousand, remarking that it was the most extensive operation that ever came under his care. The captain recovered entirely, and is, to-day, enjoying good health, using his left hand and arm with about the same facility he used his right. The amount of discharge was considerable, but at no time was there any indication of the formation of abscesses. The opening formed by the exit of tin- ligatures was the drain for all secretions, and everything went on toward a rapid and successful cure." This officer was dis- charged from service August 17, 1*34, his disability being rated as total and permanent, and was pensioned from that date. On March 22, 1337, Dr. Bland contributed a photograph of his patient, which is copied in the wood-cut (FlG. 477), and stated: "The patient is at present superintending a colliery and enjoys excellent health.'' Cask 1588.—Private A. E. H------, Co. F, 1st Maine Heavy Artillery, aged 21 years, was wounded at Yellow House, Virginia, October 2, 1334, and was sent to a Second Corps hospital. Surgeon 0. Evarts, 20th Indiana, noted: "Right arm fractured by shell. Amputation at shoulder joint." The patient was sent north, and was treated in hospitals at Beverly and Bangor, and was discharged from service from the latter place, August 30, 1865. Acting Assistant Surgeon J. S. Waggoner recorded: "Shell wound of right arm; amputation at the joint; nearly healed, with occasional discharge from a small orifice." The specimen (Fig. 478) was contributed by the operator, Surgeon D. S. Hays, llOtli Pennsylvania. It consists of "the upper part of the right [the catalogue of 1333, p. 90, has it, inadvert- ently, the left] humerus "amputated at the shoulder joint. The inner portion of the epiphysis is broken; an oblique fracture runs directly through the head and surgical neck, and several fissures extend over the articular surface." The Bangor Examining Board, Drs. R. K. Jones, J. C. Weston, and E. F. Sawyer, April 1, 1874, reported: "The limb was carried away by a shell wound, with the end of the acromial process of the scapula and probably the glenoid cavity of the scapula; the coracoid remains. The scar lies horizontally across the seat of shoulder; it is very sensitive. He wears a large shoulder pad, and a bandage to support the shoulder." This pensioner was paid June 4, 1374. While, for tlie most part, tlie amputations at the shoulder were practised for fracture Fig. 477.—Stump after primary ampu- tation at the shoulder joint. FIG. 478.—Shot fractura of the right acromion aud head of liumerus. Spec. 4115. 4- (.16 INJURIES OK THE UPPER EXTREMITIES. [CHAP. IX implicating the articular surfaces, and attended by grave lesions of the soft parts in the vicinity, there were not a few instances of exarticulations for fractures of the diaphyses by small projectiles, where extensive longitudinal fissuring existed: (.'ask 1587.—Private D. S Doyyctt, Co. F, 33th Virginia, was wounded at Brandy Station, June 9, 1833. He was sent to Lincoln Hospital, at Washington. Acting Assistant Surgeon B. P. Brown forwarded the specimen (Cat. Surg. Sect., 1803, p. 91. S/>rc. 1234), represented by FlG. 2, Plate XLVI, with the following report: "Wounded in the right arm by a pistol ball passing from before backward through the humerus, about three inches below the head, producing considerable comminution, and lodging just beneath the integument at the lower border of the axilla. He came into this hospital, Ward 16, June 11, 1863. The arm was amputated at the shoulder joint, June 11th, at three o'clock P. M., by Surgeon G. S. Palmer, U. S. V." The specimen is described in the Catalogue as: "The right humerus amputated at the shoulder joint, for a compound fracture by a large pistol ball, at the upper thirds." The patient was transferred to Hammond Hospital, Point Lookout, on November 27, 1833, and assigned for exchange in March, 1834. In the larger proportion of cases, however, the operation was practised on account of injuries produced by large projectiles—solid, or hollow and explosive: Case 1588.—Corporal J. J. F----, Co. K, 73d Indiana, aged 28 years, was wounded at Day's Gap, Alabama, April 30, 1863, while on a raid. The entire brigade Avas captured near Rome, Georgia, on May 3d. The regimental medical officers becoming separated from the men, there is no record of the patient until his discharge at Camp Morton, Indiana, October 19, 1833. Surgeon Seth T. Myers, 73d Indiana, certifies: "Discharged on account of a wound by a grapeshot, causing the left arm to be amputated at the shoulder joint, and the removal of the entire right hand with the exception of the thumb." This soldier was pensioned from the date of his discharge. His company commander certified: "* * his left arm was badly shattered near the shoulder by a grapeshot, and had to be amputated at the shoulder joint, and that at the same time and place his right hand was taken off, except his thumb, with shot or shell * * ." Examiner Luther Brusie, of Laporte, Indiana, February 5, 1833, furnished an ambrotype of the pensioner, represented by the cut (Fig. 479), and the following description: "The left arm was amputated at the shoulder joint. There is a total loss of all the fingers of the right hand, and a loss of all the metacarpal bones of the same hand except that of the little finger, and anchylosis of wrist." Tlie pensioner applied for commutation for an artificial limb in 1870. He states that the operation was performed on the field by Assistant Surgeon W. M. Spencer, 73d Indiana, Dr. Peck, and Surgeon Seth T. Myers, immediately after the injury. Case 1589.—Private T. Cole, Co. B, 5th Michigan, aged 44 years, was Avounded at the Wilderness, May 5,1834. Surgeon O. Evarts, 20th Indiana, in charge of a Second Corps field hospital, reported a " compound fracture of the arm," and " amputation May 5th." After treat- ment in Lincoln Hospital, Washington, the patient was furloughed, on June 21,1834. On July 19th, he entered St. Mary's Hospital, Detroit. Acting Assistant Surgeon D. 0. Farrand noted: "A gunshot wound ofthe right shoulder, passing through the surgical neck of the humerus. Flap amputation at shoulder joint; removal of the head of the humerus, in a field hospital, May Cth, by Surgeon Henry F. Lyster, 5th Michigan. The humerus was badly shattered. Progress was slow; the wound continued to discharge for a long time; simple dressings were employed. September 30th, the patient still under treatment." The patient was discharged from service October 1, 1864, and pensioned on account of " a gunshot frac- ture of the head of the right humerus and the lower border of the right scapula, which necessitated the amputation of the arm at the shoulder joint." The disability is rated total. The pensioner was paid December 4, 1874. Case 1590.—Sergeant J. Mills, jr., Co. D, 8th Vermont, aged 21 vears, was wounded at Win- chester, September 19, 1834. Assistant Surgeon J. Homans, jr., U. S. A., from a Nineteenth Corps field hospital, reported : " Gunshot fracture ofthe left arm; amputation at the shoulder jo'nt; favorable." On the following day he entered the depot hospital at Winchester, and was transferred to Frederick, Novem- ber 12th. Acting Assistant Surgeon W. B. McCausland noted : "Wounded by a minid ball. Admitted into this hospital from Winchester for amputation of the left arm at the shoulder joint, the result of a gunshot fracture of the left humerus, upper third, involving the joint. Arm amputated September 20, 1864, at Morgan's Mills, Virginia, by Assistant Surgeon B. A. Fordyce, of the 16th New York. Flap operation. Condition at time of operation good. November 12th, wound perfectly healthy; simple dressings applied. November 20th, wound nearly healed; discharge slight; simple dressings continued. November 28th, transferred to Brattleboro'. On leaving the hospital he was in perfect health, with the exception of a very slight discharge from the wound." The patient, after treatment in hospitals at Burlington and Montpelier, was finally discharged from service, October 12, 1865, and pensioned. The disability was rated total. This pensioner was paid March 4, 1875. Dr. H. Janes, formerly surgeon of volunteers, of Sloan Hospital, Montpelier, contributed the photograph of the patient, represented by the cut (Fig. 480), taken at the date of the soldier's discharge. Flu. 47!).—Cicatrices after amp l- tations at left shoulder, and of fingers of tlie rig-lit hand. [From a photo- graph.] Flo. 480.—Cicatrix after iiu exarticulation at left shoulder, as it appeared a year after the operation. Some examples of the character of the fractures of the humerus in the cases in which amputation was performed appear on the succeeding page. SECT. 111.] AMPUTATIONS AT THK SHOULDKR JOINT. 617 H- Case 1591.—Private G encasement near tbe Weldon Railroad, October S Ik;. 481. —Upper extremity of the right humerus shattered by shot. Spec. 4124. Co. D, 1st Massachusetts Heavy Artillery, aged 48 years, Avas wounded tit tlie 1.8ti4. The case was registered at the 3d division, 1 Corps, field hospital as a gunshot fracture ofthe arm. Surgeon O. Evarts, 20th Indiana, amputated at the shoulder joint, and sent to the Museum the pathological specimen represented by the Avood-cut (Fig. 481). The patient subsequently entered Carver Hospital, at Washington. Surgeon O. A. Judson, U. S. V.. noted: "Admitted October 31st, Avith gunshot Avound of the right arm. A conoidal ball passing, traversed through from before backward, producing compound comminuted fracture of the upper third of the humerus. Amputation of the right arm at the shoulder joint by tlie U flap method Avas performed on the field October 3d. The result was favorable; the Avound healing nicely upon admission. Treat- ment, simple dressing. Constitutional state, good. There has been no unfavorable complication in this case. Wound doing remarkably well at date of transfer, November 30, l^iil." Tlie specimen consists of "the upper half of the right humerus. The bone has been shattered throughout tbe upper third of its shaft, and Avas amputated at the joint."—(Cat. of Surg. Sect., A. M. M., 1836, p. 91.) The patient Avas treated in hospital at Readville, Massachusetts, until June 15, 1835, Avhen he Avas discharged and pensioned. The records of the Pension Bureau do not furnish evidence as to the present condition of the stump. The pensioner was paid December 4. 1>74. lie received an artificial arm from Mr. Marvin Lincoln, June 3, 1K55. The cicatrix was then in good condition. Case 1592.—Private H. K. Atkinson, Co. G, -Cth Pennsylvania, aged 47 years, Avas wounded in front of Petersburg, September 1, 1834. He Avas admitted to a Tenth Corps field hospital, and Avas operated on by Surgeon C. M. Clark, 39th Illinois, Avho reported: ''Wounded by a spherical ball, twelve pounder. The ball struck the right arm midway between the elboAV and shoulder joints, completely denuding the extensively fractured bone of its muscles and integuments, except in the axilhiry region, and a small strip of skin on the anterior surface of the arm. The artery, vein, and nerves Avere left intact, but exposed, and, to some degree, isolated from each other. The shock to the system had been extreme; however, the man managed to Avalk with assistance to my quarters, distance one-half mile. After giving him stimulants and some nourishment, a careful examination was made. The humerus had been carried aAvay to the extent of some six inches from the head of the bone, except some few pieces that adhered to the remaining tissue. After consultation with Surgeon J. Westfall, 07th Ohio, I proceeded to remove the arm, after ligating the axillary artery; then, finding the head of the bone to be implicated, the capsular ligament was divided and it removed. The flap Avas made entirely from the axillary region, and Avas brought up so as to unite with tbe severed portion of integument over the acromial region. No anaesthetic Avas given. The flap Avas secured by silk sutures and adhesive straps, then cold-water dressing and a supporting bandage. He Avas put to bed in the field hospital, and remained under my care for two Aveeks, gradually improving in strength and the Avound healing rapidly. At the expiration of this time he was sent to General Hospital, AA-here he entirely recovered, and Avhen I last heard from him he Avas at home and Avell." The patient Avas admitted to Hampton Hospital, Fort Monroe, September 23, 1834, and Avas subsequently treated at Grant Hospital, Ncav York, and at Newark. New Jersey. He avcs finally discharged the service, and pensioned November 22, 1834. The pensioner declares: "A Rpherical case shot removed the arm from the shoulder." The pensioner Avas paid December 4, 1874. Case 1593.—Private C. W------, Co. K, 1 Cth Massachusetts, aged 19 years, Avas Avounded at Spott- sylvania Court-house, May 9. 18.54. Surgeon C. C. Jewett, 10th Massachusetts, amputated at the shoulder joint, on the field, and forwarded the specimen, represented l>y the wood-cut (FlG. 482), to the Museum. The patient was admitted to the 3d division hospital, Alexandria, on May 13th. Surgeon Page, U. S. A., reeorded: "Gunshot fracture of right humerus. Immediate amputation at the shoulder joint. Transferred June 26, 18 34, to Portland, Maine." The specimen consists of "the upper third of the right liumerus, after disarticu- lation for fracture, Avith comminution in the upper third. The epiphysis has become completely separated in the preparation."—(Cat. Surg. Sect, 1856, p. 92.) The patient was treated in Cony Hospital, Augusta, until July 12th. and then transferred to hospital at Readville, Massachusetts, under the care of Acting Assistant Surgeon J. Stearns, jr. HeAvas discharged and pensioned November 19, 18.i4. The Brooklyn Board, Drs. M. K. Hogan, T. F. Smith, and J. F. Ferguson, August 19, 1-74, certify: "Amputation of right arm at shoulder joint." The disability Avas rated total. The pensioner Avas paid March 4, 1875. He applied for commutation in lieu of an artificial limb. Case 1594.—Private L. W. TI------, Co. I, 7th New Jersey, aged 27 years, Avas wounded at Spottsylvania, May 9, 1834. On the folloAving day, amputation at the shoul- der joint Avas performed by Surgeon C. C. Jewett, lGth Massachusetts. The specimen represented by the adjacent Avood-cut (Fig. 483) Avas forwarded to the Museum by the operator. On May 14th, the patient entered King Street Hospital, Alexandria. Surgeon E. Bentley, U. S. V., recorded: •'•Shell Avound of right arm. Amputation at shoulder joint by antero-posterior flaps. Patient says that the joint Avas badly fractured. Water dressings applied. Wound of amputation suppurated profusely. Stimulants and opiates given occasionally. Ligatures all aAvay, and stump nearly healed, at time of transfer to Philadelphia, June 2?, 18 54." The patient was subsequently treated in the Christian Street and Broad and Cherry Streets Hospitals at Philadelphia, and Avas discharged and pensioned October 7, 18,54. The pensioner declares "he recei\'ed a wound from a shell, shattering the right arm, from the shoulder joint to the wrist, so badly that the next day the Avhole arm had to be removed." Surgeon C. Lehlbach, 7th New Jersey, describes the fracture as inflicted by a canister-shot. This pensioner was paid December 4, 1874. 78 Fig. 482.—Shot comminution of the right humerus in a young subject. Spec. 12:1. FIG. 4S3.—Comminu- tion by shell fragment of upper half of right humerus. Spec. 2903. 618 INJURIES OF THE UPPER EXTREMITIES. 1<1IA1\ IX. FIG. 484.—Cicatrix after an amputation at the shoulder joint in a case in which the glenoid cavity was impli- cated. [From a photograph.] Two of the three following cases exemplify painful cicatrices from neuromatous enlarge- ments. Two of them are illustrated by cuts from photographs prepared after the cicatri- zition of the mutilation; the second of these shows well the elevation of the mutilated shoulder, which is so characteristic of this amputation. It does not appear that the blood- vessels or nerves were implicated in either of these three cases: Case 1595.—Private R. M. Armsden, Co. I, 11th Vermont, aged 2:> years, wounded at Cedar Creek, October 19, 1864, entered a Sixth Corps field hospital the same day. Surgeon S. F. Chapin, 139th Pennsylvania, noted: "Gunshot Avound of left shoulder joint. Amputation at tlie shoulder joint." The patient subsequently received treatment in hospital at Philadelphia, Brattleboro', and Montpelier. In 1875, Dr. H. Janes, formerly surgeon of volunteers, contributed a photograph of this man, made at the Sloan Hospital, and copied in the adjacent Avood-cut (FlG. 484), and added further particulars ofthe case: "Wounded by a minie ball, Avhich entered in front of the inner side of the head of the left liumerus, passed through, and emerged behind at the outer border of the scapula, fracturing it. The arm Avas amputated on the field, tAventy-six hours after the injury, at the shoulder joint. From the field he Avas sent to Philadelphia, being six days on the journey. He Avas trans- ferred from Philadelphia to Brattleboro', February 1, 1865, and from Brattleboro' to Montpelier, February 28, 1855. The stump healed Avithout accident before he left Philadelphia. The entrance wound closed about the first of April, but the exit wcund remained open until August 1, 1865, Avhen a small fragment of the scapula Avas removed. The sinus closed in a day or two. He Avas discharged from service August 12, 1865. Stump tender from enlarged nerves. General health good. Disability tAVO-thirds." This soldier Avas pensioned from the date of his discharge, and Avas paid March 4, 1874. Case 1596.—Lieutenant J. D. Stokes, Co. F, 140th Pennsylvania, was Avounded at Gettys- burg, July 2, 1883. He was at once admitted to the regimental hospital. Surgeon J. AVilson Wishart, 140th Pennsylvania, reported: "Compound comminuted fracture of the head and neck of the right humerus, involving the shaft, by a conoidal ball. Amputation of shoulder joint by deltoid flap, under chloroform. The reaction from the shock Avas sIoav and imperfect, and on this account the operation was delayed until the 4th. He rejoined his regiment in January, 1864, Avith a good stump, but suffering from neuralgia, with enlargement of one of the nerves of the axillary plexus." This officer died September 17, 1864, and, on the AvidoAv's claim for pension, David McKinney, M. D., attested that he was the attending physician of Lieutenant Stokes, and that "the wound received by said Stokes Avas in his right arm, which Avas amputated at the shoulder joint. That upon his return home he Avas much reduced and his Avhole physical system much disordered, a condition superinduced by the suffering from the Avound afore- said. That for some months he continued prostrate aud suffered intensely from the Avound aforesaid, but subsequently recovered to such a degree as to be able to travel about, and in some measure direct his business affairs. He, however, suffered greatly from Iiis wound at all times, and during the months of May. June, and July, 1864, the suffering from this cause became so great as to be beyond control by opiates and medicines that could be prudently administered, and rendered an operation necessary to remove the irritating cause. A second operation Avas, therefore, after due consideration and advice of eminent surgeons, performed bv Drs. Dickson, Ritter, and others, ofthe City of Pittsburg, Avho removed a portion of the flesh and a mass of nerves from the cicatrix or face of the Avound, which appeared to be the cause of the intense suffering. For a time he seemed to improve; the intense suffering was relieved, but his system AA'as so far reduced by former suffering and medicines taken to relieve the same as to be unable to rally and recover from the operation, and in a few days he began to sink; gangrene set in, and it Avas impossible to subdue it, and he dietl about three Aveeks after the operation." There appears to have been no autopsyinthecr.se. Case 1597.—Private A. C. Chase, Co. C, 17th Vermont, aged 45 years, Avas wounded at Peeble's Farm, Virginia, September 30, 1864. He Avas sent to Washington from the field, and entered Lincoln Hospital. Surgeon J. C. McKee reported: 'Admitted October Sth. Ampu- tation at the shoulder, by the external lateral flap method, had been performed on the field, September 30th, for a shot fracture of the upper third of the humerus, near the joint." The patient Avas transferred to Sloan Hospital, Vermont, in December. Dr. H. Janes, formerly surgeon U. S. V., contributed, in 1875, a photograph, represented by the annexed cut (FlG. 485), with the folloAving history of the case : " This soldier received a gunshot wound, fracturing the upper third of the left humerus. The arm Avas amputated at the shoulder joint, on the field, tAvelve hours after injury. The Avound Avas sIoav in healing, and did not completely close until about six months after the operation. No accidents. Admitted to hospital at Mont- pelier. December 2. 1834. Discharged from the service June 12, 1865; disability tAvo-thirds." This soldier Avas pensioned from the date of his discharge, and Avas paid December 4, 1874. He states that his arm Avas amputated in a l ^ J shell fragment. Spec. 2531. the first incision, disarticulating, and then cutting the vessels and nerves in a short internal flap. But the oval methods of Larrey, Guthrie, and Scoutetten were also very often employed. In most of the cases th* continuity of the humerus was destroyed near the shoulder, and strong-jawed forceps were useful in seizing the head of the humerus and turning it to facilitate its exarticulation. The importance of raising the arm from the side, that the operator or an assistant might have a hand in the axilla, to grasp the axillary artery at the instant of its division, was generally recognized. There was rarely much trouble in controlling bleeding. Indeed, primary exarticulation1 at the shoulder for injury is a very simple operation. As much cannot be said of the inter- mediary and secondary operations. i PlEOGOFF (N.) (Grundzuge der Allgcmeinen Kriegschirurgie, u. s. vr., S. 771) is inclined to regard amputation at the shoulder joint for shot injury as a safer plan than excision; and claims that, in one regard, the latter is inferior even to the expectant conservative treatment, since it is "even more frequently complicated by rapidly increasing acute purulent oedema." G20 INJURIES OF THE UPPER EXTREMITIES, [CHAP IX. Table XLIII. Summary of Three Hundred and Sixty-eight Cases of successful Primary Amputations at the Shoulder for Shot Injury. Name. Age, and Military description. Date OF INJURY Abbott, Wm., Pt., A, 58th Ohio. Abraham, S. F., Pt., D, 56th Virginia. Adams, J., Pt., 4th U. S. C. T., age 29. Adams, S. M„ Pt., K. 12th Alabama, ago 30. Albertson, It., Pt., I, 14th Michigan. Amsden, It. M., Pt., I, 11th Vermont, age 23. Angel, H., Pt., 57th Ohio, age 19. Ashcroft, J., Sergt., K. 64th Ohio, age 31. Atchinson, II. II., Pt., G, 85th Pennsylvania, age 47. Austin, A., Pt., D, 104th New York. Bagby, T. B., Pt., C, 44th Virginia, age 19. Baker,* E., Ft., G, l!)th Ken- tucky, age 21. Ballard, J. A., Pt., K, 17th Alabama, age 25. Banks, G., Pt., E, 44th New York. Barber, G. XV., Pt., E, 9th New Hampshire, age 23. Barbor, It., Pt., C. 4M In- diana. Barth, G., Pt., F, 4th 0hi.>... Baughan, M. T, Lieut., A, Sth Virginia, age 31. Bean, C. M., Lieut., G, 5th Texas, age 24. Beck. J., Pt., I, 6th Connec- ticut, age 44. Bell. A., Pt.. A, 164th New York, age 2'.). Bennett, It., Pt., F, Sth New Hampshire, age 18. Bernheisel, L., Pt., Sth Penn- sylA-ania. age 25. Bertram, J.. Sergt, H, 58th New Vork. Bissell, E. B., Pt., K, 1st Vermont, age 20. Blackburn, XV., Pt., D, 6th AViscoDsin. Blood. S. L., Pt., K, 11th Massachusetts, age 18. Boethe, 1\, Pt.. G, 1st Perm- svlvania Reserve Artillery, ago 34. Border. It.. Pt., K, 133d Pennsyh-ania, age 18. Bowers, W., Pt., F, 5th U. S. Colored Troops, age 18. Bowles. J. H.. Pt., D, 1st Massachusetts. Box. J. F., Lieut.. A, 147th New York, age 22. BoA'd. J. IL, Pt.. E. 116th Illinois, age 19. Dec. 29, 1862. June 3, .1864. Sept. 29, 1864. Julyl, 1863. Alar. 19, 1865. Oct. 19, 1864. Sept. 2, 1864. NoA-.2o. 1863. Sept. 1. 1864. Aug. 30, 1862. July 2, 1863. May 1, 1863. April 6, 1862. May 27, 1862. Dec. 13, 1862. May 30, 1864. May 2. 1863. July 3, 1863. July 3, 1863. Aug. 16, 1864. June 3, 1864. July 30, 1864. May 9, 1864. June 8, 1662. Oct. 27. 1864. Feb. 6, 1865. May 5, 1864. Feb. 7, 1864. Dec. 13, 1662. Sept. 29. 1864. Dec. 13, 1862. July 3, 1863. July 11, J 864. Bradley, A. J., Sergt., E, | June 18, 183d Pennsylvania, age 23. 35 i Briant. G. It., Pt., A, 33d Indiana. 1854. Mav 25 1864. Nature of Injury. Left humerus splintered by a musket ball. Fracture of surgical neck of the right humerus. Fracture of upper third of left humerus. Shot through right shoulder, extensiA-e comminution of hu- merus. Fracture of right humerus Shot wound of the left shoulder joint, with much laceration. Wound of right arm by a can- non ball. Shot fracture of head and por- tion of shaft of right humerus. Fracture of middle third of right humerus by a 12-lb. spherical shot; bjne denuded; artery, vein, and nerve intact. Laceration of the right sirm, by cannon shot. Shot fracture of right humerus, shoulder joint involved. Upper third of right humerus fractured; bone shattered. Shot fracture of right humerus, high up. Shot fracture of the left arm... Shell fracturo of left humerus, with great destruction of soft parts. Shot fracture of left shoulder j.iint. Sh.it fracturo of left humerus, near the j.tint. Upper portion and neck of the righthumerusshattered; chest injured. Shot fracture of the upper por- tion ofthe right humerus. Shot wouud of right arm, with fracture ofthe humerus. Wound thr.mgh left shoulder joint: humerus fractured. Shot fracture ofjright shoulder Fracture of the upper third of right humerus by shell. Fracture of the left humerus at the surgical neck, with splin- tering. Right arm nearly severed close to the body by a cannon ball. Shot fracture of upper third of left humerus. Eight humerus fractured by a conoidal ball. Fracture of head of right hume- rus; joint opened. # Shot wound of left arm, with comminution of bone. Shot fracture of the left hume- rus and elbow joint. Shell wound of the left arm in upper third. Shot wound through the left shoulder joint. Shot fracture of upper third of left humerus. Shell wound of left arm, shat- tering the humerus. Wound by a cannon ball; left arm shot away close to the shoulder. Opera- tion. Dec. 29, 1862. June 3, 1864. Oct. 1, 1864. July 2, 1863. Mar. 19, 1865. Oct. 20, 1864. Sept. 2, 1864. Nov. 27, 1863. Sept. 1, 1664. Aug. 30, 1862. July 3, I860. Mav 1, lbii3. April 7, 1862. May 29, 1862. Dec. 13, 1862. May 30, 1864. May 2, 1863. July 3. 18o3. July 3, 1863. Aug. 17, I80I. June 3, 1864. July 30. 18o4. May 11, 1864. June 8, 1862. Oct. 27, 1864. Feb. 6, 1865. May 6, 1864. Feb. 9, 1864. Dec. 13, 1862. Sept. 30, 1864. Dec. 14, 1862. Julv 3, 1863. Julv 11. 1664. June 18, 1864. May 2C, 1864. Operation and Operator. Amputation at the shoulder by external flap method. Amputated, by Surgeon Rives, 56th Virginia. Amput d by Lisfranc's method, by Surgeon A. II. Cowdrey, 37th U. S. C. T. Disarticulated at the shoulder by double flaps. Amputation, by Surgeon E. Batwell. 14th Michigan. Amputated after the battle at Cedar Creek. Amputation at the shoulder by the oAral method. Result and Remarks. Amputated, by Surg. A. Mahon, 64th Ohio. Mc- Amputated, by Surgeon C. M. Clark, 39th Illinois; flap made entirely from axillary region. Amputated at the shoulder by external flap. Amputated at the shoulder by Lisfranc's method. Amputated by Larrey's method, with an anterior V flap...... Disarticulation at the shoulder by transfixion. Amputation at the shoulder by Dupuytren's method. Amputation at the shoulder, by Surg. W. A. Webster, 9th New Hampshire. Disarticulated, by Surg. B. F. Miller, 2d Ohio. Amputated at the shoulder, by Surg.O. S.Wood,(ifith N.York. Amputated at the shoulder, by a Confederate surgeon. Amputation at the shoulder by the flap method; abscesses formed. Disarticulation at the shoulder by the oval method. Amputation at the shoulder; flap method. Amputated, by Surgeon W. A. Webster. 9th New Hampshire. Amputated at the shoulder, by Confederate Surg. Graham. Amputated at the shoulder, by Surg. C. M. F. Muecke aud Asst Surg. C. Stein. 58th New York. Amputated at the shoulder, by Ass't Surg. E. P. Fairman, Hth \rermont. Disarticulated at the shoulder by Larrey's plau. Disarticulated at the shoulder; lateral flaps. Disarticulated at the shoulder, by Surg. A. N. Dougherty, U. S. V. Amputated at the shoulder, two hours after injury, by circular method. Amputated at the shoulder, by Confederate Surg. Van Dell. Amputation, by Surg. J. M. Merron. 2d New Hampshire. Amputated at the shoulder by transfixion. Amputated at the shoulder, by Surg. A. C. Messenger, 57th Ohio. Amputated at the shoulder, by Surg. J. W. Wishart, 140th Pennsylvania. Amputated at the shoulder, by Surgeon R. F. Bence, 33d Indiana. Discharged April 18, 1863, and pensioned. Furloughed August 10, 1864. Discharged November 10, 1865; pensioned. Recovered; paroled November 12, 1663. Discharged May 16, 1865, and pensioned. Disch'd Aug. 12,1865; pensioned. Transferred to V. R. Corps, March 29, ] 86.5; discharged June 30, 1865; pensioned. Disch'd Oct. 12.1864; pensioned. Died Jan. 21, 1869, of "tuber- cular consumption resultingfrom the wound." Discharged November 22. 1864 ; pensioned. Disch'd Oct. 3, 1862; pensioned. Recovered; exchanged Septem- ber 14, 1863. Discharged September 2, 1863; pensioned. RecoA'ered; sent to military prison April 27, 1862. Discharged September 23, 1862; pensioned. Disch'd Mar. 13,1863; pensioned. Disch'd Oct. 27,1864 ; pensioned. Disch'd June 22. 1863; pensioned. RecoA'ered; exchanged March 3, 1864. Recovered; exchanged March 17, 1864. Discharged September 4, 1864; pensioned. Disch'd Mar. 31,1865; pensioned. Discharged January 20, 1865; pensioned. Disch'd May 1, 1865; pensioned. Disch'd Aug. 14,1862; pensioned. Died January 15, 1874. Disch'd July 25,1865; pensioned. Disch'd June 16,1865; pensioned. Disch'd July 25,1865; pensioned. Disch'd Nov. 18,1864; pensioned. Spec. 2042, A. M. M. Disch'd Mar. 27,1863; pensioned. Disch'd June 8,1865; pensioned. Disch'd Mar. 12,1863; pensioned. Discharged November 5, 1863; pensioned. Disch'd Oct. 24,1864 ; pensioned. Disch'd Oct. 12,1864; pensioned. Disch'd Feb. 6, 1865; pensioned. __________________________________________________________________________________________________________1______________________ * BRrANT (J.). A Short Account ofthe "Mary Ann" Hospital. Grand Gulf. Miss., in The Am. Med. Times. 1««3. Vol. VII, p. 4, CASE I SF.CT. III.l AMPUTATIONS AT THE SHOULDER JOINT. 621 Name, Age, and Military description. Broolcins, J. il., Pt., B, 37th Georgia, age 22. Brown, G.. l't., K, 25th Ohio. Brown, C I... l't.. G, 59th Massachusetts, age 28. Brown, J., Pt., E, 1st Mary- land, age 33. Brown. P. J., Pt., I, 147th Now York, ago 25. Brown, S., Pt., F, 7th In- diana, age 22. Brown. T. M. C. Pt., F, 48th Now York, aire 33. Burk. A., Pt., V, 67th Penn- sylvania, age 22. Burke. J.. Pt.. A. oth Mary- land. ISurkhart. S.. Pt., B, 88th Pennsylvania, age 28. Bumham. AA". J., Corp'l, K, 5oth Pennsylvania. Bnssey, J. F., Pt., C. 87th Indiana, age 20. Byers, J. K., Lieut.. F, 121st Pennsylvania. Coll. D., Pt., Marine Corps. Callahan. M.. Pt,, A. 30th Ohio, age 33. Cased!. M. M.. Corp'l. K, 2.'th Ge >r^ia, age 26. Catlctt. IS. J.. Corp 1. I. 55th North Carolina, age ID. Chanel. At. H.. Pt., K, Sth New Vork Heavy Artillery Charters, J., Pt.,C, 5th Maine. Chase, A. C, Pt., C, 17th A'ermont. age 45. Choate. C, Corp'l, K, 16th Maine. Clark, L. E., Pt., I, 14th Ohio, age 18. Clay, W. H., Pt., A, Gth AVisconsin. Coddington. E. H.. Sergt., F, 14th Iowa. Cole, T.. Pt., B, Sth Mich- igan, age 44. Coles. A. W., It., E, 39th Massachusetts, age 31. Conlin, J., Pt.. D, 49th Penn- sylvania, aire 30. Connell. J. E., Serge., I, 50th Georgia, age 27. Coppes, F., Lieut,, C, 72d Pennsylvania. Croft, W. N, Pt., C, 61st Georgia, age 22. Crowder, J., Sergt., F, 40th Virginia, age 27. Cunningham, J., Pt., B, 11th Massachusetts. Cunningham. F., Pt., H, 142d Pennsylvania. , Daft, J." (',.. l>t., C, 14th New Jersey, age 21. Dana, A., Corp'l, E, 2d U. S. Cavalry, age 27. Date OF Injury Nov. 30, 18,14. Mav 2. 1863. Mar. 29, 1865. May 8, 1864. July 1, 1863. May 6, 1864. July 30, 1864. June 2, 1864. Sept. 17, 1662. May 23, n-ui. Nov. 2, 1862. June 18, 1864. Dee. 12, 1862. May 22, 1664. July 21 1864. Nov. 30, 1864. Julv 3, 1863. June 3 1864. Sept.14 1864. Sept. 30, 1864. June 17, 1864. Sept. 1. 1864. Aug. 28, 18 i2. Feb. 13. 18fi2. May 5, 1864. Feb. 1865 May 6, 1864. Julv 2, 1863. Mav 6, 1864. Julv 2, 1863. July 3, 18.13. Aug. 29. 186 2. Dec. 13, 1862. Mav 13, 1864. June 11, 1864. Nature of Injury. Shot wound of right arm and puncture of tho humerus. Shell fracture of loft humerus; laceration i Is tt parts. Fracture of head of humerus and acromial process hy a fragment of shell. Shot fracturo of right humerus, with extensive lissuring and injury of vessels. Shot wound of left arm, tho humerus splintered. Shot fracture of upper third of right arm. Shot fracture of right humerus Wound of right arm, with frac- turo of the humerus. Shot fracture of left humerus, with lesions > f soft parts. Ball shattered the greater tube- rosity, fractured the articular surface, and lodged in head of the humerus. Shell wound of right arm, with fracture of the humerus. Shot fracture of right arm at shoulder. Shot wound through right arm and shoulder. Shot wound of left arm, with comminution of the bone. Shot wound of middle third of left arm, with splintering. Shot wound of left arm, the humerus shattered. Shot fracture of left humerus in upper third. Shot wound of left arm, the humerus fractured. Accidental shot fracture of left humerus: ball passed through lung and emerged from the back. Fracture of the upper third of the left humerus. Shell wound of right shoulder, the head of the humerus shat tered. Comminuted shot fracture of upper third of left humerus. Shot wound of right shoulder joint. Fracture of left humerus one inch below the head by grape- shot. Right humerus shattered at the surgical neck. Shot wound of upper third of left arm, with extensive com- minution of the humerus. Shot wound of left shoulder joint. Fracture of the left humerus by a large projectile. Shot wound of left arm........ Shot fracture of the head of the left humerus. Upper third of right humerus fractured by a conoidal ball. Shot wound of left arm, involv- ing the vessels and bine. Shot fracture of left humerus near the shoulder. Shot wound of right shoulder joint, humerus fractured. Head and four inches of shaft of right humerus fractured by a conoidal ball. Opera- tion. Deo. 2, 1864. May 3, 1863. Mar. 20, 1865. May 8, 1864. July 3, 1863. Alav (i. 1864. July 30, 1864. June 2, ept. 18, May 24, 1864. Nov. 2, 1862. June 18, 1864. Dec. 14, 1862. May 23, 1864. July 23, 1864. Dec. 1, 1864. July 4, 1863. .Tune 3, 1864. Sept. 14, 1864. Sept, 30, 1864. June 19, 1854. Sept. 2, 1864. Aug. 30, 1862. Feb. 14, 1862. May 6, 1864. Feb. 7, 1865. Mav 6, 1864. Julv 3, 1863. May 8, 1864. July 3, 1833. Julv 3, 1863. Aug. 30, 1862. Doe. 13. 186 2. Mav 13, 1861. June 11 1864. Operation and Operator. Disarticulation at the shoulder by tlie double flap method. Amputation ut tho shoulder by the oval method. Amputated by inner and piste- . rior flaps, by Surg. \V. In- galls, 5./th Massachusetts. Amputation tit the shoulder by double tlap method. A inputation at the shoulder, by a Confederate surgeon. Amputated at the shoulder, by Surgeon Geo. W. New, 7th Indiana. Amputation at the shoulder by antero-posterior flaps. Amputation at the shoulder by transfixion. Amputation at the shoulder by anteru-pr sterior flaps. Amputated at the shoulder by oval flap operation, by Surg. J. AV. Kawlings, 88th Penn- sylvania. Amputated at the shoulder, by Ass't Surg. J. C. Lyons, 56th Pennsylvania. Amputated, by Surgeon C. E. Triplett, 87th Indiana. Amputated at the shoulder, by Surg. P. F. Whitehead. Amputated at the shoulder, by Surg. Fletcher, C. S. A. Disarticulated at the shoulder by transfixion. A inputation at the shoulder by antero-posterior flap. Disarticulated at the shoulder by the oval method. Disarticulated at the shoulder, by a Confederate surgeon. Amputated at the shoulder by the circular method. Lateral flap amputation at the shoulder. Disarticulation at the shoulder, by Surg. C. Alexander, 16th Maine. Amputation at the shoulder by Lisfranc's method, by Surg. C. N. Fowler, 105th Ohio. Amputated at the shoulder, bv Surg. J. McNulty, U. S. V. Amputation at the shoulder by the OAral method. Amputated at the shoulder, by Surgeon H. F. Lyster, 5th Michigan. Amputated at the shoulder by the double flap method, by Surgeon AV. Thorndike, 39th Massachusetts. Antero-posterior flap amputa- tion at the shoulder. Amputation at the shoulder by Lisfranc's plan. Amputation at the shoulder, by a Confederate surgeon. Antero-posterior flap amputa- tion at the shoulder. Disarticulation at the shoulder by lateral flaps. Aninutation at the shoulder by (1 mble flaps. A i n [i i ;t itipn at the shoulder, by Sunr. ('. Bower, 6th Penn. Amputation at the shoulder joint; Hap operation. Amputation at the shoulder joint, by Ass't Surgeon J. W. Williams, U. S. A. Result and Remarks. Transferred to Provost Marshal, f r exchange, January 7, 1865. Discharged November 18, 1863; pensioned. Disch'd Aug. 19,1865; pensioned. Wound frequently breaks out and becomes a running sore. June 13th', second y haemorrhage, controlled by pressure on sub- clavian. Discharged May 23, 1864; pensioned. Promoted to lieutenant. Disch'd September 3, 1864; pensioned. Stump sound. Sent to his regi ment and mustered out Sept. 20, 1864; pensioned. Discharged November 7, 1864; pensioned. Disch'd Nov. 12,1864; pensioned. "Stump'vcrytender; neuralgic pains upon pressure." Disch'd Jan. 12,1863; pensioned. Neuralgia in stump. Discharged November 3, 1864; pensioned. Spec. 4126, A. M.M. Disch'd May 25,1863; pensioned. Disch'd Nov. 2, 1864; pensioned. Pension Report says: "Two inches below shoulder joint." Disch'd Oct. 14,1863; pensioned. Disch'd Oct,26, I860; pensioned. Pension Board, March 20, 1873, certifies: "Large aneurism of i subclavian above ligature." j Disch'd Mar. 2o, 1815; pensioned. Sent to Provost Marshal January 31, 1866. Exchanged March 3,1864. Disch'd Jan. 28,1865; pensioned. ] Both wounds healed without trouble. Discharged March 21, I 1865; not a pensioner. Disch'd June 12,1865; pensioned. Disch'd Dec. 7, 1864; pensioned. Disch'd Mar. 22,1865; pensioned. Disch'd Nov. 13,1862; pensioned. Disch'd Aug. 15,1862; pensioned. Shoulder weak and shrivelled; indistinct respiratory murmur over right lung. Slow progress. Disch'd Oct. 3, 1864; pensioned. Disch'd May 18,1865; pensioned. Pension Examining Board. Jan. 6, 1875, states: "About 2 inches of the superior extremity of the humerus remain, but in dislo- cated condition." Disch'd Dec. 4, 1864 ; pensioned. July 19th, gangrene of stump; sol. chlor. sod. applied; Dee. 8th, erysipelas over shoulder. Exchanged March 17, 1864. Disch'd Sept. 9, 1864; pensioned. Sent to Provost Marshal Sept. 10, 1863. Exchanged March 3, 1864. Disch'd Oct. 15,1862; pensioned. Disch'd Mar. 6, 1863; pensioned. Disch'd April 3, 1865; pensioned. Walked about day after operation. Discharged and pensioned. 022 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. 79 90 91 92 93 94 95 9G 97 98 99 100 102 103 Name, Ace, and Militauy descuh'tion. Davis, T. R., Pt., C, 1st Texas Battalion, agb 28. Dean, B. D., Sergt., A, 9th Louisiana. Dean, J., Pt., I, 9th Penn- sylvania. De Condres. L. C, Corp'l, K, 16th Wisconsin. De Graffe, C, Pt., D, 61st New York. Dennison, J. T., Corp'l, G, 67th New York, age 21. Derstine, G. A., Pt., B, 10th U. S. Infantry. Dewey, F., Pt., A, 36th Wis- consin, age 42. Dieck, A., Pt., B, 3d Mis- souri, age 32. Dietrick, G., Pt., C, 140th New York. Dietzman, G., Pt., A, 17th Missouri. Dobbins, T., Pt., E, 25th Missouri. Dodds, E., Sergt., C, 21st Now York Cavalry. Doggett, D. S., Pt., F, 35th Virginia. Dolan, J., Pt.,B, 20th Indiana, age 36. Dolph, W., Corp'l, D, 53d Pennsylvania, age 28. Dorsch, II., Pt., C, 48th Penn- sylvania. Doyle, P., Pt., K, 3d Dela- ware, age 30. Drake, J., Pt., D, 73d Ohio, age 24. Dunbar, J. L., Pt., 37th Mas- sachusetts, age 27. Dunkel, J., Pt., G, 115th Pennsylvania. Dunn, J., Pt, 1,121st Ohio.. Dusenbury, G. W., Pt., E, 40th Indiana, age 21. Eady, E. H., Sergt,, B, 9th Louisiana, age 23. Eckinroth, H., Pt., G, 148th Pennsylvania. Egner, C, Pt., K, 8th Penn sylvania Cavalry, age 28. Eichler, C, Sergeant-major, 10th Minnesota, age 36. Ettinger, G., Pt., A, 13th Indiana. Evans, E. A., Corp'l, D, 8th Georgia, age 24. Ewing, J., Pt., H, 49th Penn- sylvania, age 35. Fairfield, I. M., Pt., D, 27th Michigan, age 22. * Fallon, E., Pt., 12th New York Battery, age 26. Fellew, & H., Pt., C, 3d South Carolina. Daii: OF Injury June 14, 1863. Oct. 19, 1864. Aug. 30, 1862. Oct. 4, 1862. Sept. 17, 1862. May 6, 1864. May 24, 1864. June 18 1864. May 14, 1864. May 5, 1864. May 12, 1863. Sept, 21, 1861. Aug. 21, 1864. June 9. 1863. June 18 1864.■ July 2, 1863. Sept. 17. 1862. June 18 1864. Oct. 29, 1863. April 7, 1865. •May 3, 1863. Mar. 19, 1865. Dec. IS. 1864. Oct. 19, 1864. May 2, 1863. April 7, 1865. Dec. 16, 1864. Oct. 1, 1861. July 10, 1863. Apr'128, 1864. June 3, 1864. Mav 30, 1864. July 3, 1863. Nature ok Injury. Shaft of right humerus com- minuted to the shoulder joint by spherical case shot. Comp'd comminuted fracture of upper third of humerus. Shell wound of the righ* arm. Shot wound of the right arm, the humerus shattered. Wound of the left arm by solid shot. Compound fracture of neck of left humerus. Eight arm carried away by solid shot. Shot fracture of upper third of left humerus. Fracture of left humerus by a large projectile. Shot wound of right arm, the humerus shattered. Fracture of the right humerus; shoulder joint involved. Left arm carried away clean from body, and two ribs frac- tured, by a six-pound ball. Fracture of upper third of right humerus; shoulder joint in- volved ; also fracture of max- illary bone. Right humerus fractured three inches below the head by pistol ball. Wound of the left arm by grape, the bone shattered. Head and upper portion of left humerus shattered by a conoi- dal ball. Shot fracture of upper third of left humerus. Shot fracture of upper third of left humerus. Shot fracture of left wrist, pass- ing to the upper part of the humerus, involving the shoul- der joint. Fracture of right humerus at upper third by conoidal ball; parts crushed and lacerated. Comp'd comminuted fracture of head and shaft of the right humerus. Shot fracture of right humerus, with injury ofthe vessels. Fracture of upper third of left humerus by pistol ball. Comminuted fracture of right arm. Comminuted fracture of head of the right humerus; joint opened. Comp'd comminuted fracture of head and upper portion of left humerus; also wound of chest. Fracture of left arm by a can- non ball. Accidental shot wound of right arm, fracturing the bone. Head of right humerus shat- tered by conoidal ball. Date OF Opera- tion. June 14, 1863. Oct. 19, 1864. Aug. 30. 1862. Oct. 6, 1862. Sept. 17, 1862. May 6, 1864. May 24, 1864. June 18, 1864. May 14, 1864. May 5, 1864. May 12, 1863. Sept. 20, 1861. Aug. 21, 1864. June 11, 1863. June 18, 1864. July 2, 1863. Sept. 19, 1862. June 18, 1864. Oct. 31, 1863. April 7, 1865. May-3, 1863. Mar. 19, 1865. Deo. 15, 1864. Oct, 19, 1864. May 2, 1863. April 8, 1865. Dec. 16, 1864. Oct. 1, 1861. July 10. 1863. Wound of right shoulder joint Apr'128. by a large projectile. j 1864. Shot wound of right shoulder; June 3, humerus crushed; great dis- 1864. organization of surrounding parts. < Comminuted fracture of head May30, and upper third of humerus, i 1864. Upper third of left humerus July 5, shattered, rnd flesh wound ot 1863. upper third of thigh. Operation aud Operator. Result and Remarks. Amputation at the shoulder joint by transfixion. Amputation at the shoulder by double flaps. Amputation at the shoulder by the circular method. Disarticulated at the shoulder, by Surg. S. P. Thornhill, 8th Wisconsin. Amputated three hours after injury, by Surg. J. II. Taylor, IJ. S. V. Amputated at the shoulder, by (Surg. Ph. Leidy, 119th Penn. Amputated at the shoulder by oval method. Disarticulated at the shoulder, by Surg. C. Miller, 36th Wis. Aniput'd at shoulder, by Surg. A. T. Hudson, 26th Iowa. Amputated at the shoulder, by a Confederate surgeon. Amputated at the shoulder, by Surg. C. Forster, 58th Ohio. Amputated at the shoulder, by Surgeon J. T. Hodgon. Amputated by flap method, by Surgeon G. S. Dilts, 5th New York Heavy Artillery. Amputated at the shoulder, by Surg. G. S. Palmer, U. S. V. Circular flap amputation at the shoulder. Amputation at the shoulder, by Surgeon C. S. Wood, 66th New York. Amputation at ^he shoulder by Larrey s method. Amputated at the shoulder by the flap method, bv Surg. D. E. Wolfe, 3d Delaware. Amputated by the oval method, by Surgeon I. N. Himes, 73d Ohio. Amputation at the shoulder by Lisfranc's method. Amputation by the flap method, by Surg. C. S. Wood, 66th New York. Amputation at the shoulder by transfixion. Amputated at the shoulder, by Surg. T. L. Magee, 51st 111. Amputated at the shoulder, by Ass't Surg. E. P. Clark, 31st Massachusetts. Amputated at the shoulder, by Surgeon A. N. Dougherty, U. S.V. Amputation at the shoulder by the oval method. Amputated at the shoulder, by Ass't Surg. F. H. Milligan, 10th Minnesota. Amputated at the shoulder, by Surg. A.D. Gall, 13th Indiana. Amputation at the shoulder by Dupu}-tren's plan. Amputation at the shoulder, by Surg. Ph. Leidy, 119th Penn- sylvania. Amputated at the shoulder by OA'al flaps, by Surgeon A. F. Whelan, 1st Michigan Sharp- shooters. Amputated at the shoulder by the lateral flap method. Amputated at the shoulder by the flap method. Sloughing; portion of spino of scapula and somo tissue re- moved. Exch'd Jan. 26, 1864. Sloughing arrested by turpentine and alcohol. Sent to Provost Marshal April 1, 1865. Disch'd May 27,1865; pensioned. Died Feb. 14, 1868, of pulmo- nary consumption, caused by the wound. Disch'd Nov. 10,1862; pensioned. Stump occasionally sore. Disch'd Nov. 25,1862; pensioned. Disch'd July 4, 1864; pensioned. Died January 19, 1875. Disch'd Sept. 30,1864; pensioned. Died August 25, 1868, of pul- monary disease, caused by the wound. Disch'd Oct. 24, 1864; pensioned. Disch'd Sept, 10,1864; pensioned. Disch'd Mar. 25, 1865; pensioned. Disch'd Aug. 8,1865; pensioned. Disch'd Mar. 22,1862; pensioned. Disch'd July 5, 1865; pensioned. Exchanged March 3,1864. Spec. 1234, A. M. M. Disch'd April 1,1865; pensioned. Disch'd Feb. 4, 1865; pensioned. Killed byrailroadaccident June 27, 1865. Disch'd Dec. 7, 1862; pensioned. Disch'd Mar. 29,1865; pensioned. Disch'd April 4,1864; pensioned. Disch'd July 7, 1865; pensioned. Disch'd Mar. 4, 1864; pensioned. Disch'd June 7, 1865; pensioned. Mustered out May 8, 1865; pen- sioned. Released on parole, Feb. 15,1865. Disch'd Nov. 23,1863; pensioned. Disch'd July 26,1865; pensioned. Disch'd June 13,1865; pensioned. Disch'd Jan. 16,1862; pensioned. August 11th, gangrene; ligatures removed and nitric acid applied. Paroled Sept. 23. 1863. Disch'd Jan. 16, 1865; pensioned. Wound never healed; diarrhoea, consumption; and finally death occurred Feb. 25, 1867. Disch'd May 11,1865; pensioned. Died February 24,1869. Disch'd June 12,1865; pensioned. Paroled September 25, 1863. *La'STKR (H. F.), Operations on the Shoulder, in .,1m. Jour. Med. Sci., 1865, Vol. L, p. 367 SECT. HI.J AMPUTATIONS AT THE SHOULDKR JOINT. 623 Ferguson, H. C, l't \irgiuia. 105 Fcrner, X., l't., M, 8th New York Heavy Artillery, age 21. 106 Ferris, J. J., Corp'l, K, 73d Indiana. Fielding, C, Pt,, A, 105th Ohio. Folios, It., Pt., K, York, age li). Forker, O. II. P., Serg't, H, 5!)th Illinois, ago 23. 110 French, II. IL, Sergt, F, 6-ith New York, age 28. Ill Fritzinger, J., Pt., H, 61st Pennsylvania, age 111. 112 Frizzell, W., Corp 1, II, 2d New York, age al. Fulcher, G. XV., Pt., H, 83d Indiana. Fuller, D., Pt., G, 53d Penn- sylvania. 15 Gardiner, J. E., Pt:, B, 24th Iowa, age 24. llli Garmer, G. W., l't., E, 7th Georgia. 117 Gates. G. AV., Pt,, F, 4th Maryland, age 36. 118 Gillison, S.. Pt., A, 7th In- diana, age .23. 119 Giles, J. P., Pt., L, 1st Texas. 120 Genevan, R. H., Corp'l, D, 3d Ohio. 121 Glover, R. T, Pt., D, 43d Alabama, age 22. 122 Goodloe, D. S., Adjutant, 18th Mississippi, age 24. 123 Goodrich. H. B., Pt., F, 14th Connecticut. 124 Greer, C, Pt., A, 4th Dela- ware, age 31. 125 Greyble, Cr. L.. Pt., B, 03d Indiana, age 18. 126 Griffith, T. P., Pt., I, 48th Illinois. 127 Gutermann, C, Pt., F, 2d U. S. Infantry, age 30. 128 Gyger, A., Pt., A, 122d Penn- sylvania. 129 Hacker, A., Corp'l, E, 93d Indiana. 130 Hadlock, AV., Pt.. C, Gth Iowa, age 21. 131 Hallen, B. C, Pt., A, 36th AVisconsin. 132 Ham, I. C, Pt., B, 3d Virginia Cavalry. 133 Hambke, A., Pt., H, 15th New York Heavy Artillery. 134 Hannam, S., Corp'l, B, 2d Delaware. 135 *Hardie, J. M. W., Pt., 17th Mississippi, age 19. 136 Hardy, A. E., Pt,, F, 1st Maine Heavy Artillery, age 21. 137 Harrison, A. J., Lieut., H, 12Cth Ohio, age 26. 138 * Harrison. W. IL. Pt., Pey- ton's Virgiuia Battery, age 41. Apr'130, 1863. Oct. 1862 Deo. 16, 1864. Julv 2, 1863. May 12, 1864. Mav 3, 1863. May 28, 18*63. Sept. 17 1862. April 8. 1864. Aug. 16, 1864. June 1, 1864. May 7. 1864. Sept. 29. 1864. Oct. 8, 1862. May 17, 1864. July 2 18o3, Aug. 25. Iful. Oct. 8, 18S4. Dec. 16, 1864. April 7, 1862. May 1, 1863. May 3, 18U3. May 22, 1863. Nov. 22, 1664. June 18, 1864. June 21, 1864. Aug. 18, 1864. July 3, 1863. Sept. 17, 1862. Oct. 2, 1864. May 6, 1864. Sept. 17, 1862. Shot fracture of left arm and lesion of tho brachial artery. Grapeshot wound of middle third of left arm. Shot wound <.f tho left arm and right hand; hand totally de- stroyed with the oxception of the thumb. Fracturo of right humerus, in- volving shoulder joint; arm nearly torn off by shell. Fracture of left arm by a large missile. Shot comminution of head and upper third (if left humerus. Ball entered at anterior extrem- ity of second rib and emerged at outer sido of right arm, fracturing humerus. Shot wound of right arm at upper third. Fracture of upper third of right arm by a conoidal ball. Fracture of left arm by grape- shot. Ot'lC'tA- TION. July 3, 1863. Juno 4, 1864. \pr'130 1863. Oct. 10, 1062. May 6, 1862. Dec. 17, 1864. July 4. 1863. May 12, 1861. May 3, 1863. May 28, 1863. Operation and Operator. Shell wound of both arms, with Sept. 17, fracture of right humerus. 1862. Shot fracture of the head of the left humerus. Shot fracture of upper third of left humerus. Shot fracture of left humerus near shoulder joint. Shot fracture of upper thud of left arm. Shot fracture of upper third of left humerus. Grapeshot wound of left arm. severing arm from body. Shot fracture of the head of the humerus. Comp'd comminuted fracture of upper third of left humerus. Shot fracture of left shoulder joint. Fracture of left humerus by a cannon ball. Comminuted shot fracture of lower third of right humerus. Wound of right shoulder joint by a shell. Shot fracture of the head of left humerus. Shot wound of right shoulder joint. Fracture of left shoulder by a conoidal ball. Shell fracture of right humerus, high up. Shell fracture of upper third of left humerus. Shot wound of humerus, shat- tering its upper part. Shot fracture of left humerus. Shell fracture of left humerus; arm carried away. Conoidal ball comminuted the upper portion of the right humerus. Shell fracture of head and surg- ical neck of right humerus, acromial process of scapula. and probably glenoid cavity. Comp d comminuted fracturo of right humerus. Lower half of left arm torn off by a fragment of shell: no bleeding from torn A-essels. April 9, 1864. Aug. 16. 1864. June 2, 1864. May 7, 1864. Sept. 29. 1864. Oct. 8, 1862. May 19, 1864. July 2, 1863. Aug. 26, 1854. Oct. 9, 1864. Deo. 17, 1864. April 7, 1862. May 1, 1863. May 3, 1863. May 24, 1663. Nov. 22, 1864. June 18, 1864. June 21, 1864. Aug. 20, 1864. July 3, 1863. Sept, 17, 1862. Oct. 2, 1864. May 7, 1864. Sept. 18, 1862. Amputation at tho shoulder by Larrey's method. Amputation at the joint by cir- cular method, by .Surgeon J. L. Brenton, 8th Ohio. Left arm amputated at shoul- der, hy Ass t Surgeons W. Speneer and S. F. Myers, 73d Indiana. Amputation at the shoulder, by Surgeon C. N. Fowler, 105th Ohio. Amputated at the shoulder, bv Surgeon .1. A. Skilton, 87th New York. Amputation at the shoulder by tho antero-posterior flap method, by Act. Ass't Surg. J. E. Link. Antero-posterior flap amputa- tion, by Surg. D. E. Kclsey, 64th New York. Amputation at the shoulder by lateral flap. Amputated at the shoulder, by Ass't Surg. George King, 16th Massachusetts. Amputated at the shoulder by double flap operation,by Surg. M. W. Bobbins. 4th Iowa. Eight arm amputated at the shoulder joint. Amputation at the shoulder by the oval method. Flap amputation at shoulder, by the regimental surgeon. Lateral flap amputation, by Surgeon It. II. Robinson, 7th Maryland. Amputated at the shoulder, by Surg. G. AV. New, 7th Ind. Amputated at the shoulder, by Surg. E. M. AVaters. C. S. A. Amputated at the shoulder, by Surgeon R. R. Meens. Amputation at the shoulder ... A mputation at the shoulder by Lisfranc's method. Amputation at the shoulder, by Surg. G. Chaddock, 7th Mich. Flap amputation at shoulder, by Surg. A. A. AVhite, 8th Maryland. Flap amputation at shoulder, by Ass't Surg. G. E. Irwin, 93d Indiana. Amputation at the shoulder by Larrey's plan. A mputation at the shoulder, by Ass't Surgeon J. S. Billings, U. S. A. Amputated at the shoulder, by Surg. F. Reynolds, 88th N. Y. Amputated at the shoulder, by Surg. M. AV. Fisk, 11th Mo. Amputated at the shoulder, by Surg. R. Morris, 103d Illinois. Amputated at the shoulder, by Surg. D. W. Maull, 1st Del. Amputated at the shoulder, by Surg. E. I. Habersham.C.S.A. Amputated at the shoulder by antero-posterior flaps. Amputation at the shoulder, by Dr. Higgins. Flap amputation at the shoul- der. Amputated at the shoulder, by Surgeon D. S. Hays, 110th Pennsylvania. Amputated at the shoulder, by a Confederate surgeon. Flap amputation at the shoul- ■ der. Result and Remarks. Necrosed portion ofthe acromion process removed; retired Aug. 29, 1864. Disch'd Jan.31, 1865; pensioned. Disch'd Oct. 21, 1863; pensioned. Disch'd Dec. 30,1862; pensioned. Disch'd Aug. 8, 1862; pensioned. Nov. 14, 1862, a neuroma at the lower portion of the cicatrix was excised by Dr. F. M.'Markoe. Stump remains tender. Disch'd July 12,1865; pensioned. Disch'd Jan. 29, 1864; pensioned. Disch'd July 15,1864; pensioned. Disch'd Mar. 26,1863; pensioned. Died Jan. 28, I860, of disease of right lung, the result of wound. Disch'd J uly 27,1863; pensioned. Died February 23, 1671). Oct. 5, 1862, amputation of left forearm at upper third. Disch'd Dee. 17, 186-'; pensioned. Disch'd Aug. 5, 1864; pensioned. Exchanged August 21, 1864. June21st.sloughing; nitrateof sil- A-erandchLrine applied. Disch'd Sept, (>, 1864; pensioned. Mustered out September 20,1864; pensioned. Furloughed October 8. 1864. Disch'd Dec. 23,1862; pensioned. Fcetid discharge at first; May 31 st, convalescing. Aug. 25, 1863, abscess opened in axilla. Exch'd Mar. 3, 1864. Disch'd April 29,1865; pensioned. Disch'd July 20,1865; pensioned. Disch'd July 29,1865; pensioned. Disch'd July 17,1862; pensioned. Disch'd Feb. 5, 1864; pensioned. Mustered out May 15, sioned. Disch'd Aug. 8,1863; Disch'd Feb. 21,1865; Disch'd Sept. 27,1864; Retired from service 21, 1864. Disch'd Dec. 6, 1864; Disch'd Oct. 9, 1863; Convalescent October 1863; pen- pensioned. pensioned. pensioned. September pensioned. pensioned. 1, 1862. Disch'd Aug. 30,1865; pensioned. Stump sensitive. Spec. 4115, A. M. M. Stump sound. Disch'd Dec. 20, 1861; pensioned. October 1, 1862, doing well. * See Fischer, G. J., Report of Fifty-seven Cases of Amputation, in the Hospitals near Sharpsburg, Md., after the Battle, of Antietam, September 17, 1862, in Am. Jour. Med. Sci., 1863, Vrok XLV, N. S., p. 48. i:U INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. Name. Aoe, and Military Description. Date OF Injury. Hiwkins. W. II.. Pt., L, 21st North Carolina, age 36. Hayes. G., Pt., F, 54th Mas- sachusetts Colored Troops. Hayes, W. M., Pt., E, 2Cth Georgia Batt. of Cavalry, age 19. Haynes, W., Pt., K, 3d East Tennessee, age 24. Hazeltine, H. IL, Pt., I, 4th Vermont, age 33. Heaton, S.. Pt., F, 1st Penn- sylvania Cavalry. Hedick, A., PL, B, 23d North Carolina, age 23. Heistonbrittle, D., Pt., C, 44th New York, age 24. Held, F., Sergeant, B, 56th Ohio. Hendrickson, L. C, Pt., K, 95th Pennsylvania. Henesy, T. J., Pt., C, 10th Vermont, age 30. Henry, O., Pt., F, 61st New York. Hewins, G. W., Pt., E, 3d AVisconsin. Hicks, C. A., Pt., H, 11th Mississippi. Higgins, L., Pt., G, 148th Pennsylvania, age 31. Hill, J. A., Pt., A, 13th Illi- nois. Hobbs, G., Pt., D, 1st Mass. Heavy Artillery, age 46. Holley, H. II., Pt., II, 26th Michigan, age 20. Hollowell, C. II., Pt., G, 1st Mississippi Mounted Marine Brigade, age 23. 158 Homans. C, Corp'l, E, 39th New York, age 19. Hooper, AV. II.. Pt., K, 12th Massachusetts, age 27. Houck, A., Pt., E, 84th Penn- sylvania, age 20. Houghton, C. W., Lieut., C, 27th Michigan, age 28. Houston, R., Sergt., A, 59th New York. Huenemann, J. B.', Pt., I, 70th Ohio, ege 24. Huffmann, L. XV., Pt., I, 7th New Jersey, age 27. Sept. 19. 1864. Feb. 10, 1865. June 11, 1864. May 14. 1864. May 5, 1864. Nov. 12, 1862. May 3. 1863. Sept. 30, 1864. May 16. 1863. June 1, 1864. Oct. 19, 1864. June 29, 1862. June 9, 1863. July 3, 1863. May 5, 1864. Dec. 29, 1862. Oct. 2, 1864. May 12, 1864. June 2, 1864. May 9, 1864. July 3, 1863. Aug. 6, 1864. Mav 12, 1864. July 3, 1863. A.ug. 26, 1864. May 9, 1864. Hughes, P., Corp'l, F, 2d, May 31. U. S. Cavalry, age 28. ; 1864. Hull, B., Pt., K. 9th New Dec. 16, Jersey, age 28. 1862. 167 Hurley, C, Pt., II, 1st South ! May 3, Carolina, age 24. i 1863. 168 ' Hutchins, S., Pt., E, 2d New Aug. 14, York. 1864. Hutchinson, L. M., Pt., B, 'Aug. 21, 21 st South Carolina, age 22. | 1864. Hutton, E. R., Corp'l, O, 53d July 12, Illinois, age 21. I 1863. Ingle, XV. II., Pt., K, 49th Mayi.~, Ohio, age 22. j 1864. Jamison. J. H., Pt., E, 148th May 12, Pennsyh-ania. ; 1664. Johnson, J., PL, D, 2d Wis- Dec. 13. consin. 1862. Nature of ln.ury. Date Opera- ! TION. Comp'd comminuted fracture cf upper third of left humerus and laceration of soft parts; joint involved. Light arm shattered, forearm torn away.both eyes destroyed by accidental discharge of a cannon. Shot wound of right arm, with fracture high up. Comp'd comminuted fracture of upper third of right hu- merus ; also wound of hip. Comminuted fracture of left humerus by a grapeshot; soft parts much lacerated; joint inA'olved. Shot wound cf right, arm, Avith humerus shattered. Shot fracture of right humerus, extending into joint. Comp'd comminuted fracture of upper third of left humerus. Shot fracture of right arm near the shoulder. Shell wound of right arm, with lesion of the A'essels. Shot fracture of upper third of left humerus, extending into joint, and injury of scapula. Shell wound of right shoulder, with fracture. Shot Avound of left shoulder joint; humerus fractured. Shot fracture of neck of right humerus. Comminuted fracture of upper third of left humerus. Fracture of left humerus by a fragment of shell. Compound fracture of upper third of right humerus. Shot fracture of neck and shaft of right humerus. Wound of right arm by solid shot. Head of left humerus fractured by a musket ball. Fracture of upper third of right humerus. Shot wound of right arm; bone shattered. Shot wound of left arm, with injury of bone and artery. Shell fracture of right humerus, with laceration of the soft parts. Shell fracture of the head of the left humerus. Comminuted shell fracture of upper third of right humerus. Shot wound of right arm aboA-e and below elbow joint, badly fracturing bones. Upper third of left humerus shattered by grapeshot; soft parts, A'essels, andnerves torn; no shock. Shot fracture of upper third of arm. Shot fracture of right humerus at the surgical neck, with wound of brachial. Sept. 21 1864. Feb. 10, 1865. June 11. 1864. Mav 14, 1664. May 6, 1864. Nov. 12, 1862. May 5, 1863. Oct. 1, 1864. May 18, 1863. June 1, 1864. Oct. 19, 1864. June 29, 1862. June 9, 1863. July 5, 1863. Mav 6, 1864. Dec. 29, 1862. Oct, 3, 1864. Mav 12, 1864. June 2. 1864. May 10, 1864. July 4, 1863. Aug. 16, 1864. May 12, 1864. July 4, 1863. Aug. 26, 1864. May 11, 1864. May 31, 1864. Dec. 16, 1862. May 3, 1863. Aug. 14. 1864. Operation and Operator. Shot wound of middle third of Aug. 21, arm. 1864. Shot fracture of right humerus July 12, 1863. Shot wound of left shoulder May 29, joint. Shot fracture of right humerus Fracture of upper third of right arm bAr a cannon ball. 18C4. May 13, 1864. Dec. 13, 1862. Amputated at the shoulder by Larrey s method, by .Surgeon E. L. Brevard, C. S. A. A mputated at the shoulder, by Ass't Surg. N. S. Roberto, 21st U. S. Colored Troops. Amputated at the shoulder, by Surgeon Metcalf. Amputated at the shoulder, by Surgeon C. W. McMillan, 1st Tennessee. Flap amputation at the shoul- der, by Surgeon D. M. Good- win, 3d Vermont. Amputation at the shoulder, by Surgeon D. Stanton, 1st Penn- sylvania CaA-alry. Flap amputation at shoulder . Amputation at the shoulder by the oA-al method. Amputation at the shoulder by transfixion. Flap amputation at the shoul- der, by Surg. E. P. B. Kelly, 95th Pennsyh'auia. Double flap amputation, bv Surg. T. A. Helwig, 87th Pennsylvania. Amputation at the.shoulder by the OA'al method. Amputation at the shoulder by Lisfranc's method. Amputation at the shoulder by double flaps. Lateral flap amputation at the shoulder, by Surg. J. Eber- solc, ISth Indiana. Amputated at the shoulder, by Surg. S. C. Plummer, 13th Illinois. U-flap amputation, by Surg. D. Evarts, 2Cth Indiana. Amputated at the shoulder, by Surg. J. W. Wishart, 140th Penusylvania. Amputated at the shoulder, by Surg. J. Roberts, 1st Miss. Mounted Mar. Brigade. Amputated at the shoulder, by Surgeon P. E. Hubon, 28th Massachusetts. Flap amputation at shoulder... Flap amputation at shoulder.. Amputation at the shoulder by the OAral method. Amputated at the shoulder, by Surg. W. J. Burr, 42d New York. Amputated at the shoulder, by Asst. Surg. D. Holderman, 46th Ohio. Antero-posterior flap amputa- tion, by Surg. C. C. Jewett, 16th Massachusetts. Double flap amputation, by Asst. Surg. C. I. Wilson, U. S. A. Double flap amputation at the shoulder, by Surg. Geo. A. Otis, 27th Massachusetts. Amputation at the shoulder by transfixion. Antero-posterior flap amputa- tion. Flap amputation at shoulder... Amputation at the shoulder by the OA-al method. Amputated at the shoulder, by Surg.ILB.Tuttle.80th Illinois. Flap amputation at shoulder.. Result and Remarks. Released April 18, 1865. Disch'd Sept. 8, 1865; pensioned. Wound healed, but tender. Retired January 30, 1865. Disch'd Feb. 23, 1865; pensioned. Disch'd Oct. 22, 1864; pensioned. Disch'd Dec. 10,1862; pensioned. Furloughed July 11, 1863. Disch'd Mar. 14,1865; pensioned. Disch'd Noa'. 5, 1863; pensioned. Disch'd Dec. 5, 1864; pensioned. Disch'd May 27,1865; pensioned. Disch'd May 5, 1863; pensioned. Disch'd Oct. 7, 1863; pensioned. September 30th, wound healed; discharged October 12, 1863. Disch'd Jan. 23, 1865; pensioned. Spec. 93, A. iM. M. Died Feb. 14, 1870. Disch'd Feb. 19,1863; pensioned. Disch'd June 15,1865: pensioned. Spec. 4124, A. M. .AI. Disch'd Nov. 29,1864; pensioned. Disch'd Jan. 10, 1865; stump healed; pensioned. Disch'd Jan. 28,1865; pensioned. Disch'd April 11,1864; pensioned. Slight sloughing. Disch'd Sept. 2, 1865; pensioned. Disch'd Oct. 5, 1864; pensioned. Entered Veteran Reserve Corps April 8, 1865. Abscess formed. Disch'd Oct. 7 1863. Entered V.R.C. Disch'd June 15, 1864; pension allowed but never called for. Disch'd April 9, 1865; pensioned. Mustered out October 7, 1864; pensioned. Spec. 2903, A. M. M. Returned to duty, and discharged from service April 1, 1865, and pensioned. Jan. 16, 1863, wound cicatrized; transferred to V. R. C. Dec. 5, 1863. Discharged Sept. 9,1864; pensioned. Exchanged July 3, 1863. Sept, 30, 1864, secondary hsemor- rhage; axilla artery ligated at the stump. Dioch'd Nov. 22, 1864; pensioned. Sent to Old Capitol Prison Nov. 26. 18G4. Disch'd Dec. 4, 1863; pensioned. Disch'd Dec. 9, 1864; pensioned. Disch'd Oct. 7, 1864; pensioned. Flap amputation at shoulder, i Disch'd AprillO, 1863; pensioned. AMPUTATIONS AT THE SHOULDER JOINT. .>2/3 „ Date N'ime, Act:, and Military of Description. INJI K'v Johnson, J. R., Pt.; A, 15th New Jersey, ago 32. Jones, A., Sors't, 1,89th New York, ago 36. Jones. AV. M., Pt., B, SCth Illinois, age 2.>. Julian. M./l't.. D, 2d Ohio. Kaufman. N., Pt., II, 5th Ohio, ago 23. Keane, P., It., I, 124th New- York, age 25. Keller, C. AV., Pt., E, 145th Pennsylvania. Kelleher, J., Capt., C, 20th Massachusetts, age 35. Kennedy, R. V., Pt., A, 57th Pennsylvania. Kent, 11. A., Corp'l, B, 91st Ohio, age 34. Kerling, J., Tt.. B, 29th New York. 1862. Kidder. M. AV., Pt., F, 147th June 18 New York, age 33. Killoran, M.. Corp'l, H, 170th May 24, Aug. 18, 1864. Oct. 27, 1864. Mav 14, 1864. Got. 8, 1862. Mav -o, 1864. June 16, 1864. May 12, 1864. May IS. 1664. Julv 2, 1863. June 17 1864. Nature op Injury. Shot fracture of middle third of right humerus. Fracture of upper third of tho right humerus. Shell fracturo of tho left shoul- der joint. Wound of right arm........... Opera- tion. New York. Kilpatrick. R. L., Lieutenant- Colonel, Sth Ohio, age 48. King, AV. C. Serg't, D, 12th Kentucky Cavalry, age 37. Kipler, M.. Pt., 8th New Y'ork Heavv Artillery, ace 23. Kline. J., Pt., B, tth New York Cavalry, age -8. Knight, T.K., Serg't, A, 1st Georgia, age 3J. Lacy, J., Pt., I, 38th Massa- chusetts, age 21. Lafountaine, A., Pt., H, 1st Maine, age 26. Lahey, M., Pt., F, 2d U. S. Infantry. Lamb. P., Pt., A, 61st New York. Lehenann, J., Pt., E, 4th Texas, age 23. Leonard, G., Corp'l, G, 47th New Y'ork, age 21. Long, H. F., Pt.. I, 17th Pennsylvania Cavalry. Losey, H. P., It., A, 103d Ohio, i .-• 21. Loucl.^, i IL, Pt., G, 53d Pen;.--.-; vania, age 42. MaeNui;-., W. A., Serg't, A, 10th New York. Mangan, J., Pt.. D, 15th New Jersey, age 34. Marguet, M., Pt., C, 116th Dec. 13. Pennsylvania. 1862. Mark, F., Pt., A, 2d Missouri Mav 26, Light Artillery, age 26. 1861. Shot fracturo of right humerus. Shot wound of right arm, with injury of bone and vessels. Shot fracture of left humerus in upper third. Shell fracture of right shoulder joint; also wound of maxilla. Shot fracture of left arm, with much splintering. Shell wound of left arm near the shoulder joint. Aug. 29, Shot wound v.f left ami, with lesions of bone and vessels. Shot wound of right arm and fracture of humerus. Shot fracture of right humerus, high up. Shot fracture of right humerus and shot wound of left thigh. 1864. Mav 2 1863. Nov. 18, 1863. June 3, 1864. Aug. 25. 1864. . Nov. 30, 1864. Oct. 19, 1864. Mar. 25, 1865. June 27, 1862. June 1, 1862. Sept. 17, 1862. Sept. 5, 1863. May 31, 1864. May 14, 1864. Mar. 31, 1865. Dec. 13, 1862. May 12, 1864. Martin, D. AV., Corp'l, C, 1st New Jersey, age 31. Martling, R. F., Serg't, F, 119th New Y'ork, age 42. Mason, AAT. P., Pt., C, 1st Vermont Cavalry, age 18. Mathews, P., Pt., 1, 20th Massachusetts. May 5, 1864. July 1, 1863. July 3, 1863. July 3, Wound of right arm, with frac- ture near shoulder. Shot fracture of head of right humerus. Comp'd comminuted fracture of right arm. Shot wound of left arm and fracture high up. Shot fracture of right shoulder joint. Shell wound of right shoulder joint. Shell wound cf left arm, bone and soft parts injured. Gunshot wound of left shoulder. Left arm carried away by a grapeshot. Shell fracture of left arm, with much laceration. Shot fracture of left humerus.. Shot fracture of upper third of left humerus. Shot fracture of left humerus, shoulder joint involved. Shell wound of right arm, shat- tering all the bones about the shoulder joint. Comminuted fracture of middle third of right humerus. Aug. 19, 16.64. Oct.'28, 1864. May 14, 1861. Oct. 8, 1862. May 26, 1864. June 16, 1864. May 12, 1864. May 18, 1864. July 2, 1863. June 18, 1864. Aug. 29, 1862. Juno 19 1864. May 25, 1864. May 4, 1863. Nov. 16, 1863. June 4, 1864. Aug. 26, 1864. Dec. 1, 1864. Oct. 20, 1864. Alar. 2.3, 1865. June 29, 1862. June 2, 1862. Sept. 17, 1862. Sept. 5, 1863. June 1, 1864. May 14, 1864. Mar. 31. 1865. Dec. 13, 1862. May 13, 1864. Operation and Operator. Shot wound of left arm, with Dec. 13 injury to the bone and vessels. 1862. Both arms torn off by acci- May 26, dental discharge of cannon. 1861 Fracture of left shoulder joint by a large projectile. Shot fracture of left shoulder joint. Shot wound of right arm...... Mattis, I. G., Pt., F, 119th May 10, Pennsylvania, age 33. I 1864. Mattison, C. S., Pt., I, 76th ■ July 1, New Y'ork. 1863. Compound fracture of the left humerus. Shot fracture i f left humerus, with lesion of soft parts. Shot wound cf right arm, the humerus shattered. May 6, 1864. July 2, 1863. July 4, 1863. July 4, 1863. Mav 11, 1864. Amputated at tho shoulder, by Asst. Surg. AV. T. Smith, 2d Rhode Island. Amputated ut the shoulder, by Asst. Surg, (libbs, C. S. A. Amputated, by Surgeon J. D. Brumley, U.'s. A'. Amputated at the shoulder, by Surg. Ii. F. Miller, 2d Ohio. External flop amputation at the shoulder, liv Surgeon AV. K. Longshore 147th Penn. Flap amputation at shoulder . Amputated at tho shoulder, by Slug. J. AV. AVishart, 140tli Pennsylvania. Amputated, by Surg. N. Hay- ward, 2Uth Mass.; portions of clavicle and scapula were re- moved at the same time. Amputation at the 6houlder — Flap amputation at shoulder... Amputation at the shoulder by transfixion. Amputated, by Ass't Surgeon J. B. Ball, 6th Wisconsin. Amputated, by Surgeon AV. J. Burr, 42d New York. Amputation at the shoulder by anteroposterior flaps. Amputated at the shoulder, by Surg. R. L. Stamford, U. S.V. Flap amputation at the shoulder by double flaps. Amput'd at shoulder, by A. A. Surg. John Goldsborough. Amputation at the shoulder by the oval plan. Amputation at the shoulder by transfixion. Amputation at the shoulder by external flap. Amputated at the shoulder, by a Confederate surgeon. Amputation at the shoulder by transfixion. Amputation at the shoulder by double flaps. Amputation at the shoulder by Larrey's method. Amputation at the shoulder by double flaps. Amput'd at shoulder, by Surg. L. D. Griswold, 103d Ohio. Amputated, by Surg. W. H. Raymond, 26th Michigan. Amputated at shoulder; scapu- lar end of clavicle, neck of scapula, and two portions of blade of scapula, about three inches in length, removed by Surg. C. S. AVood, 66th N. Y. Amputated by double flap method, by Surgeon II. A. Minor, C. S. A. Amputation at the shoulder by the oval method. Left arm disarticulated at shoul- der ; right forearm amputated three inches below elbow, by Dr. Schmidt. Amputation at the shoulder by transfixion and external and internal flaps. Flap amputation at shoulder.. Amputation at the shoulder by Larrey's plan. Amputated at the shoulder, by Surgeon N. Hayward, 2Cth Massachusetts. Amputated at the shoulder, by Surg. Ph. Leidy, 119th Penn. Amputated by flap method, by Surgoon (1. AV. Metcalfe, 76th New York. Result and Remarks. Disch'd July 10,1865; pensioned Returned to duty Marcli 9, 1865 mustered out; pensioned. Disch'd July 5, 1864; pensioned Disch'd Feb. 23,1863; pensioned Disch'd Nov. 30,1864; pensioned Disch'd Sept. 1, 1864; pensioned Disch'd June 8, 1864; pensioned Mustered out July 30, 1864 ; pen sioned. Disch'd Dec. 3,1863; pensioned. June 29, 1864, symptoms of gan- grene. Disch'd Sept. 28, 1804; pensioned. Disch'd Mar. 31,1863; pensioned. Died Sept. 7, 1872. Disch'd Nov. 29,1864 ; pensioned. Disch'd Mar. 17, 1855; pensioned. Disch'd Aug. 17, 1863. Appointed Captain 42d Infantry July 28, 1866. Retired Dec. 15, 1870; pensioned. Disch'd Oct. 6, 1864; pensioned. Disch'd Sept. 24,1864; pensioned. Disch'd Aug. 2, 1865; pensioned. Sent to Provost Marshal March 7, 1865. Disch'd Aug. 7,1865; pensioned. Disch'd May 31, 1865; pensioned. Disch'd Sept. 16,1862; pensioned. Disch'd Sept. 18,1862; pensioned. Two abscesses opened in axilla. Discharged Nov. 30, 1862. Disch'd Dec. 30,1863: pensioned. Died of Bright's disease, May 23, 1868. Disch'd Nov. 28,1864 ; pensioned. Disch'd Sept. 26,1864; pensioned. Disch'd June 13, 1865; pensioned. Mustered out May 2, 1863; pen- sioned. Stump very tender. Copious haemorrhage. Disch'd May 16,1865; pensioned. Died Nov. 8, 1869. Disch'd July21,1865; pensioned. Disch'd Oct. 17, 1861; pensioned. Stumps in good condition. June 29, 1864, large abscess opened. Sent to his State, his time of service having expired June 23, 1864; pensioned. In September, 1864. carious bone removed. Disch'd March 11, 1865: pensioned. Disch'd Mar. 3, 1864; pensioned. Recovered; not a pensioner. Disch'd Sept. 21,1834; pensioned. Committed suicide December 14, 1867. Disch'd Oct. 31,1863; pensioned. 79 626 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. name, Agk, and Military Description. Date of Injury Me Anally, J. T., Corp'l, C, oth V. 5. Infantry, age 34. McCarty, (J., Corp'l, E, 19th Maine, age 24. McCauley, J., Serg't, A, 25th Indiana. McClaskey, A. J., Pt.. K, 1st Iowa Cavalry, age 27. McClintoc, J. H, Pt., F, 23d South Carolina, age 20. McDonald. D. C, Pt., II, 51st New York, age 21. McElhaney, V. J., PL, B, 2d New York Mounted Rifles, age 20. McGlynn, J., Pt., A, 11th Massachusetts. McGuire, P., Pt., D, 103d Ohio, age 18. Mcintosh, J. D., Pt., A, 120th Illinois. McKenna, J., Serg't, F, 12th New York OaA'alrv. MeKenzie, S. C, Pt., II, 82d New York. McLoughlin, A., PL, F, 57th Indiana. Meagher, T., Pt., C, 1st Mas- sachusetts. Mears, G. AV., Serg't, A, 6th Pennsy h-ania Reserves, age 20. Melvin, J., Serg't, F, 61st New York, age 22. Menzel, C. T., Serg't, B, 39th New York. Mercer, J. J., Pt., F, 30th North Carolina, age 25. Metealf, C. L., Corp'l, I, 1st Maine HeaA'y Artillery, age Miles, R., Corp'l, H, 148th PennsA'lvania. Miller, "A. B., PL, A, 8th Michigan, age 36. Miller, M., l't., 11, 8th Ten- nessee Cavalry. 233 Mills, J., Serg't, D, Sth Ver mont, age 21. Mitchell, J., PL, E,76th New York, age 27. 15 Mohl, AV., PL, A, 7th New Jersey. 236 Monaghan, T., PL, B, 48th New Y'ork, age 26. 17 Mond, August, Pt., I, 8th Illinois. 238 Montgomery, D. C, Corp'l, H. 3d Georgia, age 25. 239 Morrison, T. A., PL, A, 121st Pennsyh'ania. 240 Murray, L., PL, B, 5th New York, age 29. 241 [Nans, A. F., Pt., II, 118th Ohio, age 22. 12 Nelson. B. R.. Corp'l, I, 122d Ohio, ago 34. 13 Nichols. C. A., PL, E, 118th l'eun?vivan;.a. 244 Nioh.ls" J. AV.. Pt., D, 2d I Vermont, age 22. 245 Norris, G. C, Serg't. I, 61st GC rgia, age 29. 246 Noyes. A. M. Pt., C, 1st M'a--aohusetts Heavy Ar- tillerv. age 30. | 247 Nutter. J., Pt., K, !23d Ohio. 2481 Oakley, F. AV., Lieut., K, I 7th Wisconsin. June 22 1864. June 8, 1862. July 2, 1863. June 18, 1864. May 3, 1863. June 17, 1864. Nov. 11, 1864. - Sept. 19, 1864. May 5, 1864. Mav 3, 1863. June 2, 1864. Feb. 15, 1862. Julv 2, 1863. Dec. 13, 1862. .Aug. 18, 1864. Aug. 6, 1864. Mar. 25, 1865. Sept. 20, 1862. Mav 5, 1864. Julv 3, 1663. June 22, 1664. Juuel3, 1863. Aug. 23, 1862. Nature op Injury. Dec. 14, Shot fracture ©f right humerus. 186f July 3, Left humerus fractured at the 1863. upper third. Feb. 13, Shot fracture of right humerus 186-; Dec. 8, Shot fracture of upper third of 1863. left humerus June 16, Gunshot fracture of left arm in 1864. upper third, Sept. 30, AVound of left shoulder joint, 1864. with fracture of the head of humerus. Mar. 31, Shot fracture of middle third of 1865. left arm; two balls found in arm. July 21, Shot wound of right arm, with 1861. lesions of bone and vessels. May 14, Shell fracture of the right hu 1864. merus Mar. 30, Sh< t wound of arm near shoul 1863. der joint, with fracture. July 20, Shot Avound cf left shoulder, 1863. involving bone and artery Dec. 12, Shell wound of right wrist and 1862. shoulder. Dec. 31, Shell wound of upper third of 1862. left arm; humerus fractured, muscles lacerated. June 25, Shot wound of right arm, with 1862. fracture of humerus Noa'. 27, Shot fracture of head and neck 1863. of left humerus, outer third of left clavicle, and acromial process of scapula. Shot fracture of right arm in upper third. AVoundsof the right arm by two conoidal balls; much shat tering Shot wound of left ann, ball lodging in the shoulder joint upper third of humerus ex tensively comminuted Shot fracture of the head of right humerus; considerable haemorrhage. Gunshot wound of right arm, with comminution. Shot wound through the upper third of right humerus Shot wound of right arm by mini§ ball Shot wound of left wrist and shoulder; head of humerus comminuted; ball lodged, Comminuted shot fracture of upper third of left humerus; shoulder joint implicated. Shot wound of right arm, the bone and artery injured. Comp'd comminuted fracture of right humerus by a canis- ter shot. Shot wound in right shoulder joint. Shot fracture of upper third of left humerus. Shot wound of left shoulder, involving bone and vessels. Right foreann carried away by solid shot. Shell fracture of head and por- tion of shaft of left humerus; deltoid nearly torn away. Shot fracture of upper third of right humerus. Shot wound of right arm, with fracture of humerus. Shot wounds of left arm and right thigh. Phot fracture of left humerus in upper third. Shell fracture < f left liumerus; soft parts extensively lace- rated. Shot wound of left arm; com- minuted fracture. Upper third of right arm badly I shattered. Date of Opera- tion. Operation and Operator. Result and Remarks. Dec. 15, 1862. July 4, 1863. Feb. 15, 1862. Dee. 8, 1863. June 16, 1864. Oct. 1, 1864. Mar. 31. 1865. Julv 23, 18*61. Mav 14, 18*64. Mar. 30. 1863. Julv 20, 18*63. Dec. 13, 1862. Jan. 1, 1863. June 26, 1862. Nov.i 1863 June 22, 1864. June 10, 1862. July 2, 1863. June 18 1864. Mav 3, 18*63. June 17, 1864. Nov. 11, • 1864. Sept. 20, 1864. Slay 6, 1864. May 3, 1863. June 2, 1864. Feb. 16, 1862. July 3, 1803. Dec. 13, 1862." Aug. 19, 1861. Aug. 7, 1864. Mar. 25, 1365. Sept, 22, 1862. Mav 7, 18*64. Julv 3, 1863. June 22, 1864. June 13, 1863. A tig. 23, 1862. Amputation at the shoulder by the oval method. Amputation at the shoulder by double flaps. Amputation at the shoulder by Lisfranc's method. Amputated at the shoulder, by Ass't Surg. J. J. Sanders, 1st Iowa Cavalry. Amputation at the arm........ Antero-posterior flap amputa- tion at the shoulder, by a Con- federate surgeon. Amputated by the flap method, by Surg. R." T. Paine, 2d N. York Mounted Rifles. Amputated, by Dr. Swift, of New York. Flap amput'n at the shoulder.. Amputated, by Surgeon P. K. Guild and Ass't Surgeon S. Brownell, 120th Illinois. Amputated, by Surg. A. Potter, Sth Rhode Island Artillery. Amputation at the shoulder — Amputation at the shoulder, by Surgeon E. B. Gliek, 40th Indiana. Amputation at the shoulder by transfixion. Ann amputated at shoulder and fragments of clavicle and scapula removed, by Surg. C. Bower. 6th Penn. Reserves. Amputated at the shoulder, by Surg. J. W.AVishart, 140th Pa. Amputated at the shoulder, by Surg F. AVolf, 39th New York. Amputation at the shoulder by antero-posterior flaps. Flap amputation at shoulder; lateral and internal flaps. Amputated at the shoulder, by Surg. G. T,. Potter, 145th Pa. Amputated at the shoulder, bv Surg. AV. B. Fox, Sth Mich*. Amputated at shoulder joint, by Ass't Surg. C. AYheeler, 8th Tennessee Cavalry. Amputated, by Ass't Surg. B. A. Fordyoe, 160th New York, by antero-posterior flap meth- od; missile removed from over the second rib. Amputated by the flap method, by Surg. Stratch, C. S. A. Amputation at the shoulder by the oval method. Amputated by single anterior flap method, by Surg. J. L. Mulford, 48th NeAV York. Amputation at the shoulder by Lisfranc's method. Amputation at the shoulder by double flaps. Amputated at the shoulder, by Surg. J. A. Ranney, 121st Pa. Amputated at the shoulder, by Surg. A. A. AVhite, 8th Md. Amputated, by Surgeon J. W. Lawton, U. S. V. Amput'd at shoulder, by Surg. AV. M. Houston, 122d Ohio. Amputated at the shoulder, by Surg. J. Thomas, 118th Penn. Amputated at the shoulder, by Surg. E. M. Curtis, 6th Vt. Amputation at the shoulder by double flaps. Amputated at the shoulder, by Dr. Leicester, of New York. Amputated at the shoulder, by a Confederate Surgeon. Amputated at the shoulder, by Surgeons J. MeXultv and P. Peneo. U. S. V Disch'd May 1, 1863; Disch'd Oct. 23, 1863; Disch'd Oct. 8, 1862; Disch'd May 30,1864; Furloughed July 28, Disch'd Feb. 8, 1865; pensioned peusioned. pensioned. | pensioned. • 1864. pensioned. Disch'd Aug. 21,1865; pensioned. Disch'd Jan. 17, 1862; Disch'd Jan. 14, 1865; pensioned. pensioned. Disch'd Aug. 15,1863; pensioned. Disch'd Feb. 2, 1864; pensioned. Disch'd Feb. 4, 1863; pensioned. Disch'd Mar. 17, 1863. Entered V. R. C. Discharged Sept. 19, 1864; pensioned. Disch'd April 9,1863; pensioned. Mustered out October 20, 1864; pensioned. .Spec.2531, A. M. M. Disch'd May 20,1865; pensioned. Disch'd July 4, 1862; pensioned. Shoulder very tender. Transferred, for exchange, Nov. 12, 1863. Disch'd Mar. 22,1865; pensioned. Disch'd July 15,1363; pensioned. Slight haemorrhages. Disch'd Sept. 14, 1864; pensioned. Disch'd Sept. 11,1865; pensioned. Several abscesses formed. Mus- tered out June 25, 1865; pen- sioned. Gangrene; stump healed, Oct. 15, 1864. Discharged July 19, 1865; pensioned. Disch'd Sept. 12,1863; pensioned. Disch'd July 25,1865; pensioned. Disch'd Aug. 17,1862; pensioned. Transferred to Provost Marshal, for exchange, Sept. 1, lt-63. Disch'd April22,1863; pensioned. Disch'd Jan. 20,1865; pensioned. Disch'd Mar. 28,1865; pensioned. Disch'd June 9, 1865; pensioned. Disch'd Feb. 17,1863; pensioned. Disch'd May 12,1865; pensioned. Sent to Provost Marshal, for ox- change, Sept. 16, 1863. Disch'd Sept. 23.1864; pensioned. Disch'd Oct. 26, 1863; pensioned. Resigned September 29, 1862; pensioned. SECT. Ill] AMPUTATIONS AT THE SHOULDER JOINT. 627 Name," Age" and Military No- discription. Nature of Injury. O'Donnoll, P., Pt., A, 104th Illinois. Osbourn, F. A., Pt., I, 20th Indiana. Ott, N., It., II, 208th Tenn sylvania, age 28. Owens, D. L., l't., B, 38th Virginia, age 21. Page, L, Pt., E, 26th Mich., age 33. Pancoast, J., Pt., H, 4th New- Jersey. Parke, S. B., Pt., L, Cth May 3, Alabama, age 22. 1863. Parker, AV. B., Ft, I, 20tb July 3, Massachusetts, age 21. 18u3. Jan. 16, 1865. July 20, Fracturo of neck of right hu- 1864. Juno 25, 18112. April 2, 18(..">. Julv 3, 18u3. Aug. 16, 1864. Sept. 14, 1862. Massachusetts, age i Peck, A., Pt., H, 13th AVis- consin, Bge 24. Pellet, J. C, Serg't, E, 11th Vermont, age 40. Pentonay, M, Pt., G, 20th Massachusetts. Pickering, A\\, Corporal, G, 84th Pennsylvania, age 29. Pints, F. J/., Serg't, F, 1st Alabama, age 32. Piper, J. AV., Pt., A, 104th New York. Plyler, E., Pt., 1.148th Penn- sylvania, age 29. Po'wers, N.. Ft., C, 14th New York Artillery, age 45. Powers, P. S., Pt., B, 3d Confederate Regiment, age 36. Preston, W. E.. Pt., — A'irginia Artillery, age 23. Putnam. J. C.. Corp'l, H, 20th Massachusetts. Quattlebaum, W.. Pt., A, 57th Alabama, age 35. Ratferty, P., Pt., H, 73d New York, age 25. Raugh, J. J., Pt., C, 53d Pennsylvania, age 19. Reed, J. H., Pt.,B, 32d Maine, age 29. Reed. S. L., Pt., F, 25th Massachusetts, age 20. Richardson, S. D., Pt., B, 26th North Carolina. Rinehart, F., Pt., C, 2d Penn. Heavy Artillerv, age 44. Robbins, C. T., Pt., D, 13th Massachusetts, ago 23. Robertson, J. IL, PL, II, 2d Michigan. Rowlison, A. C, Pt., K, 22d Indiana, age 21. Ruckstool, J. I., Pt., D, 95th Pennsylvania, age 19. Russell, L., Pt., 81st New York, age 19. Rj-an, T., Pt., D, 67th Penn- sylvania, age 48. Salmon, AV., PL, A, 22d In- diana, age 19. Samoniel, L., Pt., G, 48th Illinois. *Sampson, W. C, PL, 44th "Georgia. Sanborn, C. B., Pt., M, 1st New Hampshire Cavalry. Saul, F., Corp'l, C, 14th N.Y. Heavy Artillery, age 29. Aug.21, 1664. Dec. 11, 1862. Aug. 15, 1864. Nov. 30, 1864. Dec. 13, 1862. Julv 2, 1863. June 14, 1865. Ap'l 29, 1862. Mav 12, 1864. Oct. 21, 1861. Julv 20, 18*64. Sept. 17, 1864. July 2, 1863. July 30, 1864 June 15, 1864. July 1, 1863. June 17, 1864. Aug. 27, 1862. May 31, 1862. Oct. 8, 1862. May 12. 1864. Aug. 1, 1863. Mar. 25, 1865. Mar. 19, 1865. July 28 1864. Sept. 17 1862. Sept. 14, 1863. July 27 1864. moms, with injury of artery Shot wound in left arm; the humerus shattered. Shot fracturo of upper third of left humerus. Gunshot wound of right arm; fracturo of humerus. Shot wound of left arm; hu- merus comminuted. Shot fracture ofthe upper third of right arm; shoulder joint involved. Shot fracture of upper third of humerus. Fracturo of left humerus by conoidal ball. AA'ound through left shoulder joint, comminuting head of the humerus. Shot fracture of right arm in upper third. Shot fracture of right arm and injury of bloc dvessels. Shot wound of left arm; head of humerus shattered. Shot injury near shoulder..... Shot wound of left shoulder by a large projectile. Comp'd comminuted fracture of left humerus. Shot wound of right shoulder; lesions of bone and artery. Comminution of head and neck and upper portion of shaft of right humerus; much lacera- tion and haemorrhage. Shot fracture of left humerus near surgical neck. Shot fracture of right humerus; laceration of soft parts. ■ Shot fracture cf right liumerus. Comminuted shot fracture of right humerus; wound efface. Shaft of left humerus fractured; copious haemorrhage; brachial probably wounded. Shot comminution of head of right humerus. Shell wound of left arm, with laceration of vessels. Shot wound of right arm; artery and bone injured. Shot fracture of upper third of left arm. Ball entered the upper part of left arm anteriorly, emerging in front of the middle of the inferior border of left scapula. Shot wound of right arm near the shoulder. Shot fracture of upper third of left humerus. Opera- tion. Julv'JO 1861. Juno ■.'."> 1862. April 2. 18(i'i. July 3, 1803. Aug. 16 1864. Sept. 15, 1862. Mav 3, 1K63. July 4, 1863. Jan. 17, 1865. Aug.21, 1861. Dec. 13 1862. Aug. 16, 1864. Dec. 1, 1864. Dec. 13, 1862. July 3, 18o3. Feb. 14, 1865. April 29 1862. May 12, 1864. Oct. 21, 1861. July 21, 1864. Sept. 18, 1864. Julv 4, 18ii3. July 30 1864. June 15, 1864. July 3, 1863. June 19, 1864. Aug. 2 1862. June 1, 1862. Oct. 8, 1862. Shot fracture of the left arm near the shoulder joint. Ball crushed the entire upper third of the left humerus into the joint and tore nerves and bloodvessels. Shot fracture cf right shoulder; laceration of soft parts. Shot wound of upper third of left arm. Missile fractured left humerus and severed brachial artery. Comminuted fracture of head of right humerus. Shell fracture of right humerus, joint involved. Shot wound of head and neck of left humerus. Operation and Operator. Amputated at the shoulder, by a (!onfcderate surgeon. Amputated at the shoulder, by Surg. M. Gunn, Sth Michigan. Amputation at the shoulder by Lisfranc's method. Amputation at tho shoulder by trunsfixion. Amputated at the shoulder by antero-posterior Hap method, by Nurg.J.AY.AVisliurt, 140th svlvani May 12. 1864. Aug. 1, 1863. Mar. 25, 1865. Mar. 19, 1865. July 29, 1864. Sept. 17, 1862. Sept. 14 1863. July 27 1864. Amputated by anterior flap method, by Surgeon I.. W. Oakley, 2d New Jersey. Flap amputation at shoulder by Malgaigne's method. Amputation at tho shoulder by the oval method. Amputated by the antero-pos- terior flap method, by Surg. J. Evans, 13th AVisconsin. Amputated by tho antero-pos- terior flap method, by Surg. C. B. Park, 11th Vermont. Amputated at the sfioulder, by Surg. N. Hayward, 20th Mass. Flap amputation at the shoul- der joint. Amputation at the shoulder by the oval flap method. Amputation at the shoulder by Larrey's method. Amputation at the shoulder by- double flap. Amputated at the shoulder, by Surg. AV. B. Fox, 8th Mich. Amputation at the shoulder by antero-posterior flaps. Flap amputation at shoulder... Amputated at the shoulder, by Surg. N. Hayward, 20th Mass. Amputation at the shoulder by antero-posterior flap method. Flap amputation at the shoul- der, by Surg. J. S. Jamison, 86th New York. Amputated, by Surgeon C. S. AVood, 66th New York, July 12th; ball extracted from tho- racic wall below axilla. Amputated at the shoulder by the OA-al skin-flap method; five ligatures. Amputated, by Surgeon J. M. Rice, 25th Massachusetts. Amputation at the shoulder by transfixion. Amputated at the shoulder, by Surgeon D. Seaverns, IJ. S. V. Amputated at shoulder by the antero-posterior flap method. Amputated at the shoulder, by Surgeon Z. E. Bliss, 3d Mich. Amputation at the shoulder by Dupuytren's method. A mputated by the flap method, by Surg. E. B. P. Kelley, 95th Pennsylvania. Amputated, by Surg. AV. H. Rice, 81st New York. Result and Remarks. Disch'd June 6. 1865; pensioned. Died July 17, 1870. Disch'd Aug. 13,1862; pensioned. Disch'd June 30,1865; pensioned. Paroled August 22, 1863. Disch'd Jan. 23, 18f5; pensioned. Disch'd Dec. 23,18C2; pensioned. Gangrene. Furloughed August 20, 1863. Disch'd Jan. 6, 1804; re-enlisted June 20, 1867; disch'd April 1, 1869; died March 20, 1870. Disch'd April 30,1865; pensioned. Disch'd Dec. 28,1804; pensioned. Disch'd April 9,1863; pensioned. Disch'd Dec. 6, 1864; pensioned. Sent to ProA-ost Marshal March 27, 1865. Disch'd Feb. 9, 1863; pensioned. Disch'd Oct. 23, 1803; pensioned. Disch'd May 29, 1865; pensioned. Sent to Camp Chase, Ohio, Sept. 14, 1862, for exchange. Sent to Old Capitol Prison June 30, 1864. Disch'd Sept. 8,1863; pensioned. Sent to Provost Marshal Nov. 15, 1805. Disch'd No\r. 15, 1865; pensioned. Spec. 4114, A. M. M. Vet, Res. Corps, May 12. 1864. Disch'd October 17, 1864; pen- sioned. Disch'd Oct. 30,1864 ; pensioned. Disch'd Nov. 17,1864; pensioned. Furloughed October 5, 1863. Disch'd Feb. 2, 1865; pensioned. Disch'd Oct. 3, 1802; pensioned. Disch'd Oct. 23, 1862; pensioned. Disch'd Dec. 18,1862; pensioned. Died March 14, 1808, of pulmo- nary consumption, caused by the amputation. To A'eteran Reserve Corps July 3, 1864. Discharged July 17, 1805; pensioned. Disch'd Oct. 13, 1863; pensioned. Died April 15, 1808. Amputation at tho shoulder by the OAral method. Amputation at the shoulder by double flaps. Amputated at tho shoulder, by Surg. AV. Lomax, 12th Ind. Flap amputation at shoulder... Amputated at the shoulder by the circular method. Amputated at the shoulder, by Surg. T. F. Oakes, 56th Mass. Disch'd May 26, 186;; pensioned. Disch'd June 12,1865; pensioned. Mustered out August 15, 1865; pensioned. Doing well October 1, 1862. Disch'd Dec. 5,1864 ; pensioned. Disch'd Dec. 20,1664 ; pensioned. * FISCHER (G. J.), Report of Fifty-seven Cases of Amputation in the Hospitals near Sharpsburg, Md., after the battle of Antietam, September 17, in Am. Jour. Med. Set, 1363, Vol. XLV, N. S., p. 48. n-28 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. Name, Age, axd Military Description. 86 Savage. J., Sergeant-Major, 64th New York, age 28. 287 . Schat'er, G., l't.,11,1^3dOhio, age 21. ii Schmidt, J.,PL,B, 9th Penn- sylvania. :8J Sc'hreiner, D., Pt., C, 25th AV isconsin, age 22. 10 Schwigert, C, Ft., II, 42d Illinois. 291 Searle, F. K., Pt., B, 7th Michigan. 12 Seeman, A., Serg't, B, 7th New York, age 34. 293 Severn, E. L., Lieut., K, 96th Pennsylvania, age 27. 294 Sewell, C. H., PL, G, 1st Florida, age 29. 2J5 Shaughnessy, T., Pt., D, 14th New York Heavy Artillery, age 28. 13 Shear, N. T., Serg't, H, 3d Arkansas, age 34. 297 Shelton, W., Serg't, H, 12th Virginia, age 24. 298 Shields, J. H., Pt., H, 6th Maryland, age 40. 299 Shuli, A., Pt., A, 41st Ohio. 10 Shulz, AV. G., Serg't, D, 43d New York, age 19. 301 Slattery, M., Pt., C, 33d New York. 302 Smith, B. R., PL, G, 56th Pennsylvania. 13 Smith, J., Pt., A, 28th Penn- sylvania, age 29. 304 Smith, J. A., PL, A, 5th Maryland, age 18. 305 Smith, J. L, Pt., B, 157th 1'ennsyh'ania, age 33. 306 Smith, T. IL, Ft., H, 3d Iowa. 307 Smith, AV., PL, E, 27th Mas- sachusetts, age 22. 308 Snadden, J. A., PL, B, 84th FcnnsylA-ania, age 20. 309 Spoouer, B. F., Colonel, 83d Indiana, age 48. .0 Stephens, AV. IL, Pt., D, 13th Penn. Cavuln". age 24. 31J Stevens, G. F.", PL, B, 17th New Hampshire, age 19. .2 Stiles, R., Ft., B, 199th Penn- sylvania. .3 Stokell, G. L., Pt., B, 32d Massachusetts. 314 Stokes, J. D., Lieut., F, 140th Pennsylvania. 5 Stone, R. J., Pt., D, 23d Tennessee, age 26. 316 Stautenburg, H. E., Serg't, E, 40th New Y'crk, age 24. 317 | Stutsman, A. H., PL, C, 1st Iowa Cavalry, age 25. .8 Sullivan, J., Pt., I. tth New Hampshire, age 23. .9 Summers, D., Pt., A, 15th AVest A'irginia, age 45. 10 Sunderland, J., Pt., E., 48th Penns\dvania. 321 Sutphin, F., Pt., C, 24th Vir- ginia, age 19. 322 Swens m, J., Corp'l, D, 52d Illinois. 3 Taggart, J. S.. Corp'l, E, i:,'d New Y'ork, age 19. Date OF Injury July 2, 1863. Sept, 3, 1864. Dec. 20, 1861. Aug. 10. 1864. May 9, 1862. Mav 31, 18*62. Mar. 31, 1865. May 10; 1B64. Dec. 16, 1864. June 29, 1864. July 3, 1863. Aug. 19. 1864. Mav 9, 18*14. Nov. 25, 1853. Mar. 25, 1865. Sept. 17, 1862. April 29, 1863. Nov. 27, 1863. April 2, 1865. June 28. 1864. Oct. 5, 1862. Mar. 8, 1865. May 6, 1864. June 27, 1864. Mav 28, 18*64. July 18, 1S63. April 2, 4865. Mav 5, 18*64. July 2, 1863. Dec. 16 1864. Sept. 10. 1864. Aug. 27. 1863. Sept.30. 1864. July 17, 1864. Dec. 13, 1862. May 16, 1804. Oct. 4, 1862. Mav 4, 1863. Nature of Injury. Shot fracture of right humerus near the shoulder joint. Shot fracture c f upper third and head of left humerus. Shot fracture of right humerus in the upper third. Shell fracture of head cf left humerus. Shot fracture of right humerus in the upper third. Shot Avound of right arm, with fracture, and injury of blood- A-essels. Shot fracture cf left humerus at upper third. Shot Avound of right arm and bones of clavicle. Left arm carried away by can- non shot. Shell fracture of upper third of left humerus ; shoulder joint involved; contusion of left side of chest. Right arm torn away by shell just below head of humerus. Fragment of shell struck the right nipple and passed into the shoulder joint; head of humerus fractured. Shot wound cf left arm....... Fracture of left humerus by grapeshot; much laceration. Shell comminution of shaft of left humerus. Shot wound of left arm; the humerus shattered. Shot wound cf left shoulder; fracture of humerus. Shot wound of right arm, with injury cf Aessels and bene. Shot fracture of left humerus just below shoulder. Compound fracture of upper third of right liumerus. AA'ound of right arm by canis- ter shot. Shot fracture of the upper third of the right humerus. Shot fracture of left arm by conoidal ball. Shot wound cf left humerus; ball passed through shoulder joint. Left arm almost torn off by a cannon-ball. Shot wound of left arm; ball passed through surgical neck of humerus. Shot fracture of right arm..... Shot wound of right arm...... Shot fracture of head and neck of right humerus. Shell wound of right arm, and lesions of bone and artery. Shot fracture of the upper third of the right arm; soft parts lacerated. Comminuted shot fracture of left humerus; shoulder joint opened. Fracture of right shoulder by a cannon ball. Fracture of upper third of right humerus. Shell wound of right arm___ Fracture of upper third of left humerus; flesh wound of left leg. Shot wound of left arm; the humerus shattered. Shot fracture of left humerus; laceration of soft parts. Date OF Opera- tion. Julv 2, 1863. Sept. 5, 1864. Dee. 21, 1861. Aug. 10, 1864. May 9, 1862. June 2, 1862. April 2, 1865. May 10, 1864. Dec. 10, 1864. June 29. 1864. July 4, 1863. Aug. 19, 1864. May 10, 1864. Nov. 25, 1863. Mar. 25, 1865. Sept. 18, 1862. April 29, 1863. Nov. 27, 1863. April 3, 1865. June 28, 1864. Oct. 6, 1862. Mar. 9, 1865. Mav 6, lbo'4. June 28, 1864. May 28, 1.-G4. July 18, 18*63. April 2, L805. Mav 7, 18*64. July 4, lc63. Dec. 16, 1864. Sept, 11, 1864. Aug. 29, ls63. Sept.30, 1864. Julv 18, 18*64. Dec. 13. 1862. Jlav IS, 18*64. Oct. 4, 1862. May 4. 1863. Operation axd Operator. Amputation at the shoulder by antero-posterior flap method. Amputated at the shoulder, by Ass't Surg. N. B. Brisbane, 123d Ohio. Amputation at the shoulder___ Flap amputation at shoulder. .. Amputated at the shoulder, by Surg. T. D. Fitch, 42d Illinois. Amputated at the shoulder by the circular method, bA- Surg. A. N. .Dougherty, U. *S. V. Amputation at the shoulder.... Amputation at the shoulder, with excision of four inches of claA'icle and remoA-al of in- jured portion of scapula, by Surg. D.AV. Bland, 90th Penn. Amputation at\the shoulder... Amputation at shoulder by the antero-posterior flap method. Amputated at the shoulder, by Surg. J. M. Hayes, C. S. A. Amputation at the shoulder by the oval method. Amputation at the shoulder by transfixion. Amputated at the shoulder, by Surg. J. L. Teed, U. S. V. Amputation at the shoulder by the flap method. Amputation at the shoulder by double flaps. Amputated at the shoulder, by Surgeon G. AV. New, 7th Indiana. Amputation at the shoulder by Larrey's method. Amputated at the shoulder, by a Confederate surgeon. Amputated at the shoulder by the flap method. Amputation at the shoulder by Lisfranc's method. Amputated at the shoulder, by Dr. Cox, C. S. A. Amputated at the shoulder by the flap method. Amputated at the shoulder, by Asst. Surg. C. B. Richards, 3Cth Ohio. Amputation at the shoulder by oval incisions. Amputated at the shoulder, by Surg. S. A. Greene, 21th Mas- sachusetts. Amputated at the shoulder, by Surg. F. S.Ainsworth, U. S.A'. Flap amputation at shoulder, by a Confederate surgeon. Amputated by the flap method, by Surgeon J. W. Wishart, 140th Pennsylvania. Amputation at the shoulder by the oval flap method. Amputated at the shoulder, by Surg. H. F. Lyster, Sth Mich. Amputated by Lisfranc's opera- tion, by Surgoen Joseph C. Lymph. Amputated by the flap method, by Surgeon AV. Ingalls, 59th Massachusetts. Amputated at the shoulder by the antero-posterior OA'al flap method. Amputation at the shoulder by double flaps. Amputated at the shoulder, by Surg. AV. V. Harrison, C. S. A. Amputated at the left shoulder joint, by Surg. J. Andrews, 3d Michigan Cavalry. Amputation at the shoulder by the OA'al method. Result and Remarks. Disch'd Jan. 19,1864; pensioned. Disch'd Dec. 31, 1864; pensioned. Disch'd Nov. 25,1862; pensioned. Disch'd June 11,1865; pensioned. Diseh'd Dec. 20,1862; pensioned. Disch'd July 18,1862; pensioned. Disch'd July 20, 1865; pensioned. Disch'dAug. 17,1864 ; pensioned. Sent to Provost Marshal Feb. 24, 1865. Disch'd April 1, 1865; pensioned. Sent to City Point, for exchange, November 12, 1863. Sloughing. Aug. 27th, all symp- toms favorable. Disch'd Feb. 6, 1865; pensioned. Disch'd June 10,1864; pensioned. Disch'd July 6, L05; pensioned. Spec. 4705, A. M. M. Disch'd Jan. 6, 1863; pensioned. Disch'd Sept. 12,1863; pensioned. Disch'd May 14,18C4; pensioned. Discharged November 16,1865. Disch'd May 19, 1665; pensioned. Disch'd June 14,1863; pensioned. Disch'd Aug. 2, 1865; pensioned. Disch'd Dec. 29,1861; pensioned. Disch'd April28,1865: pensioned. Disch'd Dec. 24, 1864; pensioned. Sloughing. Discharged Dee. 29, 18b3; pensioned. Disch'd June 19,1865; pensioned. Stump very sensitive. Disch'd Mar. 20,1865; pensioned. Disch'd Jan. 15,13 >4; pensioned. Neuroma of axillary plexus re- moved. Died Sept. 17, 1864. Sent to Provost Marshal March 1, 1865. Mustered out Nov. 29, 1864; pen- sioned. Spec. 4107, A. M. M. Disch'd Jan. 19. 1864; pensioned. Disch'd June 7, 1865; pensioned. Disch'd Mar. 4, 13G5; pensioned. Disch'd April 11,1863; pensioned. Retired February 3, 1365. Mustered out July 6, 1865; pen- sioned. Disch'd June 1, 1863; pensioned. SECT. III.] AMPUTATIONS AT THE SHOULDER JOINT. 629 Name, Age, ani> Military Des: ription. Taylor, T.. Tt., B, 58th Illi- nois, age 18. Thing, E., Corp'l, K, 116th Maine, nge 22. Tiimias, J. !>'., Pt., K, 21st Alabama, age 42. Tluane. 'I'., Corp'l, K, 2d New Vork. Trimball, L. A„ Corp'l, G, 9th Arkansas, age 23. Lip, C. C, Pt., 1'., 76th Penn- sylvania, ago 21. Underwood, O., l't., K, 43d Ohio. ----- Pt., 7th Michigan. A'ail, E., It., I, 159th New York. A'alence, C, Ft., E, 1st Penn- sylvania liifle Reserves. Vandersen, 11. A'., Pt., A, 11th U. S. Infantry. VanUew. J., It., G, 149th Pennsylvania, age 21. Van Raalta, 1)., l't., I, 25th Michigan, age 19. A'an Tassell, H., PL, 1, 95th New York. AVager, s., PL, B, 1st U. S. Artillery, age 21. Wagner, A., Pt., E, 45th New York. Wait, R. R., Pt., H, 4Sth New Y'ork. Walker, G. W„ Pt., 51, 6th Alabama, age 26. Waltz, C. -It., l't., C, 14Cth Pennsylvania. AVarner, G. AV., Pt., B, 20th Connecticut, age 32. Watkins, D., Pt., E. 14th North Carolina, age 33. AVebb, J. T., Pt., A, 114th Illinois. AVegman, G., Pt., I, 6th New Jersey. AA'eight, AV., Pt., D, 5th New Jersey. AVesley, S.,Landsman, Gun- boat Machinaw, age 23. AVestmeier, IL, Pt., I, 7Cth Ohio, age 20. Whitham, R., PL, C, 15th New Jersey. Widdicombe, B. F., Corp'l, H,82d Pennsylvania, age 20. Wild, E. A., Colonel, 35th Massachusetts. Wilkinson, P., Pt., L, 81st Pennsylvania. Williams, J., Pt., A, 14th Tennessee, age 24. Wimberly, R. C, Pt., A, 3d Georgia, age 22. AVinchold, AV., Pt., E, 17th Pennsylvania Cavalry, age 21. AVirts, C., PL, F, 30th Mis- souri. Wise, A., Pt., K, 7th Mary- land, age 32. AVispert, O., Serg't, C, 1st New Jersey Cavalry, age 23. May 18, 1861. Aug. 18, 18o4. April 8, 1865. Aug. 27, 1862. Dec. 15, 1861. Julv 11, 18*63. Feb. 3, 1865. Dec. 13, 1862. May 24, 18113. June 26, 1802. June 27, I86J. May 8, 18*64. Aug. 26, 1804. July 1, 1803. J une 3, 1864. July 1, 1803. May 12. 1864. July 1, lt-63. July 2, 1863. July 3, lc*03. Nature OF Injury. July 1, 1863. May 20, I kG3. Jlav 5, 186 2. June 1, 1862. Feb. 14, 1865. Aug. 18, 1864. May 3, 1863. June 3, 1864. Sept. 14, 1862. June 4, 1864. Julv 2, 1863.. JulvL 1863. June 21, 1864. May 20, 1863. Aug. 18. 1864. Shot fracture of left humerus near tho shoulder joint. Shot fracturo of left humerus at surgical neck. Shell wound of left arm, with injury of bono and artery. Shot fracture of left humerus in tho upper third. Sh.-t wound of left arm, with injury cf bono and vessels. Slo.t Iructuro of left humerus in upper third. Shot fracture of left arm, high up; laceration of soft parts. Extensive comminution of right humerus nnd fracture of the scapula nud clavicle; parts lacerated. Shot wound cf left arm, with injury of vessels und bone. Shot wound of left arm, the humerus shattered. Shot wound cf left arm, with injury of bone and artery. Comminuted fracture of right arm. Fracture of upper third of right humerus; head of bone split; missile penetrated the cheek, chipping malar bone. Shot wound in left shoulder ... Fracture of right humerus, high up, by a large projectile. Shot fracture of right humerus ; soft parts near the shoulder earned away; arm held by skin of inner surface. Shot fracture of left humerus by cannon ball. Comp'd comminuted fracture of right humerus. Shot fracture of neck and shaft of right humerus. Shell wounds of both arms; one fragment severed right arm from bod}-, another frac- tured bones of left forearm, lacerating soft parts. Comminution of right humerus and laceration of soft parts by shell. Fracture of right humerus in the upper third. Shot wound of right arm, with injury of vessels and bone. Shot wound of right arm, the liumerus shattered. Shot fracture of right humerus. Shot comminution of surgical neck of right humerus; shoul- der joint opened. Shot wound of right arm...... Opera- tion. Severe shot wound of the left shoulder joint. Loss of left arm by a round shot. Shot wound of right shoulder, the humerus shattered. Shot fracture of upper third of right humerus. Shot wound through the right shoulder joint. Comp'd comminuted fracture cf right humerus, involving shoulder joint. Shot wound of right arm...... Shot wound of left shoulder, with lesion of bone and A'essels. Mav 19, 1X64. Aug. 18, 1864. April 8, 1865. Aug. 27, 1862. Dee, 17, 1861. July 13, 1863. Feb. 3, 1865. Dec. 13, 1,-62. Mav 24, 1803. June 27, 1862. June 28. 1862. May 8, 1864. Aug. 26, 1864. J idyl, 1863. June 3, 1864. July 1, 1863. May 12 1864. July 1, 1803. July 3, 18*63. July 3, 1863. July 1, 1803. May 20, 1863. May 6, 1802. June 1, 1862. Feb. 14, 1865. Aug. 19, 1864. May 3, 1863. June 3, 1864. Sept. 16, 1862. June 4, 1864. July 4, 1863. July 3, 1863. June 21 1864. May 20, 1863. Aug. 18, 1864. May 12, Right arm carried away bya May 12, 1864. ] six-pound shot, which struck 1864 midway between elbow and shoulder. Operation and Operator. Amputated at the shoulder, by Surg. II. M. Crawford, 58th Illinois. Amputation at tho shoulder. .. Amputation at the shoulder___ Amputated at the shoulder, by Surg. L. McLean,2d N. York. Amputation at the shoulder___ Amputated, bv Surg. It. A. Kinloch, C. S. A. Amputated at tlie shoulder, by Surg. I'. M. Ri se, 43d Ohio. Amputated at shoulder joint, with removal of portions of scapula and clavicle, by Surg. C. S. Wood, 66th New'York. Amputated at shoulder joint, by Surg. C. Robertson, 159th New York. Amputation at the shoulder. .. Amputation at the shoulder___ Amputated, by Surg. W. Hum- phreys, 149th Pennsylvania. Amputated, by Surgeon A. M. AVilder, U. S. V.; fragments of bone removed from face. Amputated at the shoulder, by Surg. G.AV.Metcalf, 76th N.Y. Amputated nt the shoulder by the flap method. Flap amputation at shoulder... Amputation at the shoulder by transfixion. Amputation at the 6houlder--- Flap amputation at shoulder, by Surgeon J. AV. AVishart, 14Cth Pennsylvania. Amputation at right shoulder joint and cf left arm at lower third of humerus. Amputation at the shoulder by the oval method. Amputated at the shoulder, by Surg. M. AV. Fisk, 11th Mo. Flap amputation at shoulder, by Asst. Surg. J. H. Pooley, II. S. A. Amputation at the shoulder by double flaps. Amputated at the shoulder, by a naval surgeon. Amputated at the shoulder, by Asst. Surg. D. Halderman, 46th Ohio. Amputation at the shoulder--- Amputation at the shoulder by Larrey's method. Amputated at the shoulder, by Dr. Rogers of New York. Lateral flap amputation, by Surg. J. AV. AVishart, 140t*h Pennsylvania. Amputation at the shoulder--- Amputation at the shoulder by lateral flaps. Antero-posterior flap amputa- tion at the shoulder. Amputation at the shoulder--- RESULT AND REMARKS. Mustered out April 1, 1866; pen- sioned. Disch'd Mar. 2, I860; pensioned. Paroled June 28, 1865. Disch'd Oct. 27, 1862; pensioned. Sent to Provost Marshal Feb. 24, 1865. Disch'd Jan. 7, 1864; pensioned. Disch'd June 17,1865; pensioned. Favorable................... Disch'd July 29,1863; pensioned. Disch'd Sept. 6,1862; pensioned. Died June 24, 1870. Disch'd Aug. 29,1862; pensioned. Disch'd Oct. 22,1864; pensioned. Spec. Ill, A. M. M. Disch'd April 12, 1865; pensioned. To A'eteran Reserve Corps Sept 9,1803. June 10, 1864, secondary haemor- rhage; circumflex ligated. Di charged Mar. 16.li-65: pensioned Died Dec. ill, 1808, of consump- tion, resulting from amputation Disch'd Jan. 9, 1864; pensioned Disch'd April 7,1865; pensioned. Transferred, for exchange, Sept. 25, 1863. Disch'd Dec. 19,1863; pensioned. Disch'd Oct. 17, 1863; pensioned. Paroled September 25, 1863. Disch'd July 20,1863; pensioned. Disch'd Aug. 29,1862; pensioned. Disch'd July, 1862; pensioned. Sent to Marine Hospital in Jan- uary, 1867; pensioned. Disch'd Jan. 2, 1865; pensioned. Disch'd Sept. 25,1863; pensioned. Disch'd Sept, 13,1864; pensioned. Promoted to Brigadier General April 25, 1863. Mustered out January 15, 1806; pensioned. Discharged April 5, 1865. Sept. 4,1863, sloughing. Paroled November 12, 1863. To Provost Marshal, for exchange, September 3, 1863. Disch'd Mar. 9, 1865; pensioned Disch'd Sept. 2, 1863; pensioned. Flap amputation at shoulder, Disch'd Feb. 5, 1885; pensioned. by Surg. A. A. AVhite, 8th Maryland. Amputated at the shoulder, by , Returned to duty, to be mustered Surg. AV. AV. L. Phillips, ls't j out, August31,1864; pensioned. New Jersey Cavalry 630 INJURIES OF THE UPPER EXTREMITIES. [CHAP. ix. NO. Name, Aob, and military Description. Date OF I.NJJRV. Nature of Injury. Date of Opera-tion. Operation and Operator. Result and Remarks. 360 361 362 363 364 365 366 367 368 AVood, B. S., Corp'l, C, 1st Maine Cavalry, age 31. AVoods, C, PL, K, 16th Mas-sachusetts, age 19. AVright, L., Pt., II, 10th Iowa, age 21. Yeatter, L., Pt., G, 143d Pennsylvania, age 32. Young, G. 67., Pt., A, 7th South Carolina Cavalry. Young, I. J., PL, H, 63d Indiana, age 28. Zahrli, J., PL, G, 97th Illi-nois, age 28. Zimmers, IL, Serg't, A, 140th Pennsylvania, age 32. Zubler, R., Corp'l, A, 134th New York, age 21. April 9, 1865. Mav 9, 1864. Noa-. 25, 1863. May 5, 1864. May 30, 1864. May 14, 1864. May 16, 1863. July 2, 1863. July 1, 1863. Severe shot fracture of the left arm, extending nearly to the shoulder. Shot comminuted fracture of upper third of right arm. Fracture of left humerus in the upper third. Shot wound of left arm at upper third, with injury of vessels and bone. Shot fracture of upper third of humerus. Ball entered near the head of left humerus, passed through joint and down the side to the sixth rib, whence it was ex-tracted. Round shot passed through the middle third of the left arm; humerus shattered. Comminuted fracture of the left humerus. Comminuted shot fracture of surgical neck of left humerus; joint opened; escape of syno-via. April 9, 1865. May 9, 1864. Nov. 25, 1863. May 6, 1864. May 31, 1864. May 15, 1864. May 16, 1863. July 3, 1863. July 2, 1863. Amputated at the shoulder, by Surg. G. AV. Colby, 1st Maine Cavalry. Antero-posterior flap amputa-tion at the shoulder, by JSurg. C. C. Jewett, 16th Mass. Amputated, by Surg. L. J. Ham, 48th Indiana. Posterior flap amputation at the shoulder, by Surgeon G. AV. New, 7th Indiana. Amputated at the shoulder, by Surg. C. B. Gibson, C. S. A. Lateral flap amputation at the shoulder. Amputation at the shoulder by irregular flaps. Amputated at the shoulder, by Surg. J. AV. AVishart, 140th Pennsylvania. Double flap amputation at the shoulder. Disch'd Aug. 12,1865; pensioned. Disch'd Nov. 19,1864; pensioned. Spec. 123, A. M. M. Mustered out September 28,1864; pensioned. Disch'd May 15,1865; pensioned. Transferred June 11, 1864. Gangrene. Discharged Nov. 30, 1864; pensioned. Disch'd Feb. 3, 1864; pensioned. Disch'd June 15,1865; pensioned. Disch'd May 18,1864; pensioned. The side injured was specified in three hundred and fifty-seven of the cases here tabulated; in eleven instances this point was overlooked. One hundred and eighty-one operations were on the left, and one hundred and seventy-six on the right side. Seven patients were returned to modified duty in the second battalion of the Veteran Reserve Corps; three hundred and three were discharged and pensioned; thirty-seven were paroled or exchanged. Twenty-one of the pensioners have died since their discharge, at periods remote from the date of operation,—one from a railroad accident, one from suicide, eight from marasmus due, probably, to the' mutilation, and eleven from various diseases uncon- nected with the injury. The Museum possesses twenty-two specimens of shot fractures of the upper extremity of the humerus, successfully treated by primary amputation at the shoulder.1 Seven of them have been figured on preceding pages. Moreover, the primary appearances of shot comminutions of the upper portion of the bone are largely illustrated by wood-cuts intercalated among the abstracts of cases of excisions at the shoulder. § Unsuccessful Operations.—One hundred and seventeen primary amputations at the shoulder resulted fatally. The side implicated was specified in ninety-three instances, the right limb having been removed in forty-five, and the left in forty-eight operations. Three of the cases were complicated by other capital operations, one by amputation of the thigh, another by amputation of the leg, and a third by the removal of three-fourths of the scapula. In fourteen other cases serious wounds in other parts of the body contributed toward the 1 GUTHRIE (G. J.) has devoted a chapter of fifty pages (A Treatise on Gunshot Wounds, etc., 3d ed., 1827, pp. 420-470) to this operation. It filled with valuable practical remarks well worthy of the atteution cf the military surgeon. A few passages are here quoted: "The dread formerly entertained of this operation was very great, even by men of the best abilities: * * It can never, however, again be considered formidable, except under bad man- agement, and from extreme ignorance. The distinction between the necessity of the operation, and the possibility of aA'oiding it, requires in many cases the exercise of the nicest judgment, and a due consideration of attending circumstances; for there is no part of military surgery, in which an operation can be performed with more advantage at the instant; or delayed for a few days, with a Ariew of gaining information, with more prejudice; inasmuch as the necessary incisions are made, in the first instance, in parts disposed to take on healthy actions, and in the best possible state for undergoing surgical operations; the constitution of the patient being also at that moment generally good, and able to sustain the demands upon it under untoward circum- stances ; or of supporting, without future injury, the restraint and control requisite for the successful accomplishment of the cure. 'Ihe difference between cutting in sound and diseased parts is justly appreciated b}- every surgeon, both as to his personal convenience and ease in operating, as well as to the future healing of the wound; and the advantage here is particularly great, as, from the contiguity of the wound to the chest and the principal organs of life, it is advisable to avoid any excess of action; and experience has demonstrated, that the evil to be apprehended from the equilibrium of the circula- tion being destroyed is infinitely less than it Avould be at a subsequent period of three or four weeks, after high suppurative action has been going on. It cannot be too strongly impressed on the mind, that the necessary examinations should take place, and the operation be performed in those cases demanding it. as soon after the injury as possible, consistent with the state of the patient; and the surgeon should not satisfy himself with the idea of being able to accomplish it as safely. <>r as successfully, when suppuration has been established, and when perhaps he may have better assistance at hand; a kind of self-deceit that is occasionally permitted, but which cannot be too much reprobated. ' SECT. III.] AMPUTATIONS AT THE SHOULDER JOINT. 631 FIG. 488.—Upper half of left humerus, oravitv of the situation. In eighteen instances tlie limb was nearly or completely torn away by cannon shot. The subjects of the operations were one hundred and one Union and sixteen Confederate soldiers. Two cases in the series furnished specimens to the Museum. Brief abstracts of these are appended: Case 1600.—Private J. K------■, Co. C, l.r>f,th New York, was wounded at North Anna, Virginia, MavlB, 166-1. He Avas treated in a Second Corps hospital at Fredericksburg. Surgeon D. H. Houston, 2d DelaAvare, reported: " Fracture of left arm. Amputation at the shoulder joint, by Surgeon J. W. AVishart, 140th Pennsylvania. Arm severed by a cannon ball." The patient died May '21st. The specimen repre- sented by the Avood-cut (Fig. 488) was contributed by Surgeon \V. O'Meagher, C'Jth New Vork, and is thus described in the lStxi Catalogue, p. '.'.' : '' The upper half of the left humerus, amputated at the shoulder joint after fracture in the middle third by a round shot. A fissure three inches in length exists in the upper and outer portion of the bone, Avithout communicating with the seat of fracture." The fissure in the upper part, not extending to the point at Avhich the bone Avas shattered by the round shot, is very curious and interesting, occurring unquestionably ut the time of accident, and not in the transportation or preparation of the specimen. In robust, fleshy subjects it is sometimes exceedingly difficult to deter- mine whether the fissures from a shot comminution of the upper third of the humerus extend within the capsule. Specimen 1082 of the Surgical Series ^,*'rawS of the Museum is a good illustration. It is represented at page 30 of the shot* Spec-2323- preliminary surgical report (Circular 6, 1865, Fig. 32, and Catalogue of 1866, p. 91, Fig. 44). Before the removal of the limb it was examined by several experienced and accomplished surgeons, Avho consented to the exarticulation in the belief that the fissures penetrated the joint. On examination, the fracture was found to reach only to about two inches below the lower border of the tuberosities. In such cases, it is far better to com- mence the amputation with a view to dividing the humerus in its continuity. Should fissures be found to extend to the joint, it is easy to extend the incisions upward and effect exarticulation. Case 1601.—Private C. J------, Co. C, 12th Massachusetts, aged 2G years, Avas Avounded at Jericho Ford, May 23, 16o4. by a conoidal musket ball, and Avas admitted to a Fifth Corps field hospital. Surgeon C. J. Nordquist, 83d Nbav York, noted: "Gunshot fracture of the right humerus; disarticulation at the shoulder joint." The patient Avas sent to AVashington and entered Emory Hospital. Surgeon N. E. Moseley, U. S. V., recorded: "Admitted May 29th, from the field. Gunshot fracture of the right humerus. Ampu- tation at the shoulder joint, May 24, 18.14, on the field, by Surgeon J. XV. RaAA-lings, 88th Pennsylvania. Died June 10, 1864." The specimen represented by the adjoining cut (FlG. 48D) Avas contributed by the operator. It consists of "the right humerus, shattered in the upper third ofthe shaft, Avithout displacement of fragments." (See Cat. Surg. Sect, 1866, p. 91.) This and the foregoing specimen, 2323, are the only examples the Museum possesses of shot comminutions ofthe upper part ofthe humerus folloAved by primary unsuccessful amputation. In specimen 4149 the fissures extend, on the posterior parts, quite to the anatom- ical neck, without crossing, hoAvever, the line of the epiphysis. In nine of the fatal cases consecutive ligation of the axillary or of the subclavian was required, a large proportion of cases of bleeding from these great trunks, tied primarily in healthy subjects. The mortality here recorded is greater than that observed by Larrey, who asserted that he had saved ninety in a hundred patients amputated at the shoulder for shot injury, but compared with the general averages1 it is a favorable exhibit. t SMITH (S.), in a careful paper in the New York Journal of Medicine, 1853, N. S., Vol. X, page 9, in treating of amputation at the large joints has given a good historical review, with statistics, of amputations at the shoulder. He states that the earliest instance of the performance of the operation in this country was by Dr. John AVarrex, in 1781 (Boston Med. and Surg. Jour., A'ol. X X, p. 210), at a military hospital in Boston. He doubts the assertion of Dr. S. AV. AVilliams (Med. Biography, 1845, and A'eiu York Jour, of Med., 1852), that Dr. JosiAII GOODHUE, of Hadley, practised the operation yet earlier. He ascribes three exarticulations for injury to Dr. Amasa TltOWnitlOGE, the first in 1809, and two to Dr. AA'ilt.iam GIBSON, the earliest.in 1812. Dr. S. Smith collects seventy-one cases of exarticulation at the shoulder, with thirty-four deaths, a fatality of 47.9 per cent. Guthrie (On Gunshot Wounds, 3d ed., 1827, p. 4C9) gives the results of nineteen exarticulations at the shoulder, performed primarily on the field, from June 21st to December 24th, in the six divisions of the anny ef the Duke of AArellington, engaged at A'ittoria, Balboa, and the siege of St. Sebastian. There was but one fatal case in nineteen amputations. Of nineteen similar ulterior operations, practised in general hospitals on wounded from the same engagements, but four were successful. BttOMFIELl) (Chirurgical Observat inns, 1P73, Vol.J, p. 209) describes his uniform success in several cases of shoulder joint amputations, although he '•had but little encouragement to do it at first from those who had seen it performed in the arm}', when the shoulder had been greatly injured by gunshot, and amputation at the joint was the only chance of preserving life; fur, though the operations were seemingly well performed, and everything went on, to all appearance, well for near three weeks, yet, I am Wld, the patients all died." * .48!>.-Shot frac- ture i f the upper ex- tremity of the right humerus. Spec. 4149. Go2 INJURIES OF THE UPPER EXTREMITIES. Table XLIV. [CHAP. IX. Summary of One Hundred and Seventeen Fatal Cases of Primary Amputation at the Shoulder for Shot Injury. Name, Aoe, and Military Description. Ames, A. G., Serg't, D, 31st Maine, age 25. Andrews, M., Pt., E, 17th Vermont, age 19. Ash, D. B., Pt., B, 19th Mas- sachusetts. Austin, A. Y., Captain, F, 23d Ohio, age 27. Austin, AV. S., Pt., D, 27th Michigan, age 43. Baldwin, It. AV., Pt., C, 21st AVisconsin. Barry, It., Corporal, F, 1st New Jersey. Bates, J., 11., A, 75th Ohio Bessimer, AV., Pt., D, 137th NeAV York. Bly, J.. Lieutenant, M, Cth New York Cavalry, age 45. Boneau, P., Corp'l, G, 80th Indiana, age 22. Boyer, A., Pt.,K, 19th Maine, age 22. Brockway, O. P., Capt., A. 5th Colored Troops, age 28. Campbell, J., Pt., B, 1st Del- aware. Carr, I., Sergt., F, 10th AA'est A irginia, age 2d. Church, F., Pt_, I, 57th Xew York, age 20. Clark, C. AV., Serg't, A, 67th New York, age 25. Compton, J. A., Pt., K, 3d South Carolina. Comstock. G., Pt, F, 111th Pennsylvania. Conant, A. K., Pt., K, 8th Maine, age 22. Conner, A., Pt., C, 3d Batt., 18th Infantry. Copeland, V., Lieutenant, II, 2d North Carolina Cavalry. Corrie, J. S., Serg't, A, 11th Missouri, age 25. Cotrell, J., Pt., A, 43d New York, age 32. Cramer. J., Pt., A, 187th New- York. Crawley, M., Pt., A'oung's A'irginia Battery, ace 1!'. Crittend. E., Pt., I', 11 th Penn'a Reserves, age 22. Crotty. J. B., Pt., D, 108th New York. Davis, J. L., Pt., 2d South Carolina, age 20. May 30, lbG4. Mav 12, 18*6-1. June 25, 1862. Sept, 3, 18G4. July 30, 1864. Cet. 8, 18(12. May 6, 1864. Aug. 22, 1862. July 3, 1863. May 8, 1864. Dec. 10, 1864. June 22, 1864. June 19, 1864. May 3, 1863. April 2, 1865. June 16, 1864. May 6, 1864. May 3, 1863. May 20, 1864. Dec. 31 1862. May 22 1863. July 3, 1863. Oct. 27, 1864. Aug.21, 1864. May 8, 1864. Dec. 13, 1862. Sept. 17, 1862. Nature of Injury. Shot fracture of right humerus at upper third. Shot fracture of right humerus, extending into shoulder joint. Wcund cf right arm by musket ball, implicating bloodA'essels and bone. Shot fracture ofthe neck ofthe right humerus. Right arm carried away by a twenty-four pound solid shot. Shot fracture of the upper por- tion cf the left liumerus. Comp'd comminuted shot frac- ture of----humerus. Ball perforated right shoulder and severely lacerated the soft parts, grooving the articular surfaces. Fracture cf left arm in upper third. Shot wound of left arm; the upper extremity cf humerus shattered. Shot perforation c f the right shoulder; head and upper ex- tremity cf shaft cf humerus and scapula comminuted and shoulder joint opened. Shot wound nn § Successful Cases.—Seventy-seven of the eighty-five successful intermediary amputa- tions were practised on Union soldiers, seventy-six of whom were pensioned. Ten of these died subsequent to their discharge from service, at periods comparatively remote from the dates of injury, one from suicide, and nine from various diseases apparently without imme- diate connection with the mutilations to which they had been subjected. Eight of the operations were practised on Confederate soldiers, who were paroled or exchanged. The following are examples of successful early intermediary amputations at the shoulder joint, for complications following fractures of the upper part of the humerus: Cask 1G02.—Corporal W. M. Nesbit, Co. 1), 4th Vermont, aged 31 years, Avas wounded at Spottsylvania, May 12,1864. He Avas admitted to a Sixth Corps field hospital on the same clay. Surgeon S. J. Allen, 4th Vermont, diagnosticated a "gunshot laceration of the upper part of the left arm." Amputation at the shoulder joint Avas performed on May 16th. HeAvas transferred to Sickels Hospital, Alexandria, on the 27th. Surgeon T. Rush Spencer, U. S. V., recorded: "Gunshot wound. Amputation of left arm at shoulder joint." The patient was subsequently treated in hospitals at Brattleboro', Burlington, and Montpelier, Vermont. Surgeon Henry Janes, II. S. V., contributed the photograph represented by the cut (FlG. 400), accompanied by the folloAving memoranda: "Admitted to Sloan Hospital, Montpelier, June 14, 1835. Was wounded by a rifle ball, Avhich shattered the head of the humerus, in consequence of Avhich the arm Avas amputated at the shoulder joint. The Avound healed readily, except tAvo small places, Avhich discharged until the summer of 1835. No necrosed bone could be detected. He Avas discharged from the service July 29, 1855, Avith the stump healed, and in good health." This soldier Avas pensioned from the date of his discharge; his pension Avas paid him March 4,1875. Tliere is no evidence on file of the present condition of the shoulder. The pensioner received money compensation in lieu of an artificial limb. In the next case, the mutilation produced such profound mental depression as to lead to the commission of suicide: Fig. 490.—Cicatrix of an intermediary exarticulation of the left shoulder, a year after the operation. Case 1603.—Private Henry F. Keyes, Co. E, 12th NeAV Hampshire, aged 22 years, was wounded at Chancellorsville, May 3, 1833. He was sent to Washington, and entered Lincoln Hospital on the 6th. Acting Assistant Surgeon James N. Hyde, jr., reported: " Wounded by a ball, from an enemy forty or fifty yards distant, while he Avas kneeling on his right knee, in the act of filing his piece, his right hand grasping the breech. The ball entered the right arm in its upper third; passed through, comminuting the bone, and escaped at an opposite point posteriorly. May 7th: The patient Avas anaasthetized in the afternoon, and an examination was made of the Avound with a view to operation. Many pieces of bone Avere removed, when an incision Avas made, and it was found that eight inches of the humerus was involved in the fracture. Amputation was performed immediately, by Surgeon G. S. Palmer, U. S. V., at the shoulder joint, by double antero-posterior flaps. May 8th: Water dressing and isinglass plaster; wound granulating finely; discharge healthy; no constitutional disturbance. June 13th: AA'ound cicatrizing nicely; granula- tions red; no pain; appetite good; sleeps Avell; respiration 20; pulse 88; boAvels regular. June 2'.)tl: Water dressing and isinglass plaster; about all cicatrized; scar at the Avidest not more than four or five lines; very healthy appearance; appetite good; sleeps Avell; sits up all day." Assistant Surgeon H. Allen, U, S. A., contributed the specimen. It is described in the Catalogue ofthe Surgical Section, p. 92, as consisting of "the greater part of the right humerus, shattered at the junction of the upper thirds." The patient Avas discharged the service and pensioned, June 26,1863. On July 24,1865, the patient committed suicide by taking arsenic. His attending physician testifies : " Keyes Avas a young man in the prime of life, and feeling his future hopes and prospects clouded, he took his loss very much to heart; it continually preyed upon his mind, making him melancholic and disheartened, and while in this condition he took his oavu life." Case 1604.—Private Casper S------, Co. B, 7th New York, aged 30 years, was Avounded at Weldon Railroad, August 24, 1834. He Avas admitted to a Second Corps field hospital. Surgeon W. Vosburg, 111th Xcav York, diagnosticated "Gunshot Avound ofthe arm, slight." Simple dressings were used. The patient Avas shortly afterward sent to Washington, and entered Lincoln Hospital. Assistant Surgeon W. Lindsley, U. S. A., noted: "Admitted August 28th, Avith a gunshot Avound, causing extensive comminuted fracture of the right humerus. September 1st: Amputation at the shoulder joint, by Assistant Surgeon J. C. McKee, TJ. S. A. Eight ligatures Avere used. The anaesthetic employed Avas a mixture of chloroform and ether. The condition of the soft parts Avas tolerably good; his constitution not very good." The specimen, represented by the cut (Fig. 491), was contributed by Acting Assistant Surgeon H. M. Dean. It consists of the upper half of the right humerus, shattered in the, surgical neck, and amputated at, the joint. A portion of the fracture extends to the epiphyseal line, which is not crossed. The patient Avas discharged the service and pensioned, March 30, 1885. His disability Avas rated total. fig.401.—Shot fracture He Avas paid June 4, 1874. This pensioner was provided Avith an artificial limb by G. R. Grenell &■ Co., implicating the neck of Marcli 22, 18GG. lmmerus' *ec' 3144' 638 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. Table XLVI. Summary of Eighty-five Cases of Recovery after Intermediary Amputation at the Shoulder for Shot Injury. Name, Age, and Military Description. Allen, J., Serg't, H, 2d In- May 10, fantry, age 35. 1864. Belden, S., Pt., B, 5th Ver- June29, inont. 186; Berger, D., Serg't, I, 12Gfh -Alay 10 New Vork, age 26. ltu'4. Blackman, G. H., Serg't, E, 93d New York, age 23. Bond, 0-. J., l't., A, 74th New York, age 21. Bone, T., Corp'l, I, 35th Iowa, age 32. Borchert, AV., Pt., E, 4th Pennsylvania Reserves. Bowers, John L., Pt., C, 2d AVisconsin. Braswell, R. P., Pt., G, 15th Alabama, age 25. Brewer, D. Z., Pt., D. 115th New York, age 32. Bryant, L. J., Pt., C, 3d AVisconsin, age 24. Buck, J., Pt., F, 2d Infantry, age 30. Cain, G. W., Pt,, H, 140th Pennsyh'ania, age 19. Cliggett, J., Pt., H, 99th Pennsylvania, age 20. 'Cockefair, AV., Pt., I, 9th New A'ork Vols. Cole, P., Pt., B, 102d New York. Collins. T., Pt., E, 136th PennsylA'ania. Cook, J. W., Pt., D, 11th Mississippi, age 24. Cooper, D. D., Pt., I, 37th Illinois, age 27. Cronce, A., Pt., G, 15th New Jersey. Decker, L., Pt., H, 7Gth Pennsylvania. Dempscy, J., Pt., D, 51st New York, age 41. Donctt, L. H., Serg't, B, 82d New York. Fan-is, L., Pt., F, 48th Ohio, age 18. Fegelcy. M., Pt., K, 151st Pennsylvania. Flora, i-\, Pt., F, 7th Penn- sylvania Reserves. Flory, J.. Corp'l, G, 17th Penu'a Cavalry, age 24. Fuller, H. F., Pt., C, 3d South Carolina, age 24. Glenn, J. B., Serg't, D, 18th Virginia, age 23. 30 Hammons, R. T., Serg't 2d AVest A'irginia CaA'° airy Date of Injury Mav 6, lSl'4. Julv 2, 1863. July 14, 18(14. Aug. 30. 18b'2. Aug. 30. 1862. Aug. 14, 18(54. Aug. 16, 1864. May 3, 18(13. June 27, 1862. May 12, 1864. July 2, 1863. Aprill9, 1862. Sept. 17. 1862. Dec. 13 1862. July 2, 1863. April 9, 1865. June 4, 1864. July 12 1863. May 6, 1864. July 21, 18*61. May 22, 1863. Julv 1, leti3. June 30, 1862. Mar. 1, 1864. Julv 2, 1863. Julv 3, 1863. C. April 1. 1865. Nature of Injury. Shot fracture of left humerus two inches above the condyles; pieces of bone driven into muscles. Right humerus shattered by a conoidal ball; haemorrhage. Shot fracture of left arm in up- May 14 per third. 1864. Shot wound of right arm, with fracture cf humerus. Comminuted shot fracture of left humerus. Fracture of neck of right hu- merus by a conoidal ball. Shot Avound through left shoul- der joint; profuse suppura- tion ; sloughing. Shot wound of left shoulder, with injury of vessels and of bone. Shot fracture of upper third of right arm; soft parts disor- ganized. Shot wound of right arm, with severe lesions of bone and soft parts. Comminuted shot fracture of left humerus, involving shoul- der joint; sloughing. Compound fracture of anatom- ical neck of right humerus; fracture extended down shaft. Shot wound of Tight shoulder, with fracture of humerus. Shot fracture cf neck of left humerus, extending into the shoulder joint. Shot fracture of head of the left humerus; afterward haemor- rhage. Shot fracture of upper portion of left humerus, followed by gangrene. Shot comminution of the right humerus near the upper third. Comminuted fracture of right humerus, high up. Comminuted fracture of left humerus; soft parts infiltrated with serum and blood from A'enous haemorrhage. Fracture of lower third of left humerus; soft parts lacerated; sloughing. Gunshot wound of right arm, with injury of nerves, blood- A-esscls, and bone. AVound of the right arm near shoulder, with fracture of the humerus. Shot laceration of left arm, with fracture high up. Fracture of upper third of right humerus; arm swollen; ab- scess in the axilla burrowed beneath pectoral muscles. AVound of left arm, with longitu- dinal splintering of humerus. Shot injury of right arm, high up, with great inflammatory swelling. Fracture of the right humerus, extending into shoulder joint. Fracture of head and neck of right humerus; ball lodged in glenoid cavity. Extensive comminution of up- per portion of left humerus; great laceration of soft parts. AVound of right shoulder, with lesion cf bone and bloodvessels. Date OF Opera- tion. May IS 18*64. July 2, 1862. May 14, 1864. Julv 5, 18G3. July 23, 1864. Sept, 9, 1862. Sept. 2, 1862. Aug. 19, 1864. Aug. 19, 1864. May 8, 1863. July 20, 1862. May 20, 1864. July 12, 18*63. May 18, 1862. Sept. 20, 1862. Dec. 25 1862. July 6, 1863. April 18, 1865. June 20, 1864. July 16, ls63. May 16, 18*64. Aug. 11, 1861. June 14, 1863. July 9, 1863. July 3, 1862. Mar. 5, 1864. July 5, 1863. July 11 1663. April 8, 1865. Operation and Operator. Antero-posterior flap amputa- tion at the shoulder joint, by Surg. E. Bentley, U. S. V. Amputated at the shoulder, by Surgeon A\\ P. Russell, 5th A'ermont. Flap amputation at shoulder joint, by a Confederate sur- geon. Flap amputation, by Dr. G. A. Buck. Amputated at the shoulder, by Ass't Surgeon J. T. Calhoun, U. S. A. Amputated at the shoulder, by Surg. J. G. Keenon, U. S. V. Amputated at shoulder joint by antero-posterior flaps. Amputated at shoulder joint by transfixion. Flap amputation at the shoul- der, by Act'g Ass't Surgeon H. B. White. Amputated at the shoulder, by a Confederate surgeon. Amputated at the shoulder, by Surgeon H. E. Goodman, 28th Pennsyh'ania. Amputated at the shoulder by the oval method. Amputated at the shoulder by Lisfranc's plan. Flap amputation, by Surgeon D. S. Hayes, 110th Pennsyl- A'ania. Amputated at the shoulder by Lisfranc's double flap method, by Dr. A. B. Mott. Amputated, by Surgeon B. A. Vanderkieft,*U. S. V. Amputated, by A. A. Surgeon S. L. Loomis. Amputated at the shoulder by double flaps. Amputated, bv Surg. A. Mc- Mahon, U. S.'V. Amputated, by A. A. Surgeon J. Butterbaugh. Amputated at shoulder by the double flap method. Amputated at shoulder, by Dr. Comstock, of Harrisburg, Pa. Amputated, by Surg. S. Logan, P. A. C. S. Amputated, by Surgeon J. G. Keenon, U. S. V.; diseased surface of glenoid cavity was gouged away. Amputated at the shoulder by Larrey's method. Amputation at the shoulder by antero-posterior flaps. Flap amputation, by Surg. H. Johnson, 6th Michigan Cav'ry. Flap amputation at shoulder. Amputated at the shoulder by the oA'al method. Amputated, by Dr. AV. D. Rey- nolds, of LaAvrence, Mass. Result and Remarks. Considerable haemorrhage. Dis- charged September 26, 1864; pensioned. Disch'd Sept. 25, 1862; pensioned. Disch'd Feb. 18,1865; pensioned. Disch'd June 29,18G5; pensioned. Disch'd July 2, 1864; pensioned. Disch'd Feb. 7, 1865; pensioned. Disch'd Dec. C, 1862; pensioned. Disch'd Oct. 10,1802; pensioned. Sent to Military Prison January 12, 1865. Disch'd May 18,1865; pensioned. Disch'd Aug. 8, 1863; pensioned. Spec. 1082, A. M. M. Disch'd Feb. 4, 1863; pensioned. Disch'd Jan. 18,1865; pensioned. Died March 17, 1871. To Vet, Res. Corps Jan. 27,1864. Discharged June 30, 1864; pen- sioned. Died Dec. 25,1871. Disch'd Mav 20, 1863; pensioned. Died March 26,1872. Disch'd Dec. 6, 1862; pensioned. "Wound occasionally breaks open and discharges pieces of bone." Disch'd May 9, 1863: pensioned. Diedinl865. Spcc.544, A.M.M. RecoA'ered; transferred Septem- ber 1st, 1863. Disch'd May 24, 1865; pensioned. AVound tender and frequently discharging in 1870. Disch'd May 17,1865; pensioned. Spec. 2637, A. M. M. To Vet.Res. Corps Jan. 20,1864. Discharged October 27, 1864; pensioned. To Vet. Res. Corps Oct. 28,1864. Disch'd Sept. 6,1^65; pensioned. Disch'd Nov. 12,1861; pensioned. Mustered out Oct, 17,1863; pen- sioned. Spec. 1701, A. M. M. Mustered out July 30, 1863; pen- sioned. Disch'd Oct. 4, 1862; pensioned. Disch'd July 27, 1865; pensioned. September 16th, healed by first intention; paroled. August 2d, abscess in stump opened; paroled Aug. 22, 1863. Disch'd July 1, 1865; pensioned. Stump tender. ' The case is reported in detail by Dr. A. E. M. Purdy, in Reports of Hospitals, in Am. Med. Times, 1863, A'ol. \r, p. 132. SECT. III.] AMPUTATIONS AT THE SHOULDER JOINT. 639 Name, Age. ani> Military Description. Hanson, AV. L., Pt., I, 80th New York, age 28. Harlow, J. R., Tt., B, 44th New A'ork, age 21. Herring, J. M., Pt., K, 17th Mississippi, age 32. Henertz, J. B., Pt., D, 27th Iowa. Hickman, T. N., Pt., E, 18th U. S. Infantry. Hill, A. II., Pt,, A, 3d Iowa Cavalry. Hoggatt, J. S., l't.. C, Gth Kansas CaA-alry, age 34. Howard, J. AV., Pt., A, 31st Maine, age 38. Irwin, S., Pt., Hampton's Penn'a Artillery, age 40. Jones, C, Pt., D, 2d U. S. Colored Cavalry, age 35. Jones, D. S., Pt., A, 30th Ohio. Jones, AV. L., Pt., E, 2d Minnesota, age 29. Kastner, G., Pt., C, llGfh Ohio. Keys, H. F., Pt., E, 12th N. Hampshire, age 21. Kirhy, George C, Pt., I, 61st Illinois. Kremer, P., Serg't, B, 32d Indiana. Krome, E., Pt., K, 6th TJ. S. Infantry. Lake, H., Pt., B, 1st New Jersey Cavalry, age 28. Lastofka, XV., Pt., I, 26th Wisconsin, age 19. Lyons, M., Sergeant, C, Sth Massachusetts. Main, H. A., Pt., E, 2d New Ycrk Cavalry. McDonald, I. AAr., Pt., D, 13th Maine, age 29. McDonald. S., Pt,, I, 10th New York. McKenzie, D., Pt., B, 1st Michigan Cavalry. McMahon, F. M., l't., D, 78th Illinois, age 28. Miles, J. H., Pt., G, 24th Virginia, age 23. 'Myers, J. C, Pt., D, 61st Pennsylvania, age 21. Neshitt, AV. M., Corporal, D, 4th A'ermont, age 31. Nichols. C, Pt., B, 121st New York. Richards, F. D., Pt., C, 35th Massachusetts, age 38. Ripley, AV. IL, Pt., K, 76th New York. Robins, W. B., Pt., H, Sth New A'ork Heavy Artillery, age 28. Rochm, C, Corp'l, F, 29th New York, age 24. Julv 1, 1663. Julv 1, 1862. June 1, 1864. April 9, 1864. Dec. 31 1862. Mav 1. 1863. Aug. 3, 1864. June 16, 1864. Aug. 29, 1862. Mar. 9, 1864. Sept. 13, 1862. Sept. 19, 1863. June 5, 1864. Mav 3, 1863. April 6, 1862. Sept. 19 1863. June 27 1862. May 5, 1864. May 2, 1863. July 1, 1662. Sept. 23, 1863. April 8, 1864. Aug. 30, 1862. Aug. 30, 1802. Sept, 20, 1863,. Mav 5, 1862. June 1, 1862. May 12 1864. May 3, 1863. Sept. 17, 1862. Aug. 29. 1862. Aug. 26. 1864. May 3, 1863. Nature of Injury. Fracture of left humerus in the upper third; bleeding aud sloughing. Head and five inches of shaft of left humerus comminuted; ball lodged. Comminuted fracture of head of----humerus, with gan- grenous condition of arm. A\ ounds through mouth and left shoulder; interior left maxilla nnd head and neck of humerus fractured. Wounded by several balls in right arm and forearm. One ball entered left elbow, splintering external condyle of the humerus; another ball passed through left shoulder. Comp'd comminuted fracture ofthe left humerus, extending nearly to head; also wounds of jaw and hip. Shot wound of left shoulder, the humerus shattered and soft parts lacerated. Comminuted fracture of upper half of left humerus, with bleeding and sloughing. Shell fracture of upper third of left humerus; profuse suppu- ration of foetid pus. AA'ound of right arm just below shoulder joint, followed by haemorrhage. Right arm badly lacerated by shot. Shot wound of left arm, the humerus shattered. Ball shattered eight inches of right humerus. Shot wound of right arm near shoulder. Fracture of left humerus hy a round ball. Shot fracture of right arm near shoulder; consecutive haemor- rhage. Shot through right humerus three inches below shoulder joint; severe haemorrhage May 17th. Ball passed through axilla, comminuted the right hume- rus near the surgical neck; arm painful. Fracture of the left humerus in upper third. Shot fracture of left humerus at surgical neck. Shot fracture of right humerus in upper third. Shot wound of left arm....... Shot wound of left arm . Comminuted fracture of right arm near shoulder joint. Ball entered left arm four inches below shoulder joint; hume- rus extensively split and shat- tered. Fracture of head of right hu- merus ; head excised June 1st, by Surgeon R. M. Tindle. Shot fracture of left humerus near shoulder joint. Comminuted shot fracture of left humerus. Left humerus comminuted by a large projectile. AVound of left arm by ball and buckshot, followed by slough- ing. Extensive shot comminution of right shoulder; wound gan- grenous. Shot fracture of upper third of right humerus. Opera- tion. July 7, 1863. July 6, 1862. June 4, 1864. Mav 9, 1864. Jan. 3, 1863. Mav 4, 1863. Aug. 6, 1864. June 20, 1864. Sept. 11, 1862. Mar. 25, 1864. Sept. 17, 1862. Sept. 23, 1863. June 27, 1864. May 7, 18*63. April 12, 1862. Sept.23, 1863. July 5, 1862. May 17, 1864. Mav 15, 1863. July 6, 1862. Sept. 28, 1863. April 11, 1864. Sept. 9, 1862. Sept. 2, 1862. Sept.23, 18G3. Mav 26, 1862. June 17, 1862. Mav 16, 1864. May 6, 1863. Operation and Operator. Amputated, by Surg. R. Lough ran, 80th New York. Amputated by the Roux meth- od, by Ass't Surg. J. S. Bill- ings, U. S. A.; hall dropped out as tho posterior incision was made. Anteroposterior flap amputa- tion. Amputated at the shoulder by external and internal flaps. Amputated, by Surg. C. S. Muscroft, 10th Ohio. Flap operation, by Surgeon I. (Jastleberry, 1st Indiana Cav- alry. Antero-posterior flap operation, by Surgeon C. E. Swasey, U. S. V. Amputated at the shoulder by the oval method. Amputated, by Surg. I. Moses, U. S. V. Amputated by oval method, by Asst, Surg. J. II. Frantz, U. S.A. Amputated at the shoulder hy double flaps. Amputated, by Surg. O. Ayers, 2d Minnesota. Amputated, by a Confederate, surgeon. Antero-posterior flap amputa- tion, by Surg. G. S. Palmer, U. S.V. A mputated at the shoulder hy transfixion. Amputated, by a Confederate surgeon. Amputated at the shoulder, hy Asst. Surg. C. P. Russell, U. S. A. Antero-posterior flap amputa- tion at shoulder, by Surgeon B. G. Streeter, 4th New York CaA'alry. Flap amputation, by Surg. O. A. Judson, TJ. S. V. Amputated, by Asst, Surg. II. L. Sheldon, TJ. S. A. Flap amputation, by Dr. Black, C. S. A. Amputated at the shoulder by the oval method. Amputated, by Asst. Surg. Geo. M. McGill, U. S. A. Amputated at the shoulder by Lisfranc's method. Amputated by flap method, by Asst. Surg. AV. H. Matchett, 40th Ohio. Oval amputation, by Asst. Surg. J. S. Billings, U. S. A.; five ligatures. Amputated, by Dr. AAlllard Parker., Amputated at the shoulder___ Amputated, by Ass't Surgeon D. M. Holt, 121st New York Sept. 27, Amputated, by Asst. Surg. Geo. 1862. Sept. 7, 1862. Aug. 29, 1864. May 7, 1863. M. McGill, U. S. A. Amputated, by Acting Asst. Surg. AV. B. Crane. Amputated by double flap method, by Act'g Ass't Surg. J. It. Uhler. Amputated, by Surgeon R. Thomain, 29th New York. Result and Remarks. Disch'd Nov. 19, 1863; pensioned. Disch'd Sept, 1, 1862; pensioned. Spec. 3450, A. M. M. Furloughed July 20, 1864. Disch'd April 1, 1865, and pen- sioned. Died Dec. 15, 1871. Disch'd Mar. 11,1863; pensioned. Disch'd July 15,1863; pensioned. Spec. 1349, A. M. M. Several haemorrhages; dischar'd November 30, 1864; pensioned. Died November 4, 1866. Mustered out June 16,1865; pen sioned. Disch'd Nov. 27,1862; pensioned Died Dec. 3, 1869. Spec. 2952 A. M. M. Mustered out December 5, 1864 pensioned. Disch'd Jan. 3, 1863; pensioned Mustered out October 10, 1864 pensioned. Disch'd Mar. 7, 1865; pensioned Disch'd June 25,1863; pensioned. Spec. 119, A. M. M. Committed suicide July 24, 1865. Disch'd Aug. 21,1862; pensioned Disch'd April 28,1864; pensioned Stump occasionally painful. Disch'd Mar. 3, 1863; pensioned Disch'd Sept. 22,1864; pensioned May 22d, secondary haemoiThage; recurredjune6th; stumpopened and axillary artery re-ligated disch'd Aug. 13,1863; pensioned Specs. 1213 and 1576, A. M. M Disch'd Aug. 22,1862; pensioned. Died July 17, 1863. Mustered out August 13, 1864 pensioned. Disch'd May 22,1864; pensioned Disch'd Dec. 16,1862; pensioned Disch'd Nov. 3, 1862; pensioned Disch'd June 10,1864; pensioned Discharged September 15, 1862, Spec. 1091, A. M. M. Oct. 10, 1862, ball and several piecesofboneremoved. Disch'd Dee. 3, 1862; pensioned. Disch'd July29,18,5; pensioned. Disch'd Aug. 27,1863; pensioned. Disch'd Mar. 4, 1865; pensioned. Disch'd Dec. 13,1862; pensioned. To Veteran Reserve Corps March 2, 1865; pensioned. Mustered out June 22,1863; pen- sioned. Spec. 1540, A. M. M. 1 See Case 81, Table XXIV, p. 533 ante, and Am. Med. Times, Aug. 16, 1862, Vol. V, p. 91. 640 INJURIES OF THE UPPER EXTREMITIES. [CHAP ix. Name, A ok, and military description-. Roth, L.. Pt., E, ICth Penn- sylvania Reserves. Schmidt, C, Pt., B, 7th New A'ork IleaA-y Artillery, age 30. Sewall, N. A., Pt., B, 100th Pennsyh'ania, age 25. Shaw, J. B., Pt., D, 65th Ohio. "Shepler, J., Pt., B, 108th New York, age 24. Showman, E. AV., Pt., D, 113th Ohio, age 25. Sinex, C, Pt., A, 26th Penn- sylvania, age 40. Smith, J. A., Pt., A, 16th AA'isconsin. Spannent, C. B. A.. Corp'l, G, Sth Ohio, age 27. Stewart, A. B., Pt,, D, 121st Pennsylvania, age 23. Striker, Philip, Pt., F, 31st New York. Taylor, J. J., Pt., K, 21st New York Cavalry, age 29. Vollman, John, Pt., G, 1st Ohio. AVade,.S., Pt., A. 77th Penn- sylvania, age 19. Welahan, M., Pt., C, 25th A'irginia, age 21. AVelch, J., Pt., B, 6th Infan- try, age 26. AVendel, A., Corp'l, A., 22d Indiana. White, J. M., Pt., Carter's Battery, age 28. Willett, H. B., Pt., E, 29th AVisconsin. AVinchell, J., Pt., D, 1st TJ. S. Sharpshooters. Zane, G. B., Serg't, A, 72d Pennsyh'ania, age 23. Zluhorn, J., Pt., K, 93d Pennsyh'ania. Date OF IXJURV -iept. 14 1862. Aug, 25, 1864. June 2, 1864. Sept. 19, 1863. June 3, 1864. Oct. 7, 1863. Julv 2, 1803. April 6, 1862. May 3, 1863. July 1, 1863. June 27, 1802. May 22, 1864. June 17, 1861. Mar. 2, 1863. July 2, 1863. Mar. 18, 1865. Dec. 31, 1862. Sept, 14, 1863.• April 8, 1864. June 27. 1862. Dec. 13, 1862. May 31, 1862. Natlt.e of Injury. Shot comminution of upper por- tion of right humerus; pro- fuse suppuration. Upper portion of right humerus shattered by large large shot. Ball passed along tbe whole lengtli of right arm, commi- nuted upper two thirds of hu- merus, and opened the elbow joint. Shot comminuted fracture of upper third of right humerus. Comminuted fracture of right humerus; June 13,1864, head and four inches of the shaft excised. Fracture of inferior costa of left scapula and neck of the left humerus. Fracture of upper third of the right humerus. Shot fracture of left humerus near shoulder. Shot fracture of left humerus. AA'ound of left arm, involving bone and A'essels, high up. AA'ound of the right arm, with lesions of the bone and ofthe arteiy. Shot fracture of right arm in upper third; wound gangre- nous. Shot wound of right arm, the humerus shattered in upper third. Extensh-e fracture of upper por- tion cf right humerus; March 30th, A'iofent haemorrhage. Fracture of upper third of left humerus; profuse suppuration and sloughing. Comminution of upper part of left liumerus; axillary artery, vein, and nerves seA'ered; March 20, 1865, five inches of shaft excised, byAsst.Surg. J. E. Semple, U. S. A. Shot wound of left arm, with fracture and sloughing. Fracture of left arm and shell wound of thigh. Fracture of head and upper third of the right humerus; wound gangrenous. AVound of left arm, with injur}' of bone, nerves, and A-essels. Shell wound of left shoulder joint, shattering bone and in- juring vessels. Fracture of the left arm near shoulder. Date of Opera- tion. Oct. 2, 1862. Sept. 1, 1804. June 11 1864. Sept. 22 1863. July 13, 1864. Oct. 14, 1863. July 5, 1863. April 9, 1862. May 6, 1863. July 9, 1863. July 5, 1862. May 31, 1804. July 3, 1861. Mar. 30, 1803. July 6, 1863. Mar. 21, 1805. Jan. 12, 1863. Sept. 21, 1863. April 18, 1864. July 1, 1862. Deo. 16, 1862. June 21 1862. Operation and Operator. Flap amputation, by Surg. H. S. Hewitt, U. S. V. Amputated, by Asst. Surg. J. C. McKee, U. S. A.; eight ligatures. Antero-posterior flap operation, by Asst. Surg. A. Ingram. U. S. A.; lower part of flaps left open and dry. Amputated, by Surgeon A. McMahon, 64t'h Ohio. Amputated by Larrey's method, by Asst. Surg. J. C. McKee, U. S. A.; ten ligatures. Amputated by long lateral flap method, by Surgeon G. AV. Hogeboom, TJ. S. V. Amputated, by Surg. C. C. Jewett, 16th Massachusetts. Amputated at the shoulder by double flaps. Amputated, by Surg. A\". M. Nash, P*A. C. S. Flap amputation at shoulder joint. Amputated at the shoulder by Larrey's method. Vertical flap amputation, by Surg. J. Boone, 1st Bat. Home Brigade. Amputated at the shoulder by OA'al incisions. Poupart's flap amputation, by Surg. B. A. Vanderkeift, U. S. A. Exarticulation at shoulder by oval incisions. Amputated at the shoulder by the same operator. Amputated at the shoulder by Larrey's first method. Amputated, by Surg. Robert- son, Carter's Battery, C. S. A. Antero-posterior flap operation, by Surg. F. Bacon, U. S. A. Amputated at the shoulder by external and internal flaps. Circular amputation, by Surg. M. Rizer, 72d Pennsyh'ania. Amputated, by Acting Asst. Surg. AV. K. Cleveland. Result and Remarks. Disch'd Dec. 15.1862; pensioned. Spec. 441, A. M. M. Disch'd Mar. 30,1865; pensioned. Spec. 3T44, A. M. M. Mustered out August 31, 1864; pensioned. Spec. 2822,A. M. M. See left figure in Plate XLVI, opposite p. 640. Haemorrhage Oct. 1st; Nov. 1st, stump healed. Disch'd April 16, 1864; pensioned. Disch'd Feb. 6, 1865; pensioned. Spec. 550, A. M. M. Gangrene. Discharged April 6, 1864; pensioned. Variola. Discharged August 24, 1864; pensioned. Disch'd J une 18,1862; pensioned. Disch'd Aug. 21,1863; pensioned. Large abscess between flaps; solution ofthe sulphate of zinc. Disch'd May 24,1864; pensioned. Disch'd June 3, 1803; pensioned. Died November 0, 1871. June 8th, secondary haemorrhage. Disch'd Oct, 25,1864; pensioned. Spec. 3385, A. M. M. Disch'd Sept, 16,1861; pensioned. Mustered out October 10, 1864; not a pensioner. Spec. 1044, A. M. M. Paroled November 12, 1863. Disch'd July 3,1865; pensioned. Disch'd April 27,1863; pensioned. Furloughed December 12, 1863. Disch'd June 20,1834; pensioned. Disch'd Sept. 18,1862; pensioned. Disch'd May 2, 1864; pensioned. Disch'd Sept. 18,1862; pensioned. In these eighty-five amputations, the side implicated was specified in every case save one ; the right limb was removed in forty, and the left in forty-four. Seventy-four patients were discharged, four went to modified duty in the second battalion of the Veteran Eeserves, and seven were exchanged, furloughed, or paroled. Disarticulation was most frequently practised by making a large deltoid flap by transfixion, exarticulating, and then cutting a short internal flap; but the oval method was also frequently employed, and all the varieties of double flap procedures. The proportion of operations for wounds by large missiles was much less than among the primary operations. In many cases gangrene or hsemorrhage rendered operative interference imperative. Six of the patients had severe wounds coincident with those at the shoulder. One underwent consecutive ligation of the axillary artery; this was the patient who had previously submitted to excision at the shoulder. Two were cases in which four or five inches of the shaft of the humerus had been previously removed. i See Case C5. Table XXXIII, paj... 578 ante. ■•* 'i ij?1" .-. Q » '■* * r F.XT'<: V. \ Med. and Surg. Hist, of the Rebellion. Part II, Vol. II, Chap. IX. Ward phot. Am. Photo-Relief Fruiting Co., Philada. PLATE XLVI. SHOT COMMINUTIONS OF THE HUMERUS. Nos. 2822 and 1234. SURGICAL SECTION. SECT. III.] AMPUTATIONS AT THE SHOULDER JOINT. 641 § Unsuccessful Operations.—The proportion of fatality in the intermediary amputations at the shoulder after shot injury was nearly twice as great as in the primary series. In seventeen instances, the disarticulations were subsequent to important primary or early intermediary operations. Thus, in eleven cases, the head or portions of the shaft of the humerus had been excised; prior amputations in the continuity had been practised in two of the cases; balls and fragments of bone had been extracted and arterial branches tied, in four cases. The three following examples illustrate fatal exarticulations at the shoulder at different periods of the intermediary stage: Case 1605.—Private P. P------, Co. E, 17th Wisconsin, aged 43 years, was Avounded at Vicksburg, May 19, 1864. He was sent to Memphis on the hospital steamer R. C. Wood, and entered Gayoso Hospital June 1st. The pathological specimen represented (Fig. 492) Avas forwarded by the operator, Assistant Surgeon W. Watson, U. S. V., Avith tlie folloAving history: "Wounded by a conoidal ball, Avhich fractured the left humerus at the surgical neck. When admitted the arm Avas SAvollen and livid; the general appearance of the patient was anaemic and unpromising, but amputation Avas decided upon as affording the only chance of saving life. The arm Avas amputated at the shoulder joint June 3d. The patient gradually sank, and died June 7, 1864. The treatment consisted of concen- trated nourishment and stimulants, freely given." The specimen is thus described in the Catalogue of 1886, p. 114, by Assistant Surgeon A. A. Woodhull, U. S. A.: " The upper third of the left humerus amputated at the shoulder joint. The specimen shows a nearly transverse fracture of the surgical neck and a longitudinal fracture of the shaft for three inches, inflicted by a conoidal ball. Incipient caries is seen along the line of fracture." Case 1606.—Private John B- -, Co. C, 7th Nbav York Heavy Artillery, Pig. 492.—Upper third of humerus exarticulated at the left shoulder. Spec. 2082. aged 27 years, Avas Avounded at Cold Harbor, June 3, 1884, and treated in a Second Corps field hospital. He was thence transferred to Washington, and admitted to Emory Hospital on June 8th. Surgeon N. R. Moseley, U. S. V., noted : "Gunshot Avound of the right arm, the ball entering at the insertion of the deltoid, passing upAvard, and lodging in the shoulder joint. On June 16th, amputation at the shoulder Avas performed by antero-posterior flaps. At this time the Avound Avas ecchymosed and cedematous, and the bones comminuted; constitutional condition unfavorable, with nervous prostration. The treatment consisted of stimulants internally, and local pressure on the femoral arteries to retain blood in the trunk. The patient continued to sink, and died of collapse six hours after the operation. The specimen (Fig. 493) consists of the upper fourth of the right humerus, disarticulated for fracture of the head by a conoidal ball, Avhich destroyed the greater tuberosity and lodged. Several partial fractures extend through the head and neck." Contributed by the operator, Surgeon N. R. Moseley, U. S. V. Fig.493.—Conoidal ball impacted in the head of the right humerus. Spec. 2564. Avas accidentally shot, Washington. Surgeon Case 1607.—Corporal E. K------, of the Band of the De Kalb Regiment (41st New York), by a comrade who Avas inspecting a pistol, July 23, 1861. He Avas conveyed to the E Street Infirmary, J. W. S. Gouley, U. S. A., operated, and contributed the specimen, represented by the cuts (FiGS. 494-5), with the folloAving history: "Corporal K------ Avas sitting on his bed and leaning slightly forward, and his friend was sitting on the floor tAvo feet in front of him, cleaning a pistol, Avhich Avas accidentally discharged, the ball taking effect in his left shoulder. He Avas conveyed to the E Street Infirmary the day of the accident. The Avound Avas carefully examined, and the ball found lodged in the head of the os brachii. Keseetion Avas proposed, but objected to by the surgeon in charge. Some days subse- quent to the injury, and after due consultation Avith Surgeon R. Murray, Assistant Surgeons W. J. H. White, J. J. Milhau, U. S. A., and Acting Assistant Surgeon Butler, it Avas decided by the majority to amputate at the shoulder joint. With the assistance of these gentlemen the operation Avas performed. The patient sustained much loss of blood during the operation, and died a day and a half afterward, July 28, 1861. It is proper to state that prior to the operation the patient had exhibited symptoms of pysemia. The specimen sIioavs a conical ball embedded in the cancellated tissue of the bone, Avith two fissures, and also that it Avas a most favorable case for primary resection, for Avhen he entered the hospital his condition was excellent." The discussions to Avhich this case gave rise are believed to have promoted the faA'orable con- sideration of the views of the advocates of excision in injuries of this character. A tabular statement, including the above and sixty-nine other unsuccessful inter- mediary exarticulations at the shoulder, commences on the next page. Fig. 4!M.—Pistol ball per- foration of the head of the left humerus, which was exarticulated intermedia- rily. Spec. 347. £. FlG. 495.—Posterior view of the same specimen, show- ing the apex cf the ball, which has traversedthe head ofthe humerus. 642 INJURIES OF THE UPPER EXTREMITIES. [CHAr. ix Table XLVII. Summary of Seventy-two Fatal Cases of Intermediary Amputation at the Shoulder for Shot Injury. Name, Age, and Military Description. Date of Injury, Nature of Injury. Allen, F. A., Corp'l, G, 20th Massachusetts. Andrews, C. N., Adjutant, 85th Illinois. Bartley, J., Pt., C, 7th New York, age 27. BeckAvith, G., Pt., E, 58th Pennsylvania, ago 18. Bell, I., Pt., B, 60th Ohio, age 19. Bennett, —, Pt., Louisiana Regiment. Bissell, W. R., Capt., A, 8th Virginia. Boone, W., Pt., G, 55th Penn- sylvania. Crompton, J. T., Serg't, I, 14th New Jersey, age 25. Donaldson, T., Pt., E, 13th Ohio Cavalry, age 22. Durif, E., Corp'l, B, 131st New York, age 37. Elderkin, N., Pt., G, 18th Wisconsin. iFee, J. A., Capt., I, 48th New York, age 27. Felton, C, Serg't, K, 122d New York, age 39. June 3, 1864. June 30 1864. May 9, 1864. April 6, 1862. J'ly 1-3, 1863. Oct. 22, 1862. July 9, 1864. Oct. 8, 1864. Sept. 19, 1864. May 22, 1863. June 28, 1864. June 3, 1864. Date of Opera- tion. Ferren. J., Pt., 1,93d Indiana, Sept. 11 age 20. 1864 Gallon, C, Corp'l, F, 96th Pennsylvania. Gillies, P., Pt., II, 131st New York, age 25. Goudy, W., Pt., H, 26th Ohio. 2Green, N. S., Pt., A, 56th Massachusetts. Hall, C, Serg't, F. 25th Massachusetts, age CS. "illarrill, J. W., Serg't, B, 26th Alabama, age 25. Harrison, G., Pt., G, 61st Xew York, age 23. Hart, J., Pt., C, 59th New York, age 26. Haves, J., Sergt, K, 7th Ohio. Operation and Operator. Sept, 17, Shot fracture of the right arm; Oct. 12, 1862. Sept. 17th, arm amputated at 1862. middle third; sloughing. June 27, Shot fracture cf middle third July 19, 1864. of left humerus; Juno 27th, 1864. amputated at the junction of upper and middle thirds, by Surg. M. M. Hooton, 86th Illi- nois; gangrene. Ball lodged in right shoulder June 16, joint; great nervous prostra- 1864. tion. Shot fracture of right shoulder July 26, joint; necrosis; tissues lace- 1864. rated. Ball entered between left clairi- May 31, cle and trapezius, shattering 1864. scapula, and lodged. Hemor- rhages May 27th. 28th, 30th, and 31st. Shct fracture of humerus, with April 16, laceration cf soft parts. 1862. Shot fracture of head of hume- A few rus; fissures extending nearly days af- whole length cf shaft. terinj'y Comminution of upper third of Nov. 12, left humerus; Oct. 23d, frag- 1862. ments of hone removed. Comminuted fracture of right July 22 humerus; arm cedematous; 1864. pus buiTowing. Upper third ot left humerus; Oct. 29, honenecrcscdforseveninchcs 1864 and head of bone completely destroyed; tissues disorgan- ized. Head of left humerus commi- Sept.27, nuted; parts infiltrated with 1864. pus. Compound fracture of upper June 1, third of left humerus. 1863. Wound of right shoulder; June July 13 28th, excision cf head of right 1864. humerus; profuse suppura- tion ; secondary hsemorrhage. Wound of face and right arm; June 18, ball entered right shoulder, 1864. fractured humerus 4\ inches below head down to within 3 inches of elbow joint. Wound through chest and right Sept. 16 arm; humerus shattered at 1864. upper third. Nov. 7, Shell fracture of right humerus Nov. 12, 1863.' to the anatomical neck; parts 1863, ecchymosed. Oct. 19, Comminution of head of left Oct. 26, 1864. humerus; hoemorrhage from 1864. axillary amounting to twenty ounces. Sept. 19, Fracture of right radius and Sept. 25, 18C3. ulna; mortification extending 1863. high up in arm. May 6, Wound of left shoulder joint; June5, 1864. excision of head of humerus; 1864. haemorrhage. June 3, Ball entered upper left arm, June 14, 1864. passed along the humerus, 1864. and lodged in olboAV joint; gangrenous to near shoulder joint. July 3, AVound of right humerus; head July 12, 1863. excised, by Surgeon H. E. 1863. Goodman, 28th Pennsylvania. May 8, Shot through right clboAV: in- May 19, 1864. tense inflammation extending 1864. to the shoulder; pus diffused through arm. June 22, Fracture of the left scapula and Juno 29, 1864. shoulder joint. 1864. April 2, Comminuted fracture of hume- April 18, 1862. rus; much laceration. 1862. Result and Remarks. Re-amputated at the shoulder, by A. A. Surg. L. Fisher. Re-amputated at the shoulder, by A. A. Surg. J. A. Hall. Antero-posterior flap exarticu- lation, by Surg. N.R.Moseley. Amputation at the shoulder, by Ass't Surg. E. Curtis, U. S. A. Amputation at the shoulder, by A. A. Surg. C. H. Osborne. Amputated at the shoulder, by Ass't Surg. B. Howard,U.S.A. Amputated, by Surgeon C. S. Wood, 66th New York. Circular amputation, by A. A. Surg. T. T. Smiley. Amputated, by Ass't Surgeon R. F. Weir, U. S. A. Antero-posterior flap operation, by A. A. Surg. J. C. Morton. Flap amputation, by A. A. Sur- geon J. R. Uhler. Amputated at the shoulder... Amputation at the shoulder, by Surg. D. G. Rush, 101st Penn- sylvania. Amputated, by A. A. Surgeon H. M. Dean. Amputated, by A. A. Surgeon J. Brey. Amputated, by A. A. Surgeon W. M. Hudson. Amputated, bv Ass't Surgeon D. C. Peters," U. S. A. Amputation at the shoulder by double flaps. Amputated, by Surgeon R. B. Bontecou, U. S. V. Amputated, by Surgeon D. P. Smith, U. S. V. Pyaemia; death October 25,1862. Spec. 267, A. M. Al. Died July 23, 1864, from gan- grene. Died, six hours after operation, June 16, 1864. Spec. 2564, A. M. M. Died July 31,1864. Died May 31, 1864; tho autopsy showed cxtensiA'C stellated frac- ture of scapula and division of enprascapula artery. Died April 17, 1862. Died July 16,1863. No reaction; died November 12, 1862. Spec. 681), A. M. M. Died from shock, eight hours after operation, July 22, 1864. Died Oct. 29, 1864, from effects of chloroform and shock. Spec. 3706. A. M. M. Died October 4, 1864. Died June 5, 1863, from effect of cxcessiA-e haemorrhage during operation. Died July 15,1864. Died June 23, 1864. Spec. 2573, A. M. M. Died Sept. 18, 1864. Autopsy showed fifth, sixth, and seventh ribs fractured, and fragments of bone driven into lung and liver. Died November 20, 1853. Oct, 31st, haemorrhage amounting to 32 ounces; axillary ligated on face of stump; haemorrhage recurred; death Nov. 1, 1864. Died. Died June 7, 1864. Died June 14,1864, from exhaus- tion. Amputation at the shoulder by the oA'al method. Amputated, by Surg. E. Bent- ley, U. S. V. Double flap amputation, by A. A. Surg. T. F. Bclton. Amputated, by Ass't Surgeon B. Howard, U. S. A. Julv 19th, hsemorrhage from axil- lary; death July 21, 1863. May 25th, symptoms of pyaemia; died June 4, 1864. Sec'd'y hirmorrha^e: transfusion of blood thro' :.ic. ' ..ion back of scapula: cV-ath July 7, 1864. Died April 19, 1362. i Sec Case 13. Taiile XXV. p. 536 ante. * See Case 22, Taule XXV. p. 536 ante. sgeeCASE 27, Tadi.e XXV p. 536 ante. SECT, in.] AMPUTATIONS AT THE SHOULDER JOINT. 643 Name, Age, and Military Discretion. Herrick, M., Pt., D, 49th New York, age 21. Higgins, C, C, 41st Missis- sippi. Hoffmann, AV. H., Pt., C, 5th New Hampshire. Hoggard, J., Corp'l, E, 137th Illinois, age 20. Holmes, D., Pt., I, 140th Illinois, age 35. Horniday, D. B., Pt., C, 18th Indiana. Irwin, D., Pt., K, 33th Ohio, age 23. Kelsey, G., Pt., I, 4th New York Artillery, age 28. Kleinscbmidt, E., Corp'l, 41st New York. Kuhlman, J., Pt., I, 121st Ohio, age 23. Kuntz, J., Pt,, D, 9th Wis- consin. 'Lawson, G., Pt., A, 86th New York, age 35. Marqwart, J., Pt., A, 17th Pennsylvania Cavalry, age 24. Mason, A. B., Corp'l, A, 4th Pennsylvania Reserves. McCarthy, P., Pt., F, 57th Massachusetts, age 27. McColligan, JI., Pt., C, 56th Massachusetts, age 18. McGough, J. H.. Pt., I, 45th Georgia, age 23. McTeague, T., Pt., I, 86th New York, age 20. Meeder, J., Pt., I, 1st Maine Heavy Artillery, age 25. Moll, XV., Pt., A, 14th U. S. Infantry. Morris, F. M., Pt., G, 18th Kentucky. Mowrey, II. B., Corp'l, B, Gth Pennsylvania Reserves, age 26. May 5, 1864. Sept. 20, 1863. May 31, 1862. Aug.21, 1861. Julv 9, 1864. Oct. 19, 18G4. July 24 1864. June 18 1864. July — 1861. June 27, 1864. Sept. 29, 1862. May 7, 1864. June 21, 1864. June30 1862. June 17, 1864 May 18, 1864 May 3, 1863. May 14 1864. June 12, 18C4. Aug. 30, 1862. Sept. 1.9, 18C3. Sept. 17, 1862. 47 Mullen, B., Pt., D, 28th Aug. 30 Massachusetts. 1862. Nature of Injury. Fracturo of left humerus; same day three inches of shaft ex- cised; secondary haemorrhage May 23th; a largo sac dis- covered over scapula contain- ing about thirty ounces of blood. Right arm shattered; haemor- rhage from sloughing of tho brachial artery. AVound at upper third of left arm; secondary haemorrhage Shot fracture of upper third of righthumerus; about one-half inch of each of the fractured ends was removed with tho saw; haemorrhage from the brachial artery; September 9th, haemorrhage recurred. Shot fracturo of middle third cf right humerus; parts gangre- nous; haemorrhage from the brachial artery, necessitating amputation. Shot wound of left arm; com- minuted fracturo of liumerus, extending to joint; gangrene. Shot fracture of rigl-.t humerus; August 7th, Sth, Uth, and 10th, haemorrhages from posterior circumflex; arrested by com- pression ou subclavian. Severe shot wound of right arm; Juno 18, 1864, excision. Small conoidal ball perforated the head of the left humerus, exposing its point in the ana- tomical neck opposite; symp- toms of pyaemia. Shot fracture of right humerus; gangrene. Shot wound of shoulder....... Opera- tion. O'Dell, H., Pt., A, 1st Penn- sylvania Rifles, age 36. Tune 24, 1864. Shot comminution of the upper third of left humerus; May —, 1864, excision of head and portion of shaft; haemonhage from axillary artery. Shot wound of right forearm ; June 2oth, missile extracted; gangrene. Ball traversed surgical neck of left humerus, comminuting and splintering the bone into the shoulder joint; parts sloughing. Shot wound through the right shoulder; upper portion of humerus fractured and axil- lary artery injured. Fracture of upper third of left humerus; gangrene; June 6th, symptoms of pyaemia; June 8th, haemorrhage from brachial close to axilla; ar- rested by compression upon subclavian. Comminuted fracture of upper third of humerus: ball pass- ing into thorax and lodging. Shot wound of left arm; hume- rus comminuted about four inches from middle; pus bur- rowed around shoulder joint; symptoms of pyaemia. fracture ofthe right shoulder, opening joint and carrying away head of humerus. Fracture of shaft of left hume- rus.extending into upper third. Fracture twoinchosabove right elbow joint; gangrene. Fracture of left hamerus, ball lodging; Sept. 23d, ball ex- tracted; Sept. 2Cth, haemor- rhage, caused by sloughing of brachial; gangrene. Fracture of left arm at middle third, ball lodging in axilla; remained on field for eight days. Fracture of upper third of right humerus bya large projectile. May 26, 1864 Sept. 28, 18G3. Juno 10, 1862. Sept. 9, 1864. July 17 1864. Oct. 23, 1864. Aug. 10, 1864. July 3, 1864. July 26, 1861. July 15, 1864. Oct. 4, 1862. May 23, 1864. . June 26 1864. July 21 1862. Julv 1, 1864. June 8, 1864. May 23, 1863. June 5, 1664. June 20 1864. Sept, 15, 1862. Oct. 16, 1863. Sept. 27, 1862. Sept. 9, 1862. Julv 9, 1864. Operation and Operator. Amputated at the shoulder, by Ass't Surgeon W. Thomson, U. S.A. Amputation at the shoulder joint by lateral and internal flaps. Amputated, by A. A. Surgeon J. Neill. Amputated, by A. A. Surgeon J. Brey. Sept. 11th, haemor- rhage from axillary artery to the amount of one pint and a half. Stump opened and art- ery again ligated at tho same point. Amputated by Lisfranc's meth- od, hy A. A. Surgeon S. S. Jessup. Amputated, bv Ass't Surgeon B. Fordyce, 160th New York. Amputated, by Surgeon J. B. Lewis, U. S. V. Amputation at the shoulder joint by Lisfranc's method. Amputated, hy Ass't Surgeon J. AV. S. Gouley, U. S. A. Amputated, by A. A. Surgeon J. A. Hall. Amputation at shoulder joint by double flaps. Amputated at shoulder joint, by Surgeon R. B. Bontecou, U. S. V. Antero-posterior flap amputa- tion at the shoulder joint, by Surg. O. A. Judson, U. S. V. Amputated by transfixion, by Surg. J. H. Brinton, U. S. V. Amputated, by A. A. Surgeon C. Everard. Amputated, by Surgeon D. P. Smith, U. S. V. Amputated at shoulder joint by oval incisions. Flap amputation just above in- sertion of deltoid, and head of bone removed afterward, by Assistant Surgeon A. Ingram, U. S.A. Amputated, by Ass't Surgeon J. S. Smith, U. S. A. Amputated, by Surgeon T. E. Mitchell, 1st Maryland. Amputated, by Surgeon A. McMahon, 64t'h Ohio. Subclavian ligated in its third portion, and amputation per- formed, by Surg. A. B. Has- son, U. S. A. Flap amputation, by A. Ass't Surgeon G. McCoy. Flap amputation, by A. A. Surgeon J. M. Flood. Result and Remarks. Died one-half hour after the oper- ation, May 26,1875. Spec. 3595, A. M. M. Died October 6,18G3, of pyaemia. Died June 24, 1862, from second- ary haemorrhage. Died Sept. 12, 1864, from effects of another haemorrhage from axillary artery. Died July 29, 1864. Died October 24, 1864, from ex- haustion. Died Aug. 10, 1864, from effects of haemorrhage and tetanus. Spec. 4263, A. M. M. Died July 7, 1864, of pyaemia. Much loss of blood during the operation. Pyaemia supervened. Died July 28, 1861. Spec. 347, A. M. M. Died July 18, 1864, of pyaemia. DiedOctober25,1862, of pyaemia. Died May 31, 1864. Died June 26, 1864, from effects of gangrene. Died Julv 25, 1862. Spec. 571, A. M. M. July 2d, gangrene; died July 5, 1864, from exhaustion. Diarrhoea; died July 5, 1864, of pyaemia. Specs. 2917 and 3299, A. M. M. May 25th, severe chill. May 29, haemorrhage; flaps opened and artery secured; died June 3,18G3. Died June 17, 1864, of pyaemia and shock. Spec. 2823, A. M. M. Gangrene; died July 1, 1864. Spec. 3078, A. M. M. Died Sept. 26, 1862. Spec. 829, A. M. M. Died October 23, 1863. Died Sept, 27, 18G2, a few hours after the operation. A large ecchymosed spot on sacrum and another OA'er right scapula; both sloughing and dis- charging pus; died suddenly, Oct. 31,1862, the wound entirely healed. Spec. 1226, A. M. M. Died July 9, 18G4, from exhaus- tion, caused by haemorrhage and operation. i Sec Case 41, Taule XXXII, p. 571 ante. 6-14 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. NO. Name, Ace. and military Dkscription. Date OF Injury. Nature of Injury. Date of Opera-tion. Operation and Operator. Result and Remarks. 49 Ourish, P., Serg't, E, 32d May 30, Fracture of left humerus at up- Juno 8, Amputated by the double flap Died June 8, 1864, from shock. Massachusetts, age 19. 1^64. per third; May 31st, excision to within two inches of the head, and axillary artery liga-ted close below clavicle; June 7th, haemorrhage from axil-lary; two inches ofthe clavi-cle remoA'ed from over the artery and the vessel again ligated, by Asst. Surg. G. A. IMursick, U. S. V.; gangrene. 1864. plan, by Ass't Surgeon G. A. Mursick, U. S. V. 50 Paddock, B., Pt., E, 17th Wisconsin, age 43. May 19, Fracture of left humerus at June 3, Amputated, by Ass't Surgeon Died June 27,1863, from exhaus- 1863. surgical neck; diffuse suppu- 1863. W. Waters, U. S. V. tion. Spec. 2082, A. M. M. ration, with sloughing. 51 Peterson, P., Pt,, 2d Battalion Aug. 11, Shot wound of arm; ball struck Sept. 2, Amputated at shoulder joint Died September 4, 1862. Missouri State Militia. 1862. styloid process of the radius, passed upward.carry ing away olecranon process of ulna, and was cut out near insertion of deltoid; Sept. 1st, gangrene. 1862. by Larrey's first method. 52 •Regan, C, Pt., G, 37th New May 5, Fracture of head of left hume- May 31, Amputated, by Surgeon A. B. Died June 1, 1862, from haemor- York. 1862. rus and scapula. 1862. Mott, U. S. V. rhage. 53 Rosa, J., Pt., K, 71st Ohio, Dec. 16, Fracture of upper third of left Dec. 31, Amputated, by A. A. Surgeon Died Feb. 5,1865, of pyaemia. age 30. 1864. humerus; gangrene. 1864. M. N. Benjamin. 54 Runkle, J. G., Corp'l, A, 15th May 12, Two shot wounds of left arm; June 1, Amputated, by Surgeon D. W. Died June 7, 1864. Spec. 2395, New Jersey, age 19. 1864. one ball passed thro' shoulder, fracturing head and two inches of shaft of liumerus, the other passed through forearm, splin-tering ulna at middle third. 1864. Bliss, U. S. V. A. M. M. 55 Sankey, M. A., Pt., I, 103d Dec. 14, Fracture of right humerus; Dec. Jan. 8, Amputated at shoulder joint, Died, Jan. 8, 1863, from exhaus- Pennsylvania, age 18. 1862. 27th, excision of three and a half inches of middle third of humerus, bvSurg.C. A. Cow-gill, U. S. V.; January 8,1863, haemoiThage from brachial. 1863. by Surgeon C. A. Cowgill, U. S. V. tion. Spec. 1327, A. M. M. 56 Scroggs, J. J., Pt,, D, 16th July 3, Fracture of loft humerus, high Julv 7, Amputated at shoulder joint Died July 22, 1863, of tetanus. North Carolina, age 20. 1863. up, with sloughing. 1863. by the oval method. 57 Smith, D., Pt,, F, 13th New June 2, Fracture of the right humerus; June 13, Amputated, by Surg. E. Bent- Died June 17,1864, from exhaus- Hampshire, age 48. 1864. comminution of the head and nearly the whole of the shaft; pus diffused through the mus-cular tissues. 1864. ley, U. S. V. tion. 58 Smith, S. R., Pt., G, 207th April 2, Fracture cf entire upper third April 5, Amputated, by Ass't Surg. W. Died April7,1865, from secondary Pennsylvania, age 34. 1865. of right humerus. 1865. Can-oil, U. S. V. haemorrhage. Spec. 1162, A.M.M. 59 Smith, W., Pt., E, 40th In- Noa'. 26, Shot wound of left arm; erysip- Dec. 11, Amputated, by A. A. Surgeon Died Dec. 16, 1864, from exhaus- diana, age 39. 1864. elas; gangrene. 1864. J. H. Mclntyie. tion. 60 Spencer, J. A., Pt., K, 1st Mar. 25, Fracture of left humerus at up- April 15, Amputated, by Surgeon D. W. Died April 23, 1865. Spec. 4081, Maine. 1865. per third by two balls, one of Avhich lodged; April 15th, haemorrhage from brachial. 1865. Bliss, U. S. V. A. M. M. 61 Spies, M. S., Pt., K, 26th Sept. 17, Fracture of right elbow joint; Oct. 3, Amputated, by Ass't Surgeon Died Oct. 12, 1862. Spec. 773, New York. 1862. erysipelas; gangrene. 1862. R. F. Weir, U. S. A. A.M.M. 62 Stengele, J., 1st Serg't, E, June 18, Fracture of upper third of left June 30, Amputated, by Ass't Surgeon Died July 5, 1854, from second- 14th U. S. Infantry, age 26. 1864. humerus, with injury to prin-cipal artery. 1864. C. A. Hamilton, 76th N. York. ary haemorrhage. 63 Stokes, O., Pt., F, 100th New Aug. 14, Fracture of upper third of right Aug. 27, Lateral flap amputation, by A. Sept. 3d, secondary haemorrhage York, age 33. 1864. humerus; bone comminuted to the articulation. 1864. A. Surg. R. O. Sidney. from axillary; stump opened and artery ligated. Died Sept. 3, '64, from effects of haemorrhage. 64 Sutliff, W. T., Pt., B, 137th July 2, Fracture of right humerus, fol- July 5, Amputated, by Surgeon A. K. July 12th, secondary haemor- New York, age 30. 1863. lowed by suppuration and sloughing. 1863. Fifield, 29th Ohio. rhage. Died July 26, 1863. 65 Trafton.O., Pt.,F,32d Maine, May 18, Shot wound through left shoul- May 29, Amputated, by Surgeon R. B. Died May 29, 1864. age 32. 1864. der, fracturing head of hume-rus ; wound sloughing; scap-ula exposed. 1864. Bontecou, U. S. V. 66 Vontaine, J. R., Serg't, A, June 13, Comminuted fracture of lower July 5, Amputated at shoulder joint, Died July 5, 1864, six hours 8th New York Cavalry. 1864. part of upper third of right humerus; June 13th, excision of about four inches of shaft of humerus; June 30th and July3d,haemorrhages; wound gangrenous; a large slough remoA'ed; July 5th, hemor-rhages. Wound thro' right wrist joint, 1864. by Dr. J. Boardman, Buffalo, N. York. (Sisters of Charity Hospital.) after operation. 67 Wallson, R., Pt., I, 13th May 5, May 28, Amputated, by A. A. Surgeon June 6th, diarrhoea. Died June North Carolina, age 17. 1862. shattering styloid process of radius and ulna; gangrene. 1862. B. A. Vanderkieft. 9,1862. 6* AVcis, H., Pt., B, 48th New Aug. 16, Shell fracture of shaft of right Aug.21, Amputated, by A. A. Surgeon Died Aug. 31, 1864, from irrita- York, age 42. 1864. humerus, extending to head; great laceration of soft tissues. 1864. W. L. Weller. tive fever. 69 : Welch, B. R., Serg't, II, Aug. 25, Fracture of the left shoulder; Sept. 15, Lateral flap amputation at the Sept. 24th, haemoiThage from 1st District Columbia CaA'- 1864. Aug. 25th, excision of shoul- 1864. shoulder joint, by A. A. Surg. stump; flaps laid open and arte- alry, age 25. der joint and upper portion of humerus; Sept, 8th and 15th, haemorrhage from circumflex arteries. J. G. Morgan. ries ligated. Died October 11, 1864. Spec. 3675, A. M. M. 70 Whipple, P., Pt., K, 16th June 15, Wound of right shoulder joint; July 3, Flap amputation, by Surgeon Died Aug. 4,1864, from hiemor- Wisconsin, age 27. 1864. haemorrhage from axilla. 1864. E. M. Powers, 7th MissDuri. rhage. 71 Wiggins. K., Pt., B, 119th Mav 6, Fracture of head of right hume- Mav 14, Amputated, hy Surgeon A. F. Died May 15,1864. Pennsylvania, age 40. 18*64. rus and articulating portion of scapula; gangrene. 18*64. Sheldon, U. S. V. 72 White, T. A., Pt., E, 28th Dec. 13, Wound of left arm, with frac- Dec. 16, Amputated at shoulder joint by Died January 10, 1863. New Jersey. 1862. ture, followed by sloughing. 1862. the oval method. l See American Med. Times, 1862, Vol. V, p. 133. * See Case 76, Table XXXII, p. 572 ante. sect, in.] AMPUTATIONS AT THE SHOULDER JOINT. 645 In sixty-six of the seventy-two fatal intermediary amputations at the shoulder for the consequences of shot injury, the operations were equally divided between the two sides, thirty-three at the right and thirty-three at the left shoulder. Some modification of trans- fixion and double flap incisions was the most common operative method, although the oval nnd circular methods, the former particularly, were frequently practised. The remarks on the causes and extent of the injuries that led to the successful amputations apply to this series also; the wounds were, for the most part, from small projectiles. Tetanus supervened in two instances, gangrene in four; three patients succumbed to the shock of operation; in one case, chloroform was assigned as the cause of death. One patient had a mortal shot perforation of the lung and liver, and six others had important wounds in other regions. Secondary Amputations at the Shoulder Joint.—In the sixty-six reported cases of amputations at the shoulder joint after shot injury, practised later than the thirtieth day from the reception of the injury, the mortality was 28.7 per cent. In nearly two-thirds of the cases the exarticulations were secondary not only as regarded date, but followed other unsuccessful capital operations. ^Successful Cases. — Forty-seven, or 71.3 per cent., of these operations resulted favorably. Forty-four of the survivors were Union soldiers and were pensioned; three were Confederates, who were released on parole or exchanged. The operations were on the right side in twenty-six, on the left in twenty-one instances. Two of the pensioners died eight and eleven years, respectively, after their discharge. No less than twenty-three patients had previously undergone amputations lower down in the limb—a significant fact, corroborating the experience of military surgeons regarding the favorable results of re-ampu- tations at the hip after amputations in the continuity of the thigh. Six of the patients had previously undergone excisions of the upper extremity of the humerus, one an excision of the shaft, one an excision of the upper part of the radius, and one a ligation of the subclavian artery. Four of the patients had received serious wounds in other portions of the body. At the date of exarticulation, the glenoid cavity was gouged out on account of caries in one instance, and in one case consecutive haemorrhage necessi- tated secondary ligation of the axillary artery. Case 1608.—Private F. Lafayette, Co. G, 100th Illinois, aged 28 years, was Avounded at Chicka- mauga, September 19, 1883, and after treatment in a TAventy-first Corps hospital Avas sent to Nashville, and, on November 7th, Avas admitted to Hospital No. 19. The Specimen (Fig. 498) was contributed by the operator, Surgeon J. W. Foye, U. S. V., Avith the following history: "Admitted Avith a gunshot fracture of the upper portion of the left humerus. When he first came under observation, the soft parts of the loAver half of the arm Avere extensively involved in gangrenous disorganization. The forearm Avas much SAvqllen and oedematous. The Avound in the soft parts near the head of the humerus Avas also gangrenous, and the patient had lost much blood from haemorrhage, caused by sloughing of the muscular branches of the brachial. The heart's action was frequent and feeble, and the surface ofthe body bathed in cold perspiration. Ampu- tation being decided upon, the patient was stimulated, and the operation performed at the joint, December 13, 1883. He bore the operation Avell, convalesced Avithout a had symptom, and is hoav aAvaiting his dis- charge from service." The patient Avas discharged February 15, 1864, and pensioned. He was paid September 4, 1874. The specimen consists of "six inches of the shaft of the left humerus, shoAving a con- solidated gunshot fracture, from an amputation at the shoulder joint for secondary lucinorrhage and gangrene. fig. 496.—ill-united The union is excellent, although some necrosed fragments, sources of irritation, are yet imprisoned. The shot fracture of shaft head ofthe humerus Avas improperly removed in mounting the specimen." (Cat. Surg. Sect, 1866, p. 112.) 2175. This group of forty-seven fortunate exarticulations might be subdivided into three sub-groups, viz: Early secondary, or those practised within sixty days from the reception of injury (thirteen cases), usually on account of hsemorrhage, gangrene, or profuse suppura- tion,—later secondary amputations, or those performed from the end of the second to the end of the sixth month (fifteen cases), generally for hopeless disease of the humerus, some- GIG INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. .Ill times with consecutive implication of the shoulder joint,—and ulterior amputations (nineteen cases), commonly performed long after the injury on account of chronic osteomyelitis, or for necrosis of the entire humerus. The following is a good example of the latter variety: Cask 1609.—Private J. Potter, Co. H, 12th Illinois Cavalry, aged 43 years, Avas Avounded at Cane River, April 27, 1864, nnd Avas treated in Barrack Hospital, Ncav Orleans, from that date until January 31, 1885, Avhen he Avas transferred to Ncav York and entered De Camp Hospital. Assistant Surgeon "Warren "Webster, U. S. A., furnished the folloAving special report: " The patient was Avounded Avhile charging the enemy Avith his company. The projectile, a cylindro-conoidal ball, penetrated the posterior and inner surface of the arm at about the middle of the humerus, Avas flattened upon the bone, and passing dowmvard and outward lodged in the soft parts near the elboAV joint. He states that he did not dismount in consequence ofthe Avound, nor throAV aAvay his carbine, but rode to Alexandria, a distance of ten miles, carrying the Aveapon on his wounded arm. On the following day he Avas transferred to hospital at New Orleans, Avhere he arrived May 1, 1864. There he first received professional attention, and on the 9th of the month the ball Avas removed through an incision near the elbow. The surgeon, he says, informed him that the bone had not been fractured. The anterior part of the ball Avas deeply indented, seemingly by impingement upon the shaft of the humerus. The Avound of entrance, from the man's statement, Avas of such small size and regular appearance as to render it probable that the ball Avas of its original shape Avhen it entered the arm. After the extraction of the missile the limb rapidly inflamed, became greatly sAvollen betAveen the elbow and shoulder, and Avas affected with deep-seated and almost unsupportable pain. The constitutional disturbance appears also to have been correspondingly great. Local anodyne applications were employed, and morphine internally administered for several Aveeks. Six abscesses had appeared previously to November, 1864, some of Avhich Avere opened by the knife and others alloAved to break sponta- neously. In that month Private Potter states that a deep incision, about three and a half inches long, Avas made longitudinally on the anterior aspect of the arm, apparently for the purpose of extracting necrosed bone, but the attempt Avas abandoned. Whenever the fistulous openings in the parts Avere alloAved to close there Avas an access of deep-seated pain. The patient Avas transferred to De Camp Hospital in February, 1885. Upon his admission there he presented an appearance Avhich led those who saAV him to quite despair of his life. The long continuance of pain and exhausting discharges had brought him to the brink of the grave. For many months after his arrival at De Camp ITospital his hold upon existence Avas by the slenderest ties. By dint of most careful nursing and attention to diet, he Avas, hoAvever, so far improved in November as to render proper operative interference for the rescue of his life. At that time there Avere fourteen openings in the arm and shoulder, through which purulent matter discharged. Some of these openings did not communicate Avith bone, but Avith the axillary glands, Avhich had taken on inflammatory and suppurative action. Through numerous cloacae in the encasing of neAV osseous deposit a vast amount of necrosed bone could be detected, which appeared to extend nearly from one articulation to the other. It having been determined, in vioAv of all the circumstances ofthe case, to amputate at the shoulder joint, the operation Avas performed by Assistant Surgeon Warren Webster, U. S. A., November 10, 1835. A deltoid flap Avas raised and the knife made to SAveep aAvay as much as possible ofthe diseased gland tissue on the inner side ofthe bone. The patient rallied with difficulty from the operation, but, gradually, improvement began, and, at this date, March 12, 1838, the shoulder is nearly healed, the patient has regained his health and strength, and is acting in the capacity of ward orderly in De Camp Hospital." The patient Avas discharged the service March 28, 1888, and pensioned. He Avas paid on September 4, 1874. The specimen (FlG. 497) consists of the right humerus, amputated at the shoulder joint after contusion by a conoidal ball, Avhich is attached. The entire shaft is necrosed and surrounded by a partial involucrum. The specimen is interesting from the character of the injury, the extent of the disease, the duration of the case, and the result. It Avas contributed by the operator. The next case illustrates one of the re-amputations that occurred in this category: Case 1610.—Private W. E. Crolins, Co. A, 72d Pennsylvania, aged 30 years, Avas Avounded at Gettysburg, July 2, 1883, and Avas received into a Second Corps hospital. The folloAving Avas recorded on Army Corps Register No. 93: "Compound comminuted fracture of right arm. Amputated by Surgeon M. Rizer, 72d Pennsylvania." On July 29th, the patient Avas admitted to Camp Letterman Hospital, Avhere Acting Assistant Surgeon G. M. Ward reported that the improvement of the patient Avas uninterrupted from the date of his admission until September 3d, Avhen he was transferred to Satterlee Hospital. Acting Assistant Surgeon Thomas G. Morton contributed the specimen (FlG. 493) and reported: H Wounded by a minie ball, which passed through the upper end of his arm. Amputa- tion Avas performed tAvelve hours aftenvard, leaving about six inches of bone. The flap never entirely closed, and a probe could be passed up the medullary cavity to the head ofthe bone, the shaft of which Avas also necrosed and softened. January 8th, I re-amputated the arm at the shoulder and took aAvay the entire bone, including its head. Considerable hsemorrhage took place, and some hsemorrhage second- arily, but not to any amount, brought on by an attack of vomiting. Silver sutures Avere used; the patient did Avell. On February 10, 1864, the patient Avas about, the wound almost entirely healed." The Catalogue of 1866, page 115, says: "The specimen, embracing the head and two inches of the shaft, exhibits a profound degree of necrosis as existing six months after the first operation, and requiring the second." This soldier Avas discharged and pensioned May 3, 1664, Surgeon I. I. Hayes amputation of the right arm at the shoulder, folloAving gunshot Avound." The pensioner Avas paid June 4, 1874. dm Fig. 497.—Necro- sis of the liumerus after shot injury. Spec. 2511. £. FIG, 418.—Upper portion of right humerus, carious, after amputation in the con- tinuity for shot fracture. Spec. -C2G. certifying to SECT. IU.] AMPUTATIONS AT THE SHOULDER JOINT. 647 Table XLVIII. Summary of Forty-seven Cases of Successful Secondary Amputations at the Shoulder for Shot Injury. Name, Age, and Military Description. Alexander, C. II., l't., B, 2d Marylaud Artillery. Alley, W 3 Anderson, S. S., l't., G, 27th Alabama, n^c 24. 4 Bcachy, J. V., Pt., H, 39th Illinois, ago 22. 'Burger, S., Pt., A, 102d Illinois, age 30. Burke, M., Serg't, K, 15th Xew York Artillery. Cockran, M., Pt., C, 115th New York, age 35. Craft, E., Pt., F, 126th New York, age 24. Crolins, AV. E., Pt., A, 72d Pennsylvania, age 30. Cutler, F. R., Pt,, K, 72d Pennsylvania, age 17. Dahl, J., Pt., I, 6thKentucky Dale, J. W., Serg't, B, 25th Illinois, age 22. Davis, J. W., Serg't, F, 64th New York, age 23. *Dibble, A. H., Pt., F, 33d New York. Dowd, P., Pt., K, 8th New Hampshire. Eldridge, J. C, Pt, H, 4th Tennessee Cavalry, age 20. 17 Frain, J. F., Pt., D, 1st Penn- sylvania-Cavalry, age 19. Gilman, S. F., Pt., A, 5th Maine, age 30. Julv 1 18H2. Aug.l.- 1864. Nov. 30, 18G4. Juno 2, 1864. June 15, 1864. June 25, 1864. June 7, 1864. Julv 2, 1863. July 2, 1863. Sept. 17 1862. Sept. 20, 1863. Sept, 20, 1863. May 12, 1864. May 3, 1863. May 27, 1863. Feb. 15, 1865. June 3, 1864. June 27, 1862. Nature of Injury. Right forearm carried away by premature discharge of gun; July 1st, amputated at olbow joint, by Asst. Surg. J. S. O'Donnoll, Purnell Legion; stump painful. Fracturo cf the right humerus; amputated four inches below shoulder; lioemorrhnge eight days after operation. Shell fracturo of upper third of left humerus; gangrene. Shot fracturo of lower third of left arm; Juno 2d, arm am- putated at the middle third; necrosis. Ball passed through head of right humerus; June 15th, excision of head and four in- ches of shaft cf tho humerus; June 21st, hsemorrhage; dis- charged Dec. 17, 1864; pen- sioned. Fracture of left ulna, elbow joint involved; July 4th, cir- cular amputation at the upper third, by Act. Asst. Surg. II. M. Dean; parts erysipelatous; gangrene. Shot fracture of right elbow, opening joint; June 7, 1864, arm amputated near upper third, by Surg. J. M. Palmer, 3d New York, by lateral flap method; eedema. Left arm fractured; ball lodged; July 14th, tbe ball extracted; Aug. 12th, amputation at mid- dle third; Aug. 22d, hoemor- rhage from brachial, arrested by actual cautery; Dec. 18, 1863, re-amputated at upper third; caries. Shot fracture of middle third of right humerus; July 2d, am- putated at upper third, by Surg. M. Rizer, 72d Penn. Six inches of right humerus shattered; inflammation of the medullary cavity. Fracture of lower third of left liumerus; September20,18U3, amputated near upper third; soft parts indurated and in- flamed. Wound of left elbow joint; Oct. 8,18G3, amputated at junction of middle and lower thirds; necrosis. Fracture of metacarpal bones of left hand; gangrene; May 30, 1864, circular amputation at middle third, bv Surg. A. F. Sheldon, U. S. V.; disch'd May 10, 1865; pensioned. Fracture of upper fifth of rijrht humerus; May 4th, excision ofheadofhumerus; gangrene. Shot wound of left arm....... Fracture of left ulna, radius.and carpal bones; Mar. 5th, circu- lar amputation at elbow joint, by Surg. D. Stahl, U. S. V. Fracture ofthe right humerus; June 3, 1864, lateral flap am- putation at upper third, by Asst. Surg. L. E. Atkinson, 1st Pennsylvania CaA'alry; Sept. 30th, stump exfoliating. Fracture of the right humerus; June 28th, excision of lower part of shaft, by Surg. G. E. Bricket, 5th Maine; necrosis. Ol'KltA TION. Oct. 9, 1862. Oct. -, 1865. Mar. 13, 1865. Jan. 17, 1865. June 20, 1867. Mar. 29, 1865. Mar. 20, 1865. Dec. 22, 1863. Jan. 8, 1864. Oct. 19, 1862. Mar. 9, 1864. Jan. 16, 1864. April -, 18G8. July 22 1863. Julv 31 1863. June 28 1865. Oct. 21, 1864. Aug. 12, 1862. Operation and Operator. Amput'd by Larrey's method, by Act. Asst. Surg. J. A. Draper. Head and remaining portion of shaft removed, by Dr. J. II. Erskine. Amputated, by Surg. Franklin, C. S. A. Amputated, by Act. Asst. Surg. AV. I!. McGavren. Amputated, by Dr. Madison Reese, formerly Surgeon 118th Illinois. Head and remaining portion of shaft of humerus removed, by Acting Asst. Surg. AV. B. Chambers. Amputated at the shoulder and carious hone remoA'ed from glenoid cavity, by Surg. G. H. Hubbard, U. S. V. Head and remaining portion of shaft removed, by Act. Asst. Surg. E. Seyfforth. Amputated at the shoulder, by Acting Asst. Surgeon T. G. Morton. Amput'd by Larrey's method, by Surg. H. S.Hewit, TJ. S.V. Amput'd by Lisfranc's method, by Asst. Surg. B. E. Fryer, U. S. A. Flap amputation at shoulder., Amputation at the shoulder for consecutive necrosis, by Surg. D. W. Bliss, U. S. V. Amputated, by Dr.W.B. Alley, of Nunda, N. Y. Circular amputation, Alanson's method. Amputation at the shoulder for gangrene, by Surg. D. Stahl, U. S. V. Dead stump and head of the humerus removed. Double flap amputation, by Act. Asst. Surg. B. B. Miles. Result and Remarks. Disch'd Jan. 31, 1863; pensioned. Spec. 271, A. M. M. Recovered within a month. May 23, 1865, recoA'cred; sent to Provost Marshal May 31, 1865. Disch'd Mar. 15,1865; pensioned. Still sore and running ulcer iu 1870. Discharged November 30,1865; pensioned. Disch'd July 17,1865; pensioned. Disch'd May 19,1865; pensioned. Disch'd May 3, 1864; pensioned. Spec. 2606, A. M. M. Oct,20fh,ha3morrhage from axilla; artery ligated; discharged Aug. 10, 1864; pensioned; died May 11, 1873. Disch'd Mar. 8, 1865; pensioned. Mustered out September 5,1864; pensioned. Gangrene controlled by bromine; discharged November 16, 1863; pensioned. Disch'd Sept. 2, 1863; served in Vet, Res. Corps, then pensioned. Mustered out September 12,1865; pensioned. Disch'd April 1,1865; pensioned. Disch'd Oct. 6, 1862; pensioned. 1 See Case 21, Table XXXI, p. 554 ante. 2 See Case 24, Tadle XXIV, p. 531 ante, and Buffalo Med. and Surg. Journal, 1863, Vol. Ill, p. 41. 648 INJURIES OF THE UPPER EXTREMITIES. [chap, ix. Name, Auk. and Military Dr-- iiii'Tiox. Date of IX JURY Graham, 11. A.. Corp'l, II, 1st Pennsylvania Reserves. Haney, .!.. l't., C, 134th Pennsylvania. Ilnirnsburger, A., Pt., G, 1.1th Georgia, age 24. Ileim, Isauc, Corp'l, I, 53d Pennsylvania. Hunter, J. II., Corp'l, B, 12th New York. 'Keeler, AVm., l't., M, 8th New York Artillery. SKcnnier, B., Pt., I, 2d Mas- sachusetts, age 27. Knaplcr, J., Pt., L, 5th Penn- sylvania Cavalry, age 27. Lafayette, F., Pt,, G, 100th Illinois, age 26. Lautz, J. A., Corp'l, C, C7th Ohio. May, D., Pt., P, 90th Ohio.. Mead, Jacob, Pt., I, 58th Indiana. i'Mesley, C. L., Pt., A, 18th Infantry, age 31. Miller, W., Corp'l, II, 16th Ohio. Phelps, J. T., Pt., D, 24th Massachusetts, age 32. Poole, Theo. L., Lieut., H, 122d New York, age 25. Potter, J., Pt., II, 12th Illi- nois CaA'alry, age 45. Powers, P., Pt., C, 24th Mas- sachusetts, age 22. Richards, B., Pt,, G, 4th New Hampshire, age 29. 4Rosa, J. AV., Pt,, L, 2d New York Artillery, age 24. Sanders, J., Pt., H, 6th Hli- nois Cavalry, age 19. Sias, G. AV., Pt., G, 62d PennsvH-ania. Smedley, F. I., Pt., II, 47th PennsylA-ania, age 22. Smiley, S.C., Corp'l, A, 33d Massachusetts. Smith, W. W., Pt., C, 21st Wisconsin, age 29. May 10, 1864. Dec. 13, 1862. July 2, 1863. Julv 2, 1863. June 27 1862. June 23, 1864. Sept. 17, 1862. Mav 8, 18*64. Sept. 19. 1863. Mar. 24, 1862. Jan. 11, 1863. Dec. 31 1862. July 4, 1864. Dec. 28, 1862. Aug. 16, 1864. June 1, 1864. Ap'l 27. 1864. Aug. 16, 1864. Feb. 21, 1865. May 24, 1864. May 12, 1863. June 27, 18G2. Oct. 19, 1864. Ma a'15, 18*64. Sept. 19. 1863. Nature of Injury. Fracture of right elbow joint; arm amputated at lower third, by Surg. D. AV. Bliss, U. S. V.; discharged Oct, 8, 1864; pensioned; Sept., 1866, re-am- putation of arm. Wound of left shoulder joint; mustered out May 26, 1863; pensioned. Fracture of head and neck of left humerus; necrosis. Wound of right arm; necrosis. Wound of right elbow joint; July 7, 1862, amputated, by Act. Asst, Surg. A. Claude; discharged Sept. 6,1862; pen- sioned. Fracture of upper third of right humerus; June 23, 1864, ex- cision of headandpart of shaft, by Surg. A. Churchill, 8th New York Artillery; disch'd February 25, 1865. Right humerusfractured; Xoa\ 20, 1862, head and part of shaft excised, by Surg. A. B. Ilasson, U. S. A.; caries. Wound of lower third cf left arm by explosiA'e ball; elbow joint opened; osteomA'elitis. Fracture of upper part of shaft of left liumerus; haemorrhages from branches of brachial. Right humerusfractured; ostitis and profuse suppuration. Fracture of left liumerus at junction of middle and upper third; July 20.1863,gangrene; July 26th, haemorrhage from brachial. AVound of the left arm aboA'e elbow; January 1,1863, arm amputated, by Asst. Surg. J. It. Adams, 58th Indiana. Shell wound of right shoulder and breast; July 4th, excision of shoulder joint. Wound of left arm; January 11, 1863, arm amputated, by Act. Asst. Surg. 11. Hard. Comminution of neck of left scapula and head of left hu- merus; Sept. 26th, haemor- rhage from axillary; subcla- A'ian ligated, by Act. Asst. Surg. J. C. Morton. Compound fracture of left arm, middle third. Fracture of right humerus; en- tire humerus necrosed; four- teen fistulous orifices. AVound of right arm; August 16th, amputated three inches below shoulder joint; necrosis. Wound of right elbow joint; February 21st, amputation at the middle third; March 27th, haemorrhage controlled by ligation; discharged June 11, 1865; pensioned. Shell wound of right shoulder, humerusfractured; May25th, head andpartof shaft excised; discharged October 3, 1864; pensioned. Fracture of head of right hume- rus and coracoid process. Fracture of upper third of left liumerus; July 4th, circular amputation at upper third; discharged August 28, 1862; pensioned. Fracture of lower third of right arm, elbow joiut inA'oh'ed; Oct. 19, amputation at middle third; discharged Dec. 28, 1864; pensioned. Fracture of clavicle and head of right humerus; parts infil- trated. Left liumerus at middle third; January 11, 1864, arm ampu- tated; caries. Date OF Opera- tion. July -, 1869. June -, 1865. Oct. 28, 18G3. Aug. C, 1863. April 30, 1863. Oct. 1, 1866. Feb. 10, 1863. June 24, 1864. Dec. 13, 1863. April 28, 1862. July 26, 1863. Feb. 4, 1863. Aug. 8, 1864. Jan. 28, 1863. Sept. 26, 1864. Feb. 15, 1865. Nov. 10, 1865. Aprill3, 1865. Dec. 27, 1865. July 10 1863. Aug. 30 1865. April 25 1865. Feb. 13, 1865. Operation and Operator. The remaining portion cf hu- merus, including the head, removed, by Dr. XV. II. Hess, of Nebraska City. Amputated at the shoulder for caries, by Dr. A. G. Walter, of Pittsburg, Pa. Lateral flap amput'n, by Act. Asst. Surg. James E. Steel. Amputated, by Act. Asst.Surg. A. AA'. Colburn. Amputated at tbe shoulder by flap method, by Surg. A. B. Mott, U. S. V. Amputated, by Dr. T. A. Mc- Arthur, cf Soldiers' Home, Philadelphia. Amputated, by Surg. A. B. Ilasson, U. S. A. Amputated, by Act.Asst, Surg. E. De Witt. Amputated, by Surgeon J. AAr. Foye, U. S. V. Amputated, by Surgeon A. D. Gall, 13th Indiana. Amputated, by Surgeon C. T. Alexander, U. S. A. Amputated at the shoulder, by Surg. A. Ewing, 13th Mich. Amputated at the shoulder, by Asst. Surg. Theo. McGraw, U. S. V. Amputated at shoulder joint... Amputated, by Act.Asst. Surg. J. E. Chesley; flap operation. Amputated, by Surgeon F. M. Everlefh. 1st Maine. Amputated, by Asst Surg. W. Webster, U. S. A. See CASE 1609, p. G46. Amputated, by Act. Asst.Surg. F. C. Roper. Subsequently amputated at the shoulder joint. Amput'd,by Dr. H. S. Streeter, of Salisbury, New York. Amputated, by Surgeon J. G. Keenon, U. S. V. Re-amputated at shoulder, by Dr. G. McCook, at Pittsburg. Re-amputated, by Dr. J. H. Heinsling, of Newport, Pa. Amputated, by Act.Asst. Surg. G. S. Stebbins; oval flap. Remaining portion of humerus disarticulated, by Surg. II. Culbertson, U. S. V. Result axd Remarks. Did well after the operation. In August, 1866, stump was still discharging. Sent to Fort Delaware April 9, 1864. Disch'd July 29,1864; pensioned. RecoA'ered. Died Aug. 11,1871. Recovered; a pensioner. Disch'd April 23,1863; pensioned. Blustered out December 23,1864; pensioned. Disch'd Feb. 15,1864 j pensioned. .Spec. 2175, A. M. M. Disch'd June 3, 1862; pensioned. Disch'dSept.Sl, 18G3; pensioned. Disch'd Aug. 13,1863; pensioned. Disch'd Dec. 31,1864; pensioned. Disch'd April 14,1863; pensioned. Disch'd Dec. 13,1864; pensioned. Disch'd May 15,1865; pensioned. Disch'd Mar. 28,1866; pensioned. Spec. 2511, A. M. M. Flo. 497. Disch'd June 17,1865; pensioned. Recovered. A pensioner. Disch'd Oct. 9, 1863; pensioned. Spec. 1700, A. M. M. A pensioner. Diseh'd and pensioned. Applied for commutation in place of artificial limb, August, 1870. Spec. 2850, A. M. M. Disch'd July 8, 1805; pensioned. Disch'd July 19,1865; pensioned. 1 Sec Case 10G, Table XXXI, p. 558 ante. 2See Case 20, Table XXXV, p. 592 ante. 3 See Case 71, Table XXIV, p. 533 ante. « See Case 161, Table XXXI, p. 560 ante. SECT. Hi.] AMPUTATIONS AT THE SHOULDER JOINT. 649 NO. Name, Age, and Military Description. Date of Injury. Nature of Injury. Date of Opera-tion. Operation and Operator. Result and Remarks. 44 45 46 47 Stearns, G., Pt., A, 31st AVis-consiu, ago 38. Steen, B. S., Serg't, C, 14th New York Militia. AA'atson, AVm. D., Lieut., E, 71st Pennsylvania. Yates, 0. J., Pt,, F, 11th Maine, age 37. Mar. 19, 1865. Aug. 29. 1862. Juno 3, 1864. Ausr. 16, 1864. Right arm, at junction of upper and middle third; April 26, 1865, amputated at tho upper third; remaining bono found fractured. Right elbow joint shattered; discharged Dec. 16,1862; pen-sioned. Fracturo of right radius; Juno 3, 1864, radius excised, by Surg. M. Rizer, 72d Penn.; mustered out July 2, 1864; pensioned. Fracturo of metacarpals of loft hand; gangrene; Sept. 15, 1864, arm amputated at lower third; discharged January 20, 1865; pensioned. April 25, 1865. Mar. 23, 1864. July 23, 1864. June 29, 1865. Amputated at the joint, by Asst. Surg. S. II. Orton, U. S. A. Amputated, by Dr. J. Johnson, of Brooklyn. Amputated secondarily for sec-ondary haemorrhage and gan-grene. Amputated at the joint, by Dr. W. T. Black, of Maine. Disch'd June 15,1865; pensioned. Wound healed. AA'ound healed. Healed. § Unsuccessful Operations.—Of the nineteen cases in this category, nine had been subjected to amputation, excision, or ligation of the principal trunk prior to the exarticu- lation. The right limb was removed in twelve of the seventeen instances in which this point is specified. Sixteen of the patients were Union, and three Confederate soldiers. Pysemia was the commonest cause of death, being reported in six cases. One patient died from tetanus, and, in another, the fatal result was referred to "cardiac syncope from chloroform." Kup- ture of an axillary aneurism, general shock from operation, and pleurisy are each, in one instance, assigned as the cause of death. Exhaustion or surgical fever are made to account for the remaining fatal terminations. As an example of this group, a case in which a primary excision in the continuity, a secondary amputation, and finally an exarticulation were practised may be selected: Case 1611.—Private J. M------, Co. E, 22d Massachusetts, aged 38 years, Avas Avounded at the Wilderness, May 5, 1864, and Avas taken to a Fifth Corps hospital. Surgeon "W. E. De Witt, jr., U. S. V., noted: " Gunshot Avound of right arm; exsection of upper part of shaft of humerus, May 6th." The patient avus sent to Washington and entered HareAvood Hospital. Surgeon K. B. Bontecou, U. S. V., reported: " On admission to this hospital, May 28, 1864, the patient was in poor health, suffering from abscesses in the arm, the wound suppurating freely. The patient did Avell until August 18th, when the parts became sloughy, Avith profuse sanious discharge; but by applications of astringent lotions the arm improved up to September 17th, when secondary haemorrhage from the profunda occurred, amounting to about eight ounces. The artery could not be secured, and amputation Avas deemed necessary, and Avas performed by the surgeon in charge by bilateral flaps. The patient reacted promptly, and did tolerably Avell until September 19th, Avhen haemorrhage again occurred, this time from the anterior cir- cumflex artery. The humerus Avas exarticulated and the bleeding vessel ligated. The stump, hoAvever, became gangrenous, and the patient sank from exhaustion, and died September 26, 1864. There Avere no pyaemic symptoms existing. Treatment, supporting throughout." The specimen (FlG. 499), con- fig. 499.—Humerus that tributed by the operator, consists of the right humerus, from Avhich three inches of the shaft has been ^ Bhaft"fdTxarticuiatio°n excised. The arm Avas subsequently amputated in the continuity, and disarticulation at the shoulder at the shoulder. Spec. 3331. joint Avas finally performed. " The loAver portion of the specimen, representing the condition nearly four and a half months after the injury, * * exhibits a copious deposit of spongy neAV bone, surrounding a nearly detached sequestrum of several inches. The shaft in the upper fragment is necrosed at the extremity, and tho articular surface is eroded." (Cat. Surg. Sect., 1866, p. 112.) In the fatal, as in the successful secondary exarticulations, an unusual predominance of operations on the right side is observed. In seventeen unsuccessful amputations in which this point is specified, twelve were at the right shoulder. The fatality of the second- ary exceeds that of the primary exarticulations by 4.6 per cent., and is 17.1 per cent, less than the intermediary amputations. It will be noticed that nearly all of the fatal second- ary exarticulations were compulsory amputations, and consecutive to prior operative interference, the surgeons contesting the ground inch by inch. There were three instances 82 650 INJURIES OF THE UPPER EXTREMITIES. [CIIAP. IX. of previous amputation of the arm in the continuity. Two excisions in the continuity of the shaft of the humerus, one excision of the head and upper extremity of the shaft, two ligations of the brachial, and one of the anterior circumflex were practised prior to the exarticulations. In one case, the subclavian artery was tied after the amputation at the shoulder. Two patients had serious wounds in other regions of the body. Table XLIX. Summary of Nineteen Fatal Cases of Secondary Amputation at the Shoulder for Shot Injury. Name, Age, and Military Description. Babbitt, A., Pt., D, 66th Indiana. Battle, W. T., Lieut., D, 37th North Carolina, age 19. Blakely, A., Pt., I, 3d Mich- igan Cavalry. Brown, N. C, Pt., E, 59th Illinois, age 25. Catis, J. R., Pt., E, 1st Ten- nessee. Charters,AV. S., Pt., D, 145th Pennsylvania, age 18. Doherty, P., Serg't, C, 173d New York, age 43. Fagan, M., Pt., G, 72d New York, ago 50. Forrest, A. W., Pt., K, 141st Pennsylvania, age 21. Gallagher, C, Pt., C, 169th New York, age 32. Hoffman, A. J., Pt., E, 26th Iowa, age 55. Jackson, I. P., Corporal, E, 11th Florida. Monohan, J., Corp'l, E, 22d Massachusetts, age 38. Moore, W. K., Pt., E, 57th Massachusetts, age 23. 'Mullan, P., discharged sol- dier, age 30. Nason, H. J., Serg't, F, 28th Massachusetts. Orbin, J., Pt., F, 63d Penn- sylvania, age 33. Sanders, J., Pt., D, 89th In- diana, age 28. Smith, J., Pt., K, 143d Penn- sylvania, age 27. Date of Injury June 1, 1863. July 2, 1863. June 16, 1863. Dec. 31 1862. July 3. 1863. May 12 18G4. April 9, 1864. May 5, 1862. Mav 7, 18*04. June 1, 1864. Jan. 11, 1863. July 30, 1864. May 6, 1864. Oct. 8, 1864. Jan. 29, 1862. May 16, 1864. June 16, 1864. July 14 1864. Mav 5, 1864. Nature of Injury. Shot perforation of left wrist July 2, joint, followed by gangrene. 1863. Comminuted fracture of left Aug. 23, humerus at upper third by a 1863. conoidal ball. July 3d, excis- ion of three inches of shaft of humerus. Wound of left arm by buckshot. July 24, July 10th, haemorrhage; bra- 1863. chial artery ligated, by Surg. B. A. ATanderkieft, U. S. V. July 10th, amp. of arm at up- per third, by A. A. Surg. A. Claude. Gangrene and haem- orrhage. Musket ball perforated arm near Feb. 14, insertion of deltoid, causing 1863. compound comminuted frac- ture; caries. Shot wound of right arm by a Aug conoidal ball; sloughing and 1863. haemorrhage. Shot fracture of left arm. May Oct. 7, 12th, excision of portion of 1864. humerus, by Ass't Surgeon B. HoAvard, U. S. A. Oct. 7th, amp. at upper third of arm on account of necrosis. Compound comminuted shot July 7, fracture of upper third of right 1864. humerus. Shot wound through the right June 12, shoulder. 1862. Shot fracture of right humerus. June 7, 1864. Shot fracture of upper third of Jan. 12, right humerus. June Gth, ex- 1865. cision of two and a half inches of humerus. Comp'd shot fracture of right May 10 arm. March 12th, arm ampu- 1863 tated at middle third. Shot wound of the right arm.. Sept. 7, 1864 Shot fracture of middle third of Sept. 19 right humerus. May 6th, ex- 1864. cision of three inches of hu- merus. Sept. 17th, arm amp. at upper third, bv Surg. R. B. Bontecou, TJ. S.*V. Shot fracture of right humerus. Nov. 11 Oct. 8th, excision of portion 1864, of shaft of humerus. Shot wound of upper third of Oct. 21, arm and thoracic parietes, 1862, with injury to humerus. Oct. 20th, haemorrhage; ligation of brachial artery, bv Dre. AV. Parker and S. Smith. Shot wound of right arm; gan- Aug. 9, grene. 1864.. Shot fracture of left humerus, July 17 upperthird; anterior portion of 1864. inferior maxilla carried away. Musket ball splintered right Aug. 15, humerus and lodged. 1864. Shot fracture of upper third of Nov. 3, right humerus. May 6th, ex- 1864. cision of head and portion of shaft of humerus through a straight incision, by a Con- federate surgeon. Date of Opera- tion. Operation and Operator. Amputation of arm at shoulder joint, by Surg. J. G. Keenon, U. S. V. Amputation of arm at shoulder joint. Amputation of arm at shoulder joint, by Surg. B. A. Vander- kieft, U. S.V. Arm amputated at shoulder joint. Amputation of arm at shoulder joint, by A. A. Surg. J. B. Draper. Disarticulation at the shoulder joint. Amputation of arm at shoulder joint, by A. A. Surg. F. Has- senburg. OA-al amputation at shoulder joint, by Dr. AVillard Parker. A mputat'n at shoulder j oint, by Surg. A. F. Sheldon, U. S. V. Arm amputated at shoulder jcint, by A. A. Surgeon H. Pearce. Amputation at shoulder joint. Amputation of arm at shoulder joint. Amputation of arm at shoulder joint and ligation of anterior circumflex artery. See Case 1611, p. 649. Arm amputated at the shoulder joint, by A. A. Surgeon J. C Morton. No\'. 21st, haemor- rhage from axillary artery; subclavian ligated, by Ass't Surg. C. AVagner, TJ. S. A. Amputation by flap method, at shoulder joint, by Drs. AV. Parker and S. Smith. Amputat'n at shoulder joint, by A. A. Surg. T. B. Townsend. Amputation of arm at shoulder joint, by Surg. R. B. Bonte- cou, U. S.V. Amputation at shoulder joint, by A. A. Surg. J. Brey. Arm amputated at shoulder joint. Nov. 24th, profuse sec- ondary haemorrhage. Result and Remarks. Did not rally from shock of oper- ation. Died July 4,1863. Spec. 1705, A. M. M. Died August 23,1863, three hours after operation. Died July 26, 1863. Died March 31,1863, of diarrhoea. Died September 25, 1863. Died Oct. 21, 1864, of tetanus. Died July 7,1864, of cardiac syn- cope by chloroform. Died June 12,1862, an hour after amputation. Died June 29, 1864, of pyaemia. Died March 3, 1865, from ex- haustion. Specs. 383 and 3608, A. M. M. Died June 3, 1863, of pyaemia. Died September 9, 1864. Died September 26, 1864, from exhaustion. Spec. 3331, A.M. M. See FIG. 499. Died November 27, 1864, from exhaustion. Died Nov. 5, 1862, of pleurisy. Died August 12,1864. Died July 20,1864. Spec. 3056, A. M. M. Died Sept. 22,1864, of pyaemia. Died November 24, 1864, from the rupture of a large axillary aneurism. 1 PECK (AV. F.), Amputation at the Shoulder Joint, in Am. Med. Times, 1863, Vol. VI, p. 137. SECT. III.] AMPUTATIONS AT THE SHOULDER JOINT. 651 Amputations at the Shoulder, the Period of Operation doubtful.—There were one hundred and thirty instances in which either the date of injury, or of operation, or both data Avere Avanting, and which, therefore, could not be inserted in groups of exarticulations in the primary, intermediary, or secondary stages. The results as to fatality were ascer- tained in one hundred and nineteen of these cases. § Successful Operations.—Ninety-one cases in this category, or 76.5 per cent., termi- nated favorably. Eighty-eight of the patients were Confederate soldiers; three were Union soldiers, whose names are noAV on the Pension Roll: Table L. Summary of Ninety-one Successful Cases after Amputation at the Shoulder for Shot Injury in which the Intervals between the Injuries and Operations were not ascertained. Name, Agk, and Military Description. Ailiff, P. C, Pt., C, 18th A'irginia, age 18. Allen, G., Pt., F, 4th Texas. Anderson, J. T. C, Pt., K, 48th Alabama. Billingsley, J. M., Pt., A, 43d North Carolina. Blackwell. R. B., Pt., H, 5Cth Virginia, age 28. Bkdsoe, F. M., Lieut., 1,11th Georgia, age 27. Brown, M., Pt., K, 3d Ala- bama. Butler, W. A., Corporal, F, 61st A'irginia, age 22. Byrd, A., Pt., B, 5Cth Geor- gia. Byrnes, P., Sergeant, I, 6th Louisiana. Carter, R., Pt., C, 11th G corgia. Clark, C, Corporal, I, Sth Louisiana. Collins, T. L., Corporal, G, Gist A'irginia, age 32. Cox, J. W., Pt., K, 47th Air ginia. Crawford, M. P., Pt., G, . 1N12. 37 ! Huqq. A. P., Tt., C, 10th Mav 12. Alabama, age 26. lr-64. 38 Hussey, JI., Serg't, C, 10th Julv 2, Louisiana. 1863. 3J James, S. F., Serg't, D, 33d July -, North Carolina, age 31. 1863. 40 Johnson, W. S., Pt., A, 9th Julv 1, Louisiana. 1863. 41 Jones, J., Pt., B, 12th North July -, Carolina. 1863. 42 Jordan. M., Pt., L, Gth June 27, Louisiana. 1862. 43 Lcavrll, W. M., Pt., L, 1st Dec. 11. South Carolina Rifles. 1862. 44 Lema, J., Pt., E, lGth Louis- July 3, iana. 1863. 45 Logue, P., Pt., B, 27th A'ir- June 9, ginia, age 49. 1862. 46 Long, D. J., Pt., K, 19th June 30, Mississippi. 1862. 47 Loyle, M., Pt., K, 47th North July -, Carolina. 1863. 48 Magill, W. J., Colonel, 1st Sept. 17, Georgia Regulars. 1862. 49 Martin, J. R., Pt., E, 3d Sept. 17, South Carolina. 1862. 50 Mayer, C, Pt., E, 12th Mis- June 27. sissippi. 1862. 51 McCormick, J. C, Pt., I, 15th Alabama. 52 Mc Govern, W., Sergeant, F, Dec. -, Phillip's Georgia Legion. 18G3. 53 McLean, G. A., Corporal, B, May 3, 12th Mississippi. 1863. 54 McLean, J. M., Pt., M, 21st Julv 1, North Carolina, age 25. 1863. 55 McLcod, Z. O., Pt., C, 26th Julv 9, Georgia, age 28. 1864. 56 McPhaal, W. D., Pt., F, 13th Julv -, Mississippi. 1863. 57 Mooney, E. D., Pt., I, 56th North Carolina. 58 Moorehouse, A. J., Pt., G, April 9, 24th Missouri, age 23. 1864. 59 Morrell, R. F., Pt., K, 4th Julv 2, Texas. 1863. 60 Palmer, R., I, 41st A'irginia, age 29. 61 Parker, J., Pt., E, 6Cth N. July 12, Carolina, age 29. 1863. 62 Pope, A. B., Sergeant, F, 5th July I, Alabama. 1863. 63 Pritchell, J. M., Pt., D, 41st Alabama. 64 Putnam, H. M., Pt., F, 6th Georgia. 65 Riner, D. W., Pt., G, 52d Oct. 19, Virginia, age 36. 1864. 66 Roberts, J., Pt., D, 16th A'ir- May 16, ginia. 1864. 67 Royal, W. P., Pt., C, 23d Sept. 17. Airginia, age 25. 1862. 68 Ruff', J. S., Pt., G, 3d Ala- May 3, bama. 1863. 69 Ryan, D., Corp'l, I, 3d North Carolina Artillery, age 32. 70 Scott, A. A., Lieutenant, 6th Sept. 14, Alabama. 1862. 71 Seay, B. D., Pt., A, 14th July 3, A'irginia, age 26. 1863. 70 Stay. J. M.. Corp'l, C. Hol-comb's S. Carolina Legion. 73 : Sharpton, P.. l't., G, 1st S. May 3, Carolina. 1863. 74 ' Shellman, 11". F., Adjutant, June 1, 8th Georgia. 1864. 75 Smith. J. P., Pt., C, 56th April 3, A'irginia, age 20. 1865. 76 Smith, P., Pt., B, 45th North July -, Carolina. 1863. 77 Stanley, H., Pt.. A, 28th N. April 2, Carolina, age 19. 1 lfcC5. 78 Stewart, C, Ft.. E. 48th N. , Mav 6, Carolina, age 36. lto'4. 79 Thomas. G. H., It., C, 14th |........ Tennessee, age ~9. 80 Thornhill, E. A.. Pt., I, 16th Mav 3, Georgia, age 22. 1863. Nature of Injury. Shot wound of left arm........ Gunshot wound of left arm___ Shot fracture of right humerus- Shot wound of the right shoul- der. Shot fracture of head of right liumerus. Shot wound of right shoulder.. Shot wound of shoulder joint.. Shot perforation of right arm.. Gunshot wound of arm........ Shot fracture of humerus...... Gunshot wound of right arm... Shot wound of shoulder....... Shot wound of left arm........ Gunshot wound of left arm___ Shot fracture of left humerus; excision. Gunshot wound of right shoul- der. Gunshot wound of right shoul- der. Gunshot wound of right shoul- der. Shot fracture ofthe right shoul- der. Gunshot wound of right arm... Gunshot wound of right arm... Gunshot wound of arm........ Gunshot wound cf arm........ Shot fracture of left arm at the elbow joint; arm amputated at lower third, on field, by Surg. C. Winne, 77th Illinois. Shot wound of left shoulder... Shot fracture of left arm. Wound of right arm by a can- non ball. Shot fracture of right arm___ Gunshot wound of shoulder___ Shot wound of right arm...... Gunshot wound of right arm... Shot wound of right shoulder.. Shot fracture of right humerus Shot wound of shoulder....... Gunshot fracture of the right humerus. Shot wound of right arm and thorax; comminuted fracture of liumerus; haemorrhage from axillary artery. Shot wound cf right arm...... Shot wound of right arm. Shot wound of right arm. Shot wound of right arm. Fracture of left arm bya conoi- dal ball. Shot fracture of right arm___ Shct fracture of left arm..... Gunshot wound of right arm. Shot wound of left arm...... Gunshot wound of left ann.. Date of Opera- tion. July - 1863. July - 1863. July- 1863. Sept. - 1862. July - 1863. June - 1864. Julv- 1863. April- 1865. Operation and Operator, Amputation at shoulder joint.. Amputation of arm at shoulder joint. Amputation at shoulder joint.. Amputation at shoulder joint.. Amputation at shoulder joint.. Amputation at shoulder joint.. Amputation of arm at shoulder joint. Amputation of arm at shoulder joint, Amputation at shoulder joint.. Amputation at shoulder joint.. Amputation of apn at shoulder joint. A mputation of arm at shoulder joint. Amputation of arm at shoulder joint. Amputation of arm at shoulder joint. Amputation at shoulder joint.. Amputation at shoulder joint.. Amputation of arm at shoulder joint. Amputation at shoulder joint.. Amputation of ann at shoulder joint. Amputation of arm at shoulder joint. Amputation of arm at shoulder joint. Amputation of arm at shoulder joint. Amputation at shoulder joint.. Amputation of arm at shoulder joint, by Surgeon AA'inne. Amputation at shoulder joint.. Amputation at shoulder joint.. Amputation of arm at shoulder joint. Amputation at shouldor joint.. Amputation at shoulder joint.. Amputation of arm at shoulder joint. Amputation of arm at shoulder joint. Amputation of arm at shoulder joint. Amputatkm of arm at shoulder joint. Amputation of arm at shoulder joint. Amputation of arm at shoulder joint. Amputation of arm at shoulder joint, by Surg. E. D. Dailey, U. S. V. Amputation of arm at shoulder joint. Amputation at shoulder joint.. Amputation at shoulder joint.. Amputation at shoulder joint . Amputation of arm at shoulder joint. Amputation of arm at shoulder joint. Amputation of arm at shoulder joint. Amputation at shoulder joint Amputation of arm at shoulder joint. Amputation of arm at shoulder joint. Result and Remarks. Retired from service Feb. 8,1865. Retired from service Feb. 8,1865. Discharged January 4, 1865. Transferred to Eufala, Ala., April 5, 1864. Transferred, for exchange, Sept. 1, 1863. Furloughed November 3, 1863. Transferred, for exchange, Sept. 5, 1863. Retired from service Oct. 22,1864. Transferred to Columbia, S. C, May 22, 1863. Furloughed February 23, 1864. Retired from sen-ice Feb. 20,1865. Furloughed October 16,1863. Paroled September 23, 1863. Retired February 3, 1865. Transferred December 3, 1862. Retired from service January 11, 1865. Furloughed Nov. 27, 1863. Furloughed Sept. 23, 1864. Furloughed June 18, 1863. Retired from service January 17, 1865. Retired from service January 2, 1865. Paroled Sept. 5, 1863. Furloughed Sept. 14, 1864. Disch'd Jan. 18, 1865; pensioned. Furloughed Sept. 5, 1863. Doing well. Retired from service Feb. 6,1865. Furloughed October 1, 1863. Furloughed December 23, 1864. Furloughed December 19, 1862. Retired from service Feb. 10,1865. Furlcughed June 25, 1864. Retired from service Feb. 9,1865. Furloughed July 4, 1863. Released June 29, 1865. Paroled and sent to his home. Paroled Sept. 26, 1863. Furloughed Dec. 11, 18G4. Furloughed July 3, 1863. Furloughed June 27, 1864. Transferred to Military Prison Mav 15, 1865. Paroled Sept. 5, 1863. Transferred to CampDistribution June 21, 18C5. Retired from service Dec. 29, 1864. Retired from service Fcb'ry 21, 1*65. Retired from service March 18, 1665. SECT, in.] AMPUTATIONS AT THE SHOULDER JOINT. 653 Name, Age, and Military Description. Tindel, J., Pt., E, 3d Geor- gia. Tshear, N. T., Serg't, II, 3d Arkansas. Tucker, B. H, Sergeant, K, 56th A'irginia, ago 24. Tucker, J. W., Pt., D, 59th Georgia. Unknown.................. Unknown.................. Vickers, F. M., Pt., O, 19th A'irginia CaA-alry, n;jo 22. AVheaton, A. S.. I'orp'l, G, 104th Now York, njre 22. Wheeler, C, Sergeant, F, Sth Georgia. Willkousky, L., Pt., B, 9th Louisiana. Wyedmer, A., —, Dobalds- ville Artillery. July-, 1863. Oct. 7, 1864. \wr. 30, ii*;3. Dec. 10, 18G4. \pril 30 1853. Nature of Injury. Gunshot wound of risrht arm. Gunshot wound of right shoul- der. Shot wound of right arm..... Gunshotwoundqf left shoulder. G unshot wound of arm..'..... G unshot wound of nrm....... Gunshot wound of right arm... Shot wound of left arm....... G unshot wound of right arm.. Gunshot wound of arm......., Shot wound of arm.......... Opera- tion*. July -, 18G3. 18G4. OPERATION AND OPERATOR. Amputation of arm at shoulder joint. Amputation of arm at shoulder joint. Amputation of arm at shoulder joint. Amputation of arm at shoulder joint. Amputation of arm at shoulder joint. Amputation of arm at shoulder joint. Amputation of arm at shoulder joint. Amputation of arm at shoulder joint. Amputation at shoulder joint.. Amputation at shoulder joint . Amputation at shoulder joint.. Result and Remarks. Furloughed Oct. 1G, 1864. Furloughed Jan. 20, 1864. Paroled Sept. 25, 1863. Stump healed. Furloughed Nov. 18, 18G4. Recovered. Recovered. Retired from service Jan. 19,1865. Disch'd Oct. 8, 1862; pensioned. Discharged June 13, 1865. Furloughed June 7, 1863. Transferred to Danville March 12, 18G3. Amputation Avas on the right side in forty-five, on the left in twenty-eight instances; in eighteen cases, this point was unnoticed. The method of operation was noAvhere specified. In one case, an amputation above the elbow, and, in another, an excision of the upper extremity of the humerus, preceded the amputation at the shoulder. In one case, excision of a portion of the fibula was practised at the same time as the amputation. Eighty-five of the men were exchanged, paroled, released, or furloughed; two were discharged, and four were not accounted for. In one case, probably a primary one, the arm was torn off by a cannon shot; in the remainder the character of the projectile was not referred to, or else the wound was ascribed to a musket ball. § Unsuccessful Operations.—TAventy-eight cases, in the series of amputations at the shoulder for shot injury, in which the stage at which the operations were practised could not be determined with precision, resulted fatally: Table LI. Summary of Twenty-eight Fatal Cases of Amputation at the Shoulder for Shot Injury, in which the Intervals between the Injuries and Operations were not ascertained. Name, Age, and Military Description. Andrews, S., Pt., I, 57th N. Carolina. Baker, J., Sergeant, A, 61st New York. Bradley, J., Pt., A, 2d Con- necticut Artillery. Chambers, B., Pt., D, 4th Alabama. Cheney, —, 2d South Caro- lina, age 30. Cobb, S. S., Pt., B, 41st Ala- bama. Dillworth, L., Serg't, C, 61st Pennsylvania. Downey, A., Pt, I, HGtb Pennsylvania. Edwards, J. D., Pt., F, 44th North Carolina. Everly, F. M., Pt., G, 17th Kentucky. Gaines, John P., Pt., D, 11th Kentucky. Goodrich, C. O., H, 12th A'irginia. Horner, —, Pt., I, Sth Texas. May 8, 18G4. June 2, 1864. 1862. Sept. 17, 1862. 1865. 1862. Dec. 13, 18G2. 1864. April 7, 18G2. Dec. 30, 1862. 1864. July -, 1863. Nature of Injury. AVound of right shoulder...... Shot fracture of right humerus. AVound of right arm and chest. Shot fracture near shoulder___ AVound of right arm; constitu- tional syphilis; amputation of arm. AVound of arm and fracture of right tibia. AVound of shoulder........... Compound fracture of left hu- merus. Shot wound near shoulder..... Fracture of right humerus..... AVounds of both legs and shoulder. Shot fracture of upper third of humerus. AVound at shoulder joint....... Opera- tion. Mav -, 18*64. June - 18G4. 1862. 1865. 1862. Dec. -, 18S2. 18G4. April - 1862. 18G(?). July -, 1863. Operation and Operator. Amputated at the shoulder--- Amputated at the shoulder, by Surg. J. AV. AVishart, 140th Pennsylvania. Amputated at the shoulder--- Amputated at the shoulder--- Re-amputation at the shoulder, by Surg. J. J. Knott, C. S.A. Amputated at the shoulder--- Amputated at the shoulder--- Amputated at the shoulder--- Amputated at the shoulder--- Amputated at the shoulder--- Amputated at the shoulder--- Amputated at the shoulder.. Amputated at the shoulder.. Result and Remarks. Died June 24, 1863. Died June 25, 1864. Died June 11, 1864. Died September 18, 1862. Died. Died February 4, 1865. Died June 28, 1862, of pysemia. Died January 6,. 1863. Died June 11, 1864. Died April 20,1862, from scc'd'ry haemorrhage from subclaA'ian. Died March 31, 1863. Died November 21, 18G4. Died July 17, 1863. 654 INJURIES OF THE UPPER EXTREMITIES. [CHAP. ix. NO. Name, Age, and Military Date of Injury. DlSCRirTIOX. 14 Johnson, G. F., Pt., K, 4th July -, Maine. lMi3. 15 Kinsey, B., Pt., D, 53dPenn-SA'lvania. 1865. 16 Miller, J. A., Pt., B, 18th Georgia. 1863. 17 Moor, C. H., Serg't, H, 61st Georgia. 1862. 18 Padgett, T. H., Pt., F, 26th A'irginia. 1864. 19 Ransom, B. H., F, 4th South Carolina. 1861. 20 Sanderson, Geo., Serg't, K, April 6, 44th Indiana. 1862. 21 Shaw, C, Pt., E, 48th Ala- July -, bama. 1863. 22 Smith, G. D., Pt., E, 11th Aug. 30, Ponnsyhrania. 1862. 23 Smith, James, Pt., Naval Battery. 1865. 24 TooU, J., Pt., D, 14th Louis-iana. 1862. 25 Townsend, H. M., Corp'l, I, Mar. 8, 9th IoAva. 1862. 26 Tuten, J., Pt., B, 5lh South Carolina CaA'alry. 1864. 27 Williams, J., Pt., D, 46th North Carolina. 1864. 28 Willi ford, T., Pt., G, 2d July -, North Carolina. 1863. Nature of Injury. AA'ound of left arm............ AVound of left shoulder....... AVound of right shoulder...... Shot Avound of shoulder joint.. Shot fracture near shoulder___ Shot fracture of upper third of humerus. AVound of left arm, high up... AVound of arm, with fracture.. AVound of arm, with fracture near shoulder. Shot fracture of upper third of cs brachii. Shot wound, with fracture of humerus. AVound of right arm near the shoulder. AVound of arm; fracture of left femur. AVound of arm and penetrating wound of thorax. Fracture of left humerus...... Date of Opera- tion. July -, 1863. 1865. 1863. 1862. 1864. 1861. 1862. July 3, 1863. 1862. 1865. 1862. 1862. 1864. 1864. July -, 1863. OPERATION AND OPERATOR. Amputated at the shoulder. Amputated at the shoulder., Amputated at the shoulder.. Amputated at the shoulder.. Amputated at the shoulder.. Amputated at the shoulder.. Amputated at the shoulder.. Amputated at the shoulder.. Amputated at the shoulder.. Amputated at the shoulder.. Amputated at the shoulder.. Amputated at the shoulder.. Amputated at the shoulder.. Amputated at the shoulder.. Amputated at the shoulder.. Result and Remarks. Died July 9, 1863. Died April 17,1865, from second- ary haemorrhage. Died June 2, 1863. Died July 3, 1862. Died June 29, 1864. Died August 2, 1861. Died May 14,1862. Died July 20, 1863. Died September 11, 1862. Died April 18, 1865. Died July 3, 1862. Died April 23, 1862. Died December 20, 1864. Died September 15,1864. Died August 5, 1863. The side on which the amputation was practised was specified in only twelve (right 7, left 5) of the twenty-eight cases. In some instances the period of operation was implied, though not with precision.1 One operation was a reamputation. Twelve of the patients were Union, and sixteen Confederate soldiers. § Operations with Unknown Results.—In eleven cases of shoulder joint amputations for shot injury, compiled from authentic but very scant memoranda, it was impracticable to ascertain the results as to recovery or fatality, or the exact dates of operation: Table LII. Summary of Eleven Cases of Amputations at the Shoulder, in which neither the Results nor the Periods intervening between the Injuries and the Operations were ascertained. Name, Age, and Military Description. Bruce, J. D., Major, 47th A'irginia. Corriher, R. A., Pt., K, 57th North Carolina. Deiss, G., Pt., G, 5th Ala- bama. Gngg, S. C, Pt., K, 49tb North Carolina. Murphy, Jno., Pt., B, 13th North Carolina Artillery. Norville,—, Pt.,K,4th Texas Pierson, J. A, Pt,, B, 46th North Carolina. Robinson, W. A., Pt., I, 4th Georgia, age 20. Shook, J. A., Pt., B, 54th North Carolina. Sparks, Solomon, Pt., 25th Tennessee. Staton, Wm., Corp'l. C, 10th North Carolina Battery.- Date of Injury 1863. 1863. July -, 1863. 1863. 1864. July -, 1863. Sept. 17, 1862. May 2, 1863. 1864. 1863. 1864. Nature of Injury. Shot wound of left arm....... Shot fracture near shoulder___ Shot fracture of upper third of humerus. Shot wound of left arm........ Right arm torn off by shell fragment. AVound of shoulder........... Shot wound of right arm...... Shot fracture of the humerus, high up. Shot Avound of right shoulder.. Shot wound of shoulder joint.. Shot fracture of left humerus-. Date of Opera- tion. 1863. 1863. July- 1863. 1863. 1864. July- 1863. 1862. 1863. 1864. 1863. 1864. Operation and Operator. Amputated at the left shoulder. Amputation at the shoulder___ Amputation at the shoulder.... Amputated at the left shoulder. Amputated at the right shoul- der. Amputation at the shoulder___ Amputated at the right shoul- der. Amputation at the shoulder.... Amputated at the right shoul- der. Amputation at the shoulder__ Amputation at the shoulder. Result and Remarks. It is hoped and requested that any one cognizant of the exact dates, or of the terminations of any of the cases in this category, will communicate the facts to the Surgeon General's Office. This series completes the reported cases of amputation at the shoulder for shot injury. All of these cases were taken from Confederate records. In the six instances in which i Cases 3, 4, 8, 13, 14, 16, 17, 19, and 28 were probably primary exarticulations, and much the larger proportion of the cases appear to have been either primary or early intermediary operations. It is hardly possible to suppose circumstances that would warrant so considerable a number of exartic- ulations at the shoulder, in cases attended by probably mortal wounds elsewhere, as are here recorded: E. g., in Cases 3 and 27, there were penetrating wounds of the thorax ; in Case 2G, fracture of the femur; in Case 11, wounds of both legs, etc. SECT. III.] TREATMENT OF SHOT INJURIES AT THE SHOULDER. 655 the point was noticed, the operations were equally divided between the right and left sides. No complications, or prior or consecutive operations, are mentioned in the reports. Recapitulation.—In the foregoing subsection, eight hundred and fifty-two exarticula- tions at the shoulder,1 for shot injury, or for disease consequent on shot injuries, or the oper- ations undertaken for their relief, have been enumerated. Four hundred and ninety-nine cases related to primary operations, one hundred and seventeen terminating fatally, the results in fourteen cases being unknoAvn, and the remaining three hundred and sixty-eight resulting successfully,—a mortality rate for the determined cases of 24.1 per cent. Fifteen of the successful and two of the unsuccessful cases were detailed, with five cuts from photographs of recovered patients, and eight cuts representing the pathological specimens preserved. One hundred and fifty-seven cases of intermediary exarticulations were illus- trated by details of three successful and three unsuccessful operations, with a wood-cut of a case of recovery, a plate and five cuts shoAving osteological specimens. The fatality in this series, in which the termination of all the cases was determined, was 45.8 per cent. Sixty-six secondary exarticulations Avere recorded, with details of one fatal and three successful operations, and wood-cuts of four specimens, and tabulations showing a mortality rate of 28.7 per cent. A fourth series, embracing one hundred and thirty cases, in which it was impracticable to determine precisely the interval between the injury and operation, • included one hundred and nineteen in which the result as to fatality was known to be 23.5 per cent. The facts ascertained regarding these cases were presented in tabular form. The mean death-rate of the entire series of eight hundred and twenty-seven cases was 28.5 per cent. Adding fourteen cases, from the preceding Section, in which exarticulation at the shoulder was practised on account of lesions of the blood-vessels or the soft parts, this series of eight hundred and forty-one cases gives a ratio of mortality of 29.1. In seven hundred and sixty-six of these cases the side on which the operation had been practised was specified, and a slight predominance in number and fatality on the right side was indicated: in three hundred and ninety-one amputations at the right shoulder, the death-rate was 25.2 per cent.; in three hundred and seventy-five exarticulations on the left side, the mortality was 24.9 per cent. I On exarticulation at the shoulder, the following authorities, besides those cited on page 613, may be consulted: Plainer (J. Z.) (Institulionea Chirurgia rat, Lipsise, 1758, § 251, p. 125) describes his method of operating; LE Laumier et Poyet (De methodis amputandi brachium ex articulo, Paris, 1750) devote a thesis to the operative details; VAN Glscher (Verhandcling van het afzetting der dye in het gewricht, Amsterdam, 1760) has a treatise on the ablation of tbe arm at the shoulder; BRA8D0R (P.) treats of exarticulation at the shoulder in his essay Sur les amputations dans les articles, in the Mem. de I'Acad. de Chir., 1774, T. V, p. 747; Alanson (E.) describes his circular method, in his Practical Observations on Amputation and the After-treatment, London, 1782; Haselberg (L. AV.), in 1782, published, at Gottingen, a Commentatio chirurgica, in qua novum hnmerum ex articulo extirpandi methodnm is contained; Flajaxi (G.) wrote Osservatione pratiche sopra Vamputazione degli articoli, Roma, in 1791; Seeburg (D.), in 1795, published at AVittemberg an example of successful ablation of the arm at the shoulder: Extirpatio ossis humeri exemplo felice probata; Mub- STNNA (C. L.) printed in his journal, 1801, B. 1, S. 101, a paper Von der Ablosung des Armes im Schultergelenke ; Schreixer's dissertation, Uber die Amputation grosser Gliedmassen nach Schusswunden, Leipzig, 1807, includes a section on amputations at the shoulder. Dissertations on the subject follow in rapid succession, as those by AA^altiier (P. F.) (Uber die Amputationen in den Gelcnken, Landshut, 1810); Kloss (G.) (De amputatione humeri ex articulo, Gottingen, 1809, Frankfort, 1811); Fraser (AV. AV.) (An Essay on the Shoulder Joint Operation, London, 1813). To the systematic authors who treat of the subject, and are mentioned in the note on page 613 ante, may be added Sir Charles Bell (System of Operative Surgery, London, 1814, Vol. II, p. 30); Lisfuanc et Ciiampesne printed in Paris, 1815, a Nouveau procidi opiratoire pour l'amputation du bras dans Varticulation scapulo- humirale, an expeditious method that has had a great vogue. Consult, farther, MEUNIEU (F.) (Sur l'amputation du bras dans son articulation avec l'omoplate, Paris. 1815); KLEIN (C) (Resultate der in den Kaiscrlich Russischcn Hospitalern im Wurttembergischen gemachten Ausschalungen aus dem Schultergclcnkund dem Mittelfuss, sowie andcren ungew'ohnliehen Amputationen, Stuttgart, 1817); MANN (JAMES) (Observations on Amputation at the Joints, in The Medical Repository, 1822, A'ol. ATI, N. S., p. 14); Muenzenthaler (Versuch iibcr die Amputationen in den Gelenken, Leipzig, 1822); Hubbard (T.) (On Amputation performed at the Joints, in The Medical Repository. 1822, Vol. ATI, N. S., p. 264); Oberteuffer (J. G.) (Anatomisch- chirurgische Abhandlung von der Lbsung des Oberarms aus dem Schultergelenke, AVurzburg, 1823); HUBBARD (On Amputation at the Joint, in New York Med. Repository, 1823, Vol. XXII, p. 264); Mann [Observations on Amputation at the Joints, in New York Med. Repository, 1823, Vol. XXII, p. 14); SCOUTETTEN (La methode avalaire, ou nouvelle mithode pour amputer dans les articulations, Paris, 1827); Janvicki (De brachii cxtirpationc, A'ilna, 1828); Cornuau (Nouveauprocidi opiratoire pour pratiqier l'amputation dans Varticulation scapulo-humirale, Paris, 1830); COOPER (S.) (Diet of Pract. Surg., 1838, Vol. I, p. 78, Amputation at the Shoulder Joint); Debexey i'A.) (Dans quels cas et comment pratique-t-on la disarticulation de Vepaule, Paris, These, 1838, No. 341); CONFOULAXT (F. L. F.) (Dans la disarticulation de Vipaule, a- quelle mithode faut-il donner la preference, Paris, Thise, 1838, No. 234); Eloire (J. P.) (Essai dun nouveau procide pour la disarticulation scapulo-humirale, Paris, Th6se, 1841, No. 289); Sciiillbach (E. L.) (De exarticulatione ossis humeri, Jenae, 1850); McKinley (S. E.) (Amputation at the Shoulder Joint, in New Orleans Mid. and Surg. Jour., G56 INJURIES OF THE UPPER EXTREMITIES. [CHAP. ix. Concluding Observations on Shot Injuries at the Shoulder.—In this Section, twenty-three hundred and twenty-eight of shot injuries of the shoulder joint, or of periar- ticular wounds necessitating operations at the articulation, have been somewhat fully discussed, and it seems proper, after adducing such a mass of evidence, to sum up the principal conclusions indicated by the facts, and to advert to the practical reflections on this subject of experienced military surgeons. The cases were analyzed under three heads: Those treated by expectant conservative measures, those in which excision was practised, and those in which recourse was had to ablation of the limb, and the facts will be reviewed in the same order. In seventy-two instances, in which it was believed, from the escape of synovia and otlier symptoms, that shot penetration of the shoulder joint existed without injury of the osseous tissue, expectant treatment was pursued, and but six cases, or 8.33 per cent., terminated fatally, a result that assuredly justifies the repetition of such conservative attempts in all similar cases. Of five hundred and five patients with shot wounds of the shoulder attended by fracture of some portion of the articulation, treated on the expectant plan, one hundred and thirty-nine, or 27.5 per cent., died. In many of these cases, free incisions were made into the joint, and detached fragments or exfoliations were removed, and occasionally carious surfaces were gouged away. With few exceptions, the cases appear to have been judiciously selected for the expectant plan, and, although the rate of mortality was greater than that of primary amputations at the shoulder, it was decidedly less than that of primary decapitations of the humerus. But it is, of course, to be taken into account, in instituting any comparison between the results of expectant and operative measures, that the cases treated in the early stage by* expectation, in which compulsory ulterior operations are practised, and in which the ratio of fatality is disproportionately great, are subtracted from the former and added to the latter category. But it is absurd to attempt to decide this question purely from numerical data.1 The importance of the arm is so great, and even a limited use of it is so valuable, that, as Guthrie declares,2 it is justifiable to hazard much to save it when there is a tolerably fair prospect of success. Dr. Eeudorfer, a very reliable writer,3 with opinions formed from a vast personal experience, is another earnest advocate of expectant measures in this class of cases. 1853-54, Vol. X, p. 858); SMITH (S.) (Amputation at the Large Joints: Statistics of Amputations at the Shoulder and Elbow Joints, in The New York Jour, of Med., 1853, ATol. X, N. S., p. 9); HODGES (R.) (Amputation of the Shouldir Joint under the Influence of Chloroform, in a case of gunshot wound, in Assoc. Med. Jour., 1854, Vol. II, p. 1042); LARREY (H.) (Observation d'ampulation scapulo-humerale, etc., Paris, 1857); Lessere (C.) (Nouveau mode operative pour l'amputation du bras dans Varticulation scapulo-humerale, etc., Paris, 1831, Thdse No. 57); MALGAIGNE (J. F.) (Manuel de Mede- cine operat., Paris, 1861, Amputation scapulo-humerale, p. 313); MOON (AV. P.) (Amputation of Right Shoulder Joint (Incisions modified to suit case), in Am. Jour. Med. Sci., January 1866, p. 143); AsHHURST, jr. (JOHN) (Observations in Clinical Surgery, No. II, &c, Case III, Necrosis of Humerus} Amputation at Shoulder Joint, Recovery, in Am. Jour. Med. Sci., January, 1868, p. 40); Ciiamraud (J. G.) (De la disarticulation scapulo-humerale (Modifications au precede" LARREY), ThSse & Paris, 1870, No. 62); BLACK (J. J.) (Amputation at the Shoulder Joint for extensive Gunshot Wound ofthe Arm and Shoulder, in Phila. Med. Times, 1874, p. 551). iPoncet (F.) (Contribution & la relation med. de la guerre de 1870-71, Hopital mil. de Strassbourg, in Montpellier Medical, Dec, 1871—Mara, 1872) inquires: " Is it better to amputate or to attempt conservation ? Truly we cannot comprehend why that question is propounded, or why it should be sought to solve it by commentary on statistics. Far better would it be to enquire what are the hygienic conditions, what the power cf vital resistance of each patient. Each day these conditions A-ary with the o\rercrowding of the wards, Avith meteorological conditions, with the regimen of the patients, and the moral condition of those subjected to operations. Looking solely at the number of surviArors and dead, and seeking, Avhen remote from the facts, to establish by a comparative arithmetical computation the line of conduct of the surgeon, is, if we may be believed, to expose ourselves to conclusions that bear no truthful relation (sans aucun rapport de virite) to the question. It suffices, to prove this, to take the ptirely numerical results laboriously and conscientiously collected by Dr. CiiENi', and then to reA'iew under what conditions it has been sought to reduce rules for surgery. AA'e beg those who would themselves, without prejudice, re-analyze this work, to take special account of the columns 'undetermined wounds or those Avithout precise indica- tions,' so often neglected in statistical works. They suffice, nevertheless, to change the proportions ofthe results." 2 Guthrie (G. J.), A Treatise on Gunshot Wounds, London, 3ded., 1827, p. 421. 3NEUDORFER (J.) (Handbuch der Kriegschirurgie, 1872, Zweite Halfte, S. 1145) remarks: "OneAvho performs immediate resection is not al all to be censured, but such a resection is not indicated, that is, indispensably, in a scientific point of view. AVe at least, and our followers, would, in such cases, prefer to extract the loose fragments, and to secure free admission of air to the capsule of the joint by means of insertion of an appropriate siphon." SECT III | RESULTS OF EXCTSTONS AT THE SHOULDKR. G57 Of one thousand and eighty-six patients subjected to excisions at the shoulder, completed histories are wanting in one hundred and thirty-five instances.—nine on the Union, and one hundred and twenty-six on the Confederate returns. The results of eight hundred and seventy-six1 determined cases are analyzed in detail on page 59'), and the results of the se\*enty-five completed cases from the (Confederate reports are summed up on page 606. The operations are arranged in groups, comprising true excisions of the scapulo-humeral articulation, portions of the scapula or clavicle having been removed with the head of the humerus,—partial excisions of the head of the humerus,—decapitations of the humerus,— excisions of the head and part of the shaft of the liumerus. The first group, of forty-two cases, is illustrated by the details of six instances, a plate; and three Avood-cuts of specimens, and three cuts of photographs of cases of recovery. Of the second group, of fourteen cases, two are related in detail, with tAvo cuts of recovered patients, and two of pathological specimens. The numerous decapitations are subdivided into primary, intermediary, and secondary operations, and those of unknown date, and further separated into groups of successful and unsuccessful cases. They are illustrated by three plates and three wood-cuts of recovered patients, seven wood-cuts of specimens, and twenty-two detailed abstracts. The fourth group, comprising five hundred and seventeen cases, similarly divided as to stages of operation and results, is illustrated by twenty-seAren pictures of patients after recovery, twenty-six cuts of pathological specimens, and narratives of sixty-six cases. Of the nine hundred and fifty-one determined cases; three hundred and forty-eight terminated fatally, or 36.6 per cent. Recourse was had to amputation at the shoulder after only fourteen of the operations of excision. One hundred and forty-six operations on Confederate soldiers appear on the Union returns, and tAvo hundred and one on the annexed Table XL, or three hundred and forty-seven cases. Of the seven hundred and thirty-nine Union soldiers subjected to this operation, four hundred and seventy-six survived. Of these, the names of three hundred and eighty are now (July. 1875) borne on the Pension Roll. It may be assumed that the medical examiners of the Pension Office, Avho have inspected these pensioners biennially, have usually represented the disabilities of the limbs in as graA7e a light as may be compatible with the facts observed, in order that the mutilated men may enjoy the largest rates of pension allowed by the laws.2 The return " arm totally useless," is not infrequent in cases where the forearm and hand retain their functions in their' integrity.3 Dr. Thomas B. Hood, the medical referee of the Pension Commissioner, informs the writer that it is contemplated by the Bureau to institute an enquiry into the exact condition of the limbs that have undergone excisions. When this is done, precise statements on the subject will be practicable. After carefully analyzing the reports of the pension examiners, and comparing a large number of personal observations on pensioners visiting the Army Medical Museum, and special reports from numerous correspondents, I am convinced that the average extent of usefulness of the limb retained after excisions at the shoulder for injury is not overstated in the paragraph on that subject on page 611. 1 It has been shown, on page 600, that the mortality ofthe eight hundred and seventy six determined cases of excision on tho Union reports was bin 34.8 per cent. The rate is increased by the addition of the seventy-five completed cases from the Confederate return, with a high ratio of mortality, whicli would almost certainly have been reduced, could the results of the remainder of the case.s in the series of two hundred and one have been ascertained. ; It is not, by any means, intended to imply that the duties of the Pension Kxamining Uoards and of individual examiners are not faithfully per- formed; but the brief reports of disability total (or partial), of the first (or second, or third) grade, are unintelligible to any but those familiar with the complex system of pension laws, endlessly modified by successive enactments. Most of the pensioners were laboring men prior to enlistment, and, as the examiners invariably enquire into the avocations of applicants, a limb may be reported as "absolutely useless" for hard manual labor, when, for clerical or many mechanical tasks, it may be eminently useful. ' The reports ofthe pension examiners in this class of cases may be summarized as follows: "Slight," or "partial," or "impaired, ' use of arm, 146, useful. 4 ; entire loss of motion. 5; equal to loss of arm 31 ; equal to loss of hand. 24 ; useless, 131; disability not stated in 39 cases. 83 658 INJURIES OF THE UPPER EXTREMITIES icnAP. ix The amount of after-mobility in the limb appears to depend greatly upon the extent to which the nerve trunks and muscular attachments have been respected bv the missile and by the knife, and upon the precautions taken in the after treatment. Dr. 0. Heyfelder divides the results as to mobility in recoveries from excision at the shoulder into four categories: a, The arm hangs powerless by the side, incapable of active movement, but susceptible of being moved by the sound arm. But the pendulous limb can raise consider- able Aveights, and, when the elbow is supported, the functions of the forearm and hand may be perfect. These cases are not uncommon where a large portion of the shaft has been removed together with the head, and the muscles have atrophied through lesion of the nerves or from disease. The nerve-lesions appear to be irremediable ; but much may be done, even at a late period, to relieve what Professor B. von Langenbeck terms "inactivity- paralysis."1 • The absence of mobility in the upper arm after operations extending to a large portion of the diaphysis, as has been proved by numerous examples.2 The important precautions appear to be to divide the muscular insertions as near the bone as practicable, to guard against injury of the long head of the biceps, to support the elbow and bring the upper end of the diaphysis near the glenoid cavity, that the divided muscles and aponeuroses may become rerattached as high up as possible, and lastly, to persevere in passive move- ments from the earliest moment at which they may be safely begun. Unless the nutrition of the limb is impaired by lesions of the vessels or nerves, by resolutely stimulating the muscular contractility by frictions and exercise, the patient regains control over the move- ments of the upper arm to a remarkable extent.3 b, Dr. 0. ITeyfelder's4 second category comprises those cases in which a new scapulo-humeral articulation is formed and the mobility and other functions of the arm are restored. A ginglymoid takes the place of an arthrodial joint, the action of the rotator and abductor muscles being greatly impaired or abolished, Avhile the flexors and extensors acquire a compensatory power. This favorable result is happily the most frequent, and obtains, according to Dr. Heyfelder, in fully one- half of the survivors of excision at the shoulder. In the sense in which the term ginglymoid articulation is here used, I am satisfied that this statement, if applied to the survivors of excision at the shoulder in the American war, would not be exaggerated. A true new articulation with a synovial membrane and ligaments was rarely, if ever, formed; but in a larger proportion than one-half some control over the movements of the upper arm was retained, and often very perfect power of flexion, extension, and adduction, c, The third category comprises cases in which there is restricted mobility after the removal of the head with a very large extent of the shaft; and the fourth, d, includes the cases of absolute immobility, arising from paralysis from nerve injury, from prolonged disuse of the arm, or from bony anchylosis. i I,angi:ni:eck (B. v.), Chir. Beobachtungen aus dem Kriege, 1874, p. 143, observes: "By the preceding observations I believe to have pro\-en that 'lame members' from resection of the head of the humerus are nothing but art products of a deficient after treatment, owing especially to the indolence ofthe wounded, to the vicissitudes of war, and to the fact that, on account ofthe necessity of dispersing the wounded, the surgeon's supervision is frequently interrupted. The great difference between the inactivity-paralysis and mutilation ofthe nerves may be recognized by the fact that the former readily yields to proper stimulating and gymnastic treatment, while the latter, as a rule, cannot be cured in any way." 'In the ea.-e of Reardon, detailed on page 5.VJ (C.vsi: 1529), in which fully six inches of the humerus was removed, and a half-inch ring of bone subsequent ly exfoliated from the sawn extremity of the shaft, although there has been no regeneration of bone, entire cpntrol of the movements permitted by the ginglymoid articulation that has fonned are practicable. The deltoid and biceps are as fully developed as on the opposite side. The pensioner can place his hand on the top of his head, and execute all the movements of the upper arm except abduction. Even when a still larger portion of the shaft or even the entire humerus was remoA'ed, a certain amount of mobility of the upper arm was attained by encasing it in an apparatus, a sort of exo-skeleton, as in the cases of Cleghom. p. ."xlS, Kegerries. p. 594, AATolff, p. 573. and AVoods, p. 580. a Iu the case of Lieutenant 11. O. Jacobs (p. 5.33;, the control of the movements of the arm was far greater in 1875, nearly twelve years after the operation, than ton years before. There was considerable power of abduction even, the arthrodial character of the articulation being preserved. There are many like instances that have come uuder my own observation. ♦ Hf.VFEI.OF.R iO.). Lehrbuch der Resectionen. Wien. 1801, Nachbchandlung der Resection des Schultergelcnkcs, S. 221 SECT. III.]' RESULTS OP EXCISIONS AT THE SHOULDER. 659 True bony anchylosis appears to have rarely resulted among the survivors of excision for injury that have been kept under observation. It is true that it is stated that this condition exists in tAventy cases;1 but, in most of these, the stiffness of the joint was apparently only partial, was, in fact, false or spurious anchylosis. This conforms to the experience of Dr. Esmarch in SchlesAvig-Holstein, and to observations after other wars,2 and might be anticipated from the structure and latitude of movement permitted by the shoulder joint. True bony anchylosis after either disease or injury is of rare occurrence. There are but two examples in the Army Medical Museum,3 and Dr. Hodges states that, in 1855, the museums in London and Paris possessed but four specimens illustrating such a condition. Dr. Albrecht Wagner declared, in 1853, that "ankylosis after resection of the shoulder joint has not been observed up to the present time.' 4 The reports justify the conclusion of Dr. Richard M. Hodges, that "comparatively rapid recovery folloAvs excision for injury." Brigadier General E. B. Brown, U. S. V. (Case 1495, page 522), used the forearm and hand freely three-weeks after the operation, and guided his horse with the mutilated arm five Aveeks after a shot fracture of the head of the humerus Avith division of the long head of the biceps. There were many other instances in Avhich officers and non-commissioned officers returned to duty, and privates to modified duty, within six months from the date of injury.5 Complete regeneration of the portion of bone excised was not observed in any instance, and partial regeneration to'any appreciable extent was extremely rare. Sub-. periosteal excisions were seldom attempted, probably never after the systematic method adopted by Dr. Oilier6 and Professor v. Langenbeck* and such results as are reported by 'Namely: Case 1499, p. 527, Hatfield; Cask 1497, p. 523, Hogan; Case 1492, p. 521, Harvey; Case 8, Taule XXIII, p. 528,Jones; Case 11, Table XXIH, p. 528, Robbins: Case 14, Taule XXIII, p. 528, Yeazall; Case 55, Taule XXIV. p. 532, Kidder; Case 15, Taule XXVI, p. 539, Pierson; Case 11, Taule XXATU, p. 543, Turner; Case 5, Table XXX, p. 547, Hayward; Case 12, Taule XXX, p. 547, ATan Scoter; Case 152, Tab: K XXXI, p. 559, Regan; Case 2U8, Table XXXI, p. 561, Yellot; Case7, Table XXXIII, p. 576, Bickford; Case 20, Table XXXIII, p. 576, Coolream; Case G7, Table XXXIII. Shockey; Case 1575, p. 539, Lewis; Case 12, Table XXXAr, p. 591, Gahagan; Case 13, Table XXXV, p. 591, Gravel; and Case 13, Table XXXVII, p. 597, Scott. 2Esmauch (F.) (Vfeber Resectionen nach Schusswunden, Kiel, 1851, S. 43). Lceffle;i (P.) (General-Bericht, u. s. w., p. 291), in the Danish AVar of 1864, saw a solitary case, which he details, of anchylosis at the shoulder. SOCIN (A.) (Kriegschir. Erf., 1872, S. 154) met with a single instance. 3 The specimens in the Army Jledical Museum are numbered 5287 and 5982, of Section I, and are from the cabinet of the late Professor AVilliam Giuson. Dr. HODGES (The Excision of Joints, p. 25) makes his statement on the authority of Mr. Holmes Coote in the Medico-Chirurgical Trans- actions, 1855, A'ol. XXXVTII, p. 95, and the same writer, in The Lancet, 1801, A'ol. I, p. 381. The four specimens referred to by Mr. Coote are: two in St. Bartholomew's Museum, Series II, Sub. B, Nos. 22 and 50, one in the Alusee Dupuytren, No. 656, and one in the Richmond Hospital Museum, Dublin, mentioned by Professor R. AAr. .Smith (Dublin Jour. Med. Sci., 1842, A'ol. XXI, p. 295). 4AVagne:s (A.), Ueber den Heilungsprozess nach Resection und Exstirpation der Knochen, Berlin, 1853, S. 9. 5 E g., Colonel Dulaney, p. 566; Lieutenant AV. L. Horton, 24th Massachusetts, p. 577; Lieutenant Rand, p. 523; Lieutenant Bigger, p. 554; Sergeant Smyser, p. 539; Sergeant Fisher, p. 566; Private Black, p. 547; Private Mahon, p. 538; Private Grant, p. 566, etc. Ofthe four hundred and seventy-one Union soldiers who recovered after excision at the shoulder, one hundred and eleven, or nearly one-fourth, returned to modified duty. 60luer (L.) (Des rejections des grands articulations, Lyon, 1869, p. 15, and Traiti expirimental et clinique de la rigeniration des os et de la pro- duction artificielle du tissu osseux, Paris, 1867, T. II, Chapter VHI, p. 187). Consult, also: RACOUD for a case of regeneration of the entire humerus, in Gazette Midicale de Paris, 1842, p. G39; LAUGlll (Risection sous-periostea de 87mm. de la diaphyse humerale pour une ostiite suppurie, in Gazette Heb- domadaire, 1858, No. 50); AVagnek (A.) (op. cit, S. 9); BOISELLI (Cenni storico-pathologici intorno alle resezione sottoperiostie, Torino, 1858); Giraldes (Bulletin de la Sociile de Chirurgie de Paris, Avril 15, 1863). 7 LANGENBECK (B.v.) (Cliir. Beob. aus dem Kriege, Berlin, 1874, S. 140) relates that: "Lieut, v. Roll, 35th Infantry, was wounded at Mars le Tour, August 16, 1870, by a ChassepOfc ball, which passed through the upper third ofthe right humerus. He was taken to the residence of Dr. Petebgand, at Gorze. On August 26th, seven pieces of bone were removed through the wound of entrance. On Sept. 14th, pysemic symptoms appeare.1. September I6th, the head of the bone and portions of the shaft were excised, with complete preservation of the muscles ofthe scapula in conjunction with the care- fully separated periosteum. In October, 1870, the patient was transferred to Berlin, under charge of Dr. Grcethuyson, who hid assisted Dr. Langen- beck in the treatment at Gorze. During the journey, it became necessary to make several incisions into the lower part of the arm to allow the escape of pus. Lieutenant v. U611 was admitted to the "Konigin- Augusta" Hospital at Berlin, in charge of Professor Dr. SCIIOXBOUN. It soon became evident that the elbow joint was involved. About the end of November, Dr. SCII8NBORN resecied the elbow joint, and at the samo time extracted tho remaining epiphysis of the humerus, which had become necrosed. Dr. Langenbeck continues: "In the fall of 1871, I saw v. Roll in Berlin. The entire upper arm bone is completely regenerated, and forms a really strong bony shaft. The elbow joh* is so perfect in form and function that you are compelled to inspect the plainly visible resection-cicatrix to convince yourself that the elbow joint has really been removed. Hand and forearm are capable of all motions and functions. * * In November, 1871, v. Roll, from a severe fall on the street, suffered a transverse fracture of the nesvly-formed humerus just above the elbow. I immediately applied a gypsum bandage, which remained five weeks. On its removal the fracture had completely united. Similir accidents recurred in the spring of 1872. three times, the new bone being fractured in a different place each time —in the middle, at the end of the upper third, and at the beginning of the upper third, just below the new head of the humerus. Recovery ensued, the prypsum bandage being applied as before. In consequence of the arm being fixed continually, until the spring of 1872, in gypsum bandages, its use hud been entirely lost. * * On May 24, 1873, six weeks after the removal of the last gypsum bandage, a careful examination gave the following result: tho entire right extremity rwo TNJURTKS OF THE UPPER EXTREMITIES. [CHAP. IX. thesr surgeons, do noi. appear to have been achieved; nor was the scooping out of the diseased head of the liumerus, the evidement des os, commended by M. Sedillot.1 resorted to in any reported instance. It is true that in the accounts of a few of the operations it is stated that care Avas taken to preserve as much of the periosteum as possible; but these were almost all instances of early excisions, in which the methodical separation of the periosteum is a very different task from its removal when inflamed and thickened and ready to peel away on the application of a slight force. The reported instances of partial resto- ration of bone are enumerated below.2 There were a few examples among the early fatal cases of detailed reports of the necroscopic appearances, no attempts at reparation having been observed.3 In the infre- quent instances of deaths at remote periods after the operation, the valuable opportunities for ascertaining the conditions of the parts appear to have been neglected,4 which is the more to be regretted as science possesses so few precise facts on this subject.5 I have nothing further to add to the remarks that have been made on the mode of performing excision at the shoulder for injury, save that there is a tendency toward unanimity in accepting the single straight anterior incision, commended by Professor v. Langenbeck, as the best procedure, and that the position of the shot openings need not be much regarded.6 The results of the treatment of shot injuries of the shoulder by amputation at the joint have been so recently recapitulated, on page 655, that it is unnecessary to review them here, except for purposes of statistical comparison with the results obtained on other occasions. Of the twenty-three hundred and sixty-nine determined cases referred to in the pre- ceding tables, five hundred and seventy-seven (577) were treated by expectancy, with a mortality of 25.1 per cent.; nine hundred and fifty-one (951) by excision, with a mortality of 36.6 per cent.; eight hundred and forty-one (841) by amputation, with a mortality of 29.1 percent.,—in all, seven hundred and thirty eight cases terminating fatally, or 31.1 per appears a little smaller, probably because it had participated little, since August. 1870, in the progressive development of the skeleton. Especially noticeable is the smallness ofthe right scapula in all dimensions as compared with the left scapula. Less observable is this backwardness in the growth of the rest of the extremity, and the right forearm and hand appear eA'ea more strongly developed than the left. The right upper arm from the end of the acromion to the external condyle is nearly four centimeters shorter than the left, and its muscular development is inferior; the new bone is a little thinner, and the places of the four fractures are observable. " * Th3 active mobility of the arm forward and backward is quite extensive. Patient carries the hand to the mouth, uses it for eating, for buckling his cravat; carries it to the back, etc." ' Sedillot (Ch.), De Ievidement sous-periostc des os, 1860, 2me ed., Paris, 1837. and Traite de medecine opiratione, Paris, 3me ed., 1865, T. I, p. 474. 2In Case 1503, p. 529, Surgeon J. J. Knott, V. A. C S., enclosed a letter from the patient, stating that there "was a mere gristle attaching itself to the shoulder and to the end of the bone about five inches doAvn the arm." In Case 1534, p. 562, Surgeon G. C. Hablan, 11th Pennsyh'ania Cavalry, reported that "two and a half inches of new bone have been formed,'' five years after the operation. In Case 1575, p. 589, Surgeon R. 15. Bontecou, U. S. V., reported that "a new shaft had supplied the part of the bone removed," this a few months after the injury. In the case of D. Gravel (Table XXXV, No. 13), the Examining Board at Detroit reported, nine years after the operation, "the bone has been reproduced.'' 3 In Case 1584, p. 596, Professor JOSEPH Leidy examined the shoulder of a man who died thirteen days after an excision of the upper extremity of the left humerus, for a shot injury received eleven months previously, and found "no restoration of bone." Assistant Surgeon J. S. BILLINGS, U. S. A., examined, five days after the operation, a fatal case of intermediary excision at the right shoulder and discovered "no attempt at repair in the wound." * Among the five hundred and fifty-one survivors of this operation, twenty-five pensioners are known to have died at periods remote from the opera- tions ; but no account of an autopsy haA-ing been made is recorded in any instance. 6Dr. A. AVagner (On the Process of Repair after Resection and Extirpation of Bones. HOLMES'S Trans. New Syd. Soc, 1859, p. 119) informs us that he was able to find (in the year 1853) but five "examples of dissection of the human body after resection of the head of the humerus. Three ■ >f these belong to Textou and two to Syme. (Hummel, Ueber die Resection im Oberarmgelenk, WUrtzburg, 1832; TEXTOU (C), Neuer Chiron., Thl. I Stck I, 3; Textou (C.), Ueber die Wiedererzeugung der Knochen nach Resection bei Menschen, AATtirtzburg, 1843, S. 11; SYME (J.), Treatise on the Excision of Diseased Joints, Edinburgh, 1831, pp. 51, 58; Contributions to Practical Surgery, Edinburgh, 1848, p. 97.) The patients had survived the operation six months, six, ten, eleven, and nineteen years, »spectively. The usefulness of the arm had been very great in all of them. * * Syme found in both of his patients,—Avho had died, one six months, the other ten years, after the operation,—the head of the humerus rounded off and united by a firm ligamentous tissue to the shoulder blade. TEXTOR, however, gives expressly two cases, six and eleven years after the operation, of formation of bone, which in the first appeared as a bony styloid prominence, resembling the styloid process of the ulna, directed upward, and in the second covered the upper end of the humerus, in the form of an nneA'en tubercular mass, about half an inch long."' In the latter case, and in that of a patient who died nineteen years after the operation, TEXTOU found a meniscus-shaped, moveable, fibro-cartilaginous formation between the upper extremity of the bone and the glenoid eaA-ity. In one only of the five cases, a new articular capsule appeared to have formed. BMayer (L.) (Kriegschir. Mitthcilungen, in Deutsche Zeitsehrift fiir Chir., 1873, B. Ill, S. 70) says: "I agree with Socin, that the surgeon should not allow himself to beinduced. by the location of the wound openings, to modify the position and direction of the incision of LANGENBECK's method." SECT. III.] EXPECTATION, EXCISION, AND AMPUTATION. 661 cent.1 Let us compare these results with those of otlier wars of the last half century, when excision as Avell as expectation and amputation became a common alternative: Table LIII. Showing the Mode of Treatment and Results of Injuries invoicing the Shoulder Joint on the Occasions named and from Authorities quoted. ACTION, Kit'. MODE OF TREATMENT. Revolution in Paris, 1830 (H. Larrey8)..................................... Revolution in Paris, 1830 (Meniere)........................................ Siege of Antwerp (H. LARREY)............................................. Revolution in Paris, 1830 and 1848 (ROUX).................................. Revolution in Paris, 1848, (Jobert he Lamballe).......................... French in Algiers (Baudexs)..........................!................... Revolution in Paris. 1848 (BAUDEXS)........................................ Peninsular AVar (ALCOCK)................................................. From Civil Life (ALCOCK)................................................. Algiers and other occasions (Baudens3)..................................... Austrians in Italy, 1818-49 (BECK).......................................... AA'arin Sleswick-Holstein, 1848-51 (Stromeyer, Esmarch).................. French in Algeria, 1854-56" (BERTHERAND)................................... Crimean AA'af, 1S54-56, Russians (HUBBEXET)............................... Crimean AA'ar. 1854--56, French (Chenu)..................................... Crimean AVar, 1854-56, British (M.VTTHEAV)................................... Italian AVar, 18.">:M>0. French (CHENU)....................................... Italian AVar, 1859-60, Austrians i Demme)................................... New Zealand AVar, 1863-65 (Mouat)........................................ Danish War, 1864. (Lceffler).............................................. Prussians in Six AVeeks' War, 1866 (Stromeyer, Beck, Biefel, Maas)....... Army of the United States (Circular 3)...................................... Franco-German AA'ar, 1870-71, Germans (H. Fischer, SociN, Beck, BILLROTH, ruffrecht. sfjcke, schulleb, g. fischer, lossen, steinberg, meter, Hopmann,-1 CEsterlen, Kibchner, Koch, Schinzinger, Stumpf, Mosetig, Graaf). Franco-German War, 1870-71, French (Panas, COUSIN, CHRISTIAN, PONCET, Hekrgott, Gros, F., Tachard, Sedillot, Grellois.s Chipault,Vasltn, McCormack, Evans). EXARTICULATION'. 14 1 19 1 20 42 16 19 26 9 35 13 2 126 4 10 12 80 222 45 75 21 Of the aggregate of 11846 cases about one-seventh were treated by expectant measures, with a mortality of 49.7 per cent.; one third by excision, with a mortality of 42.0 per cent.; and over one-half by exarticulation, with a mortality of 54.8 per cent. The death rate of the whole number of determined cases is 50.0 per cent. 'A total of twenty-three hundred and twenty-eight cases of shot injury at the shoulder are spoken of at the commencement of this Section. The scapulo-humeral articulation was believed to be primarily implicated in fourteen hundred of these, and involved consecutively, either by disease or opera- tion, or both, in nine hundred and twenty-eight. To the twenty-three hundred and twenty-eight cases were added two hundred and one Confederate cases of excision, and fourteen scapulo-humeral amputations for complications of flesh wounds (from Section I, p. 468), or a total of twenty-five hundred and twenty-nine cases (2,529). Of these, nine excisions, twenty-five amputations, and one hundred and twenty-six of the added Confederate cases, or one hundred and sixty cases, were undetermined, leaving twenty-three hundred and sixty-nine (2,369) determined cases for analysis. i Larrey (H.) (Relation chir. des evenemens de Juillet, 183J, pp. 75 and 78); Meniere (L'Hotel-Dieu de Paris en Juillet et Aout, 1830, Paris, 1830); Larrey (H.) (Hist. chir. du siege d'Anvers, in Rec de mem.de med., 1833, T. XXXIV, pp. 284-377); ROUX (Des plaies d'armes d. feu. Communications faites & I'Acad. nat. di mid., par MM. les docteurs Baudexs, Roux, etc., Paris, 1849, pp. 37, 38); Jobert (de Lamballe) (Plaies d'armes a-feu. See Comm. faites A I'Acad. par Baudens, Roux, etc., 1849, pp. 151-155); Baudens (L.) (Clinique des plaies d'armes & feu, Paris, 1836, pp. 542, 545). 'Reference to this and the succeeding authorities will be found in connection with Table XLI, p. 607 ante. < Hopmann. Aus Vereinslazarethen der Jahre 1R07 und 1871, in Deutsche Zeitsehrift fur Chirurgie, 1873, B. II, S. 555. 5 Gbellois (E.), Histoire mid. du Blocusde Metz, 1870. pp. 348 and 353. 6 It would be easy to swell this statement by citing cases from earlier authors, such as those adduced in notes on pages 608 and 613, but these are frequently returns of successful cases only, and it seems fairer to quote those statistics professing some claim to completeness. t)G2 INJURIES OF THE UPPER EXTREMITIES. [CHAI IX. The high rate of fatality exhibited in Table LIII is mainly due to the excessive losses presented in most of the French reports. Whether these lamentable results are traceable to unfavorable hygienic conditions in the French military hospitals, managed by intendants,—as M. Sedillot believes,—to inferior power of vital resistance in the French soldiery, or to persistence in depletory measures in the after-treatment of operations,—as some critics aver,—the fact is certain that there is a startling disparity between the results of major operations as reported by French surgeons and those reported by the surgeons oi Great Britain, Germany, and the United States. Although H*atin had set a good example in recording the remote results of injuries in the inmates of the Hdtel des Invalides, and D. J. Larrey and Dupuytren bestowed much attention on the ulterior effects of surgical mutilations, no systematic census of the condi- tion of the survivors of the wounds and injuries of war has, until recently, been attempted. The English returns of the Crimean and Indian pensioners were fragmentary. In M. Chenu's Crimean and Italian narratives, the cases were dropped as soon as pensioned. Until I met Professor Hannover's work on the Danish invalids of the war of 1864, I thought that the initiative in this difficult task had been undertaken by this Office. The path opened by Professor Hannover has been further explored, and the appended table presents a limited number of facts on the subject collected by German and English authors: Table LIV. Tabular Statement of One Hundred and Fifty Invalid Pensioners recovered from Shot Injuries implicating the Shoulder Joint, and treated either by Expectation, Excision, or Amputation. Inspectors or Reporters. Hannover1 (Danish War)............ MossalvOAVski3 (Franco-German War). SeggeP (Franco-German War)....... KleAvitz4 (Franco-German War)...... Kratz5 (Franco-German War)........ Berthold6 (Franco-German War)---. Langenbeck7 (Franco-German War).. Eilert8 (Franco-German War)........ Longmore9 (Sepoy Mutiny, 1857-58).. Treatment. Expectation. Excision 17 11 9 37 15 6 16 6 33 5 12 3 1 97 Amputation. 16 Totals. 16 28 16 6 33 17 21 3 10 150 It will be observed that the number of invalids surviving excision largely predom- inates over the combined numbers of those recovering after expectant treatment and amputation; and, when compared with the scanty records that have come down to us of the pension asylums in the early part of the century, this and the preceding table indicate a 1 Han'NOA'EU (A.), Die Danischen Invaliden aus dem Kriege, 1864, in LANGENBECK's Arch, fiir Klin. Chir., B. XII, p. 386, 1870. !MOSSAKOAVSKl (P.), Statistischer Bericht uber 1415 franzosische Invaliden des deutsch-franz. Krieges, 1870-71, in Deutsche Zeitschr. fiir chir., 1872, B. I, p. 321. 3 SEGGEL, Rcsultate der wdhrend des Krieges von 1870-71 ausgefuhrten Gelenkresectionen, in Deutsche Militararztl. Zeitsehrift, 1873, B. 2, S. 315. 4Klea\ttz. see Seggel, ante. * KlLATZ, Resultate der wdhrend des letzten Feldzuges ausgefuhrten Gelenkresectionen, in Deutsche Militararztl. Zeitsehrift, 1872, B. I, S. 399. 6 BERTHOLD, Statistik der durch den Feldzug 1870-71, invalide gewordenen Mannschaften des 10 Armee-corps, in Deutsche Militararztl. Zeitsehrift. 1872, B. I, S. 4(i9. ; LAN E.vr.ECK (B. v.), Chirurgische Beobachtungen aus dem Kriege, Berlin, 1871. " EILERT, Resultate der wahrend des Krieges von 1870-71 ausgefuhrten Gelenkresectionen, in Deutsche Militararztl. Zeitsehrift, 1873, B. 2, S. 536. 9 LOXGMOUE (T.), Resection of the Shoulder Joint, in Stat. San. and Med. Reports of the British Army Med. Dept, 1865, Vol. A', p. 562. SECT. 111.] TREATMENT OF SHOT INJURIES AT THE SHOULDER. 663 great diminution in the frequency of recourse to exarticulation for shot injuries of the shoulder. It has been claimed by Professors Hannover, v. Langenbeck,1 and others, that the ulterior results are better after successful expectant treatment than after excisions at the shoulder. At page 505 et seq. many examples are adduced that lead some of our surgeons to share in this view. This may be conceded without detracting from the inestimable value of excisions at the shoulder,2 which finds its application in cases in which expectant measures are utterly inadmissible.3 Professor Hannover is undoubtedly in error in contend- ing that remote amelioration after excisions for injury rarely or never occurs. I have under personal observation more than a score of pensioners in whom progressive improvement has continued for ten or twelve years after excision at the shoulder for shot fracture; and in several of them all the functions of the upper arm except abduction have become nearly perfect. Indeed, the testimony on this point is cumulative,4 and will doubtless be fully put in evidence in an exhaustive treatise on the subject, now in preparation by Professor Gurlt, of the University of Berlin.5 A pamphlet on excisions, circulated during the war for the instruction of medical officers in the field,6 contains the precept that " excisions of the larger joints should never be practised on the battle-field." I must utterly dissent from this dictum of the distin- guished authors, and further demur to the assertion that " statistics show that secondary 1 Langexueck (B. A'.) (Chirurgische Bcobachtungen aus dem Kriege, Berlin, 1874, S. 114) observes : "In regard to the value of the resection of the shoulder joint, as compared with the expectant mode of treatment, surgeons, who have examined invalid pensioners, generally arrive at the conclusion that better results are obtained by the conservative mode of treatment than by resection." Hannover (A.) (Die Ddnischcn Invaliden aus dem Kriege, 1864, Berlin, 1870, S. 35) remarks: "Among our men, we haA-e neverseen amelioration at a remote period [after excision]. Their condition eitherremained unchanged, or deteriorated in a high degree; so that the resected arm proved to the invalid a burthen and a hindrance. AA'hether this unfortunate result was due t<» the improper selection of subjects and modes of operation cr to the after-treatment is difficult to decide. Evidently the conditions are different in shot wounds and in chronic disease." Dr. LOEFFLElt, on the other hand, is a staunch advocate of the superior end-results of excisions (Langenbeck's Archiv fur Klinische Chirurgie, 1871, B. XII, S. 310), and seeks to controvert Professor Hannover's statements. 'Langexueck (B. \'.) (ChirurgischeBeobachtungen aus dem Kriege, Berlin, 1871, S. 15C) sums up his conclusions regarding the comparative value and indications of treatment by expectation, excision, or amputation, in shot injuries at the shoulder, as follows: " 1. All less severe shot injuries of the shoulder joint justify the attempt at expectant treatment, under the presumption that in many of these cases secondary resection will become necessary. 2. All extensive shot fractures ofthe shoulder joint indicate primary resection. 3. Crushing of the shoulder joint with laceration ofthe soft parts does not, of itself, indicate exarticulation, but secondary resection. 4. The aim ofthe conservative treatment is to aA'oid anchylosis, to restore mobility to the joint. 5. Anchylosis at the shoulder joint having supervened, the usefulness of the arm may be improved by secondary resection of the head of the humerus. 6. The formation of a new shoulder joint with voluntary motion will be most readily secured by subperiosteal resection. 7. After subperiosteal resection the most careful after-treatment is required to restore useful joints. 8. A gradually increasing deterioration, through increasing atrophy of muscles, does not occur after resection of the head of the humerus. The so-called lahmungsartige Zustand (lame-like condition) is nothing but paralysis from inaction. 9. The paralysis caused by want of exercise can be removed by appropriate treatment even a long time after resection, and the usefulness ofthe extremity may afterward be re-established." SchUllkr (M.) (Kriegschir. Skizzen aus dem deutsch-franzosischen Kriege, 1870-'71, Hannover, 1871, S. 38) remarks: "In shot wounds ofthe shoulder joint generally resection is preferable to expectant treatment. By the removal of the voluminous head the sup puration is considerably diminished, in the first place because the suppurating surface is contracted, and, in the second place, the patient escapes the tedious process of eliminating the necrosed fragments." 3 Billroth (TH.) (Chirurgische Briefe aus den Kriegslazarcthen, u. s. w., Berlin, 1872, S. 217) says: " We would undoubtedly be justified, from the end-results of the shoulder excision, to ponder the question whether this operation might not be more frequently avoided. For my own part, I have learned to value the life-saving results of this operation yet higher, and find that we cannot sufficiently thank the men who introduced this procedure into the surgery of war." 4 Even Dr. NEUDORFER, who is an advocate of deferred or secondary excisions for injury, in a paper he has had the kindness to send ine (Die End-resultatc der Gelenkresectionen, extracted from the Wiener Medizischc Presse, 1871), concedes the amelioration of the functions of the arm after excisions at the shoulder. "AVTiat," he enquires, "are the results of favorably ending joint-suppurations under the expectant conservative treatment.' The question may be in general answered that traumatic suppuration of the joint, as well as that from pathological causes, is only very rarely cured with complete motion of the joint. If, therefore, resection is indicated, it is justifiable iu all cases where suppuration threatens the life of the patient; but the peril, the jeopardy to life must have begun, the suppuration of the joint in itself not necessarily imperilling life." This position will be regarded by many as untenable; but, on the point at issue, Dr. Neudorfer, after citing a case of shoulder excision for shot injury, adds: " Yet to-day, ten years later, the result is the same as early after recovery, indeed the present condition is even better than then, as, at tho last examination, I found that sensation in tho parts to which the ulnar nerve is distributed was partially restored." 5 Professor Gurlt writes me, May 5, 1874 : " I am occupied in making up the history and statistics of all the resections of joints that have beeu made for gunshot wounds since the wars at the end of the last century. My purposo is not only to elucidate some points in the history of these operations that have been partially forgotten, but principally to point out the ultimate results of these resections many years after their execution, a subjeet almost unexplored till now. Almost all the publications on this subject have been made up a short time subsequently, the results being recorded a year or two later than the operation, and when the restoration of the functions of the limb was incomplete. Thus it was that the publication of Professor Hannover, of Copenhagen, on the miserable state ofthe Danish invalids, excised by Prussian surgeons in the Dano-Prussian war of 1864, produced a painful impres- sion, which was by no means lowered by the observations printed after the Franco-German war regarding the condition of the invalids who had undergone resection. Fortunately, we now know that the results have greatly improved after the limbs have been for some years in constant use. This I intend to prove by as many exemples as possible, derived from all a\-ailable sources. I have been enabled to collect information of the ultimate results and present condition of invalids with joint resections, in the Schleswig-Holstein campaigns (24-26 years ago), of the Dano-German war of 1864, and some others * * ." HA Report on the Subject of Excision of Joints for Traumatic Cause, by Drs. Hayward, TOAVNSEND, Ware, J. M. Warren. Cabot, Dale, and Hodges, Cambridge, 1862. 661 INJURIES OK THE I'PPER EXTREMITIES ICI1AI'. IX excisions arc more successful than primary in the proportion of 17 to 10," as unfounded on reliable data, and in flagrant contradiction with the real facts. I regard the recommenda- tion of deferred operations as pernicious, and believe that, in the light of our present experience, it will never gain a foothold among military surgeons. In regard to partial excisions of the head of the humerus, important eA'idence has been presented (p. 526-8) in confirmation of that precept of Baudens: En principe il faut limiter la rese< tion d la lesion et respecter le plus possible le tissu osseux. The late Medical Director Hewit and Drs. Bontecou, B. HoAvard, Armsby, and W. Thomson especially advocated and exemplified the utility, under some circumstances, of partial excisions of the epiphysis.1 In 1862, excision at the shoulder was practised in the proportion of 2.3 in a thousand cases of shot injuries returned; in 1863, in 3.4 per thousand; in 1864, in 4.4 per thousand; in 1865. in 4. per thousand. The facts that have been adduced in this Section appear fully to warrant the conclu- sions—1. That in slight shot injuries of the shoulder joint an expectant conservative treatment is justifiable.2 2. If a ball is impacted in the head of the bone, or if the epiphysis is much comminuted, unless there is injury to the blood-vessels and nerves, or very grave injury of the other soft parts, primary excision should be practised. 3. Concomitant fractures of the acromial end of the clavicle, or of the neck or processes of the scapula, or of the upper third of the shaft of the humerus, do not necessarily contraindicate excisions at the shoulder.3 4. Intermediary excisions should seldom or never be practised. If, in an attempt at expect- ant conservative treatment, intense suppurative inflammation arises, it should be combated by free incisions, drainage, emollient applications, etc., and every endeavor should be made to avoid inflicting another wound upon the inflamed medullary tissue, and to await the secondary stage, before undertaking operative interference.4 5. The after-treatment of securing comparative immobility and support of the limb and efficient drainage of the wound; and the ulterior after-treatment of judicious passive and active movements of the arm, are of essential importance in restoring the functions of the member. 6. Primary 1 Baudens (O.) (Comptes-rendus de VAcadimie des Sciences, Paris, FeA-rier 26, 1855. and Recueil de Mem. de Med. Mil., 2Sme s6r., T. XAr, p. 180) says: '' D'apres ce principe il nous est arrivti de n'extraire que la moitie de la tete de l'hum6rus, ce qui n'avait jamais 6t6 fait encore, que nous sachions." IIEAVIT (II. S.) (Appendix to Part I of Med. and Surg. Hist, of War of the Rebellion, 1870, p. 312) remarks: "Partial excisions of the head of the humerus is a safe and successful operation. * * Scapular motion makes great compensation for anchylosis, aud it is frequently better to accept this result, rather than to incur the risk to life of the more brilliant procedure of complete excision." See als3 PlXKXEV (X.), Am. Jour. Med. Set, 1840', Vol. XII, p. 330. - Geissel (II.) (Kriegschirurgische Rcminiscenzcn von 1870 b s 1871, in Deutsche Zeitsehrift fiir Chirurgie, B. Ar, 1874-5, S. 36) remarks: " AVrith vox Laxgexiseck. I believe in accepting, as a practical rule, that all slight injuries of the shoulder joint * * justify the attempt at conservatiA-e surgery. with an anticipation of intermediary or secondary resection if necesfiry; but all extensive shot fractures indicate pi imary resection. If an expeetative treatment has been resolved upon, under all circumstunces an active mobile joint should be aimed at by early g3^mnastic exercise. Should, neverthlcss, anchylosis supervene, the attempt may be made to obtain an active mobile joint by resection." Dr. Geissel relates the case of P. Dorweiber, wounded at Gravelotte, August 18, 1870; resection of head and three inches of diaphysis three days afterward. This man was examined four years afterward. Xo new bone-formation was found, but Dr. CEISSEL thinks the case confirms the opinion given by A'OX LAXGEXBECK, that results once achieved after resec- tion of the joints will not be subsequently lust under judicious active after-treatment, and controA'erts the opinion of Hannover, of Copenhagen, that the end-results of joint resections deteriorate from year to year.'' The italics are by the editor. 3 As this sheet is going to press, I have received an interesting monograph (Die Resultate der Gelenkresectionen im Kriege, Oiessen, 1874) by Dr. E. Bei»;Manx, professor of surgery at Dorpat, and one ofthe surgeons of the great military hospitals at Carlsruhe and Mannheim during the war of 1870-71. He fully describes 15 intermediary aDd secondary excisions at the shoulder, with 12 recoA'eries. These and other successful resections are beautifully illustrated by Albertotype plates. Active mobility of the joiut " in all directions " was achieved in one case, the patient declaring that he " could lift the arm upward to the top of the head, sideward to the top of the shoulder, and revolve the arm in a circle, without pain." In another case (Fall 23, S. 18, 15. < long, Gth Bavarian Infantry, wounded at KtiA'al, byshell. <)ot< ber C, 1870), part of the scapula was removed on the third, and the head and part of shaft iif liumerus on the thirteenth day. "All the soft parts on the outer posterior arm, Avith a portion of the acromion and spine of scapula, were so completely tern away that the fractured acromial process and the fissui'ed head of the humerus were plainly visible. Abscesses formed in the course ofthe treatment, - * and even gangrene supervened. KeA'ertheless, a result was obtained that leaA'es nothing to be desired. The muscles are splendidly restored, as is shown in Plates IX and X. * * Since Langenbeck, in I860', saved, by resection, the arm of------, in a case where all the surrounding parts, with the exception cf the large vessels aud nerves and the triceps and latissimus muscles, were torn away, and even enabled the patient t.i re-enter the military service, to vide horseback, and carry the sword with the right (the resected) arm, this case is the most notable example that shot fracture of the shoulder joint with extensiA'e laceration cf the soft parts does not indicate primary amputation.'' i In all three stages, gtati>i:cs of large aggregates teach that the risk of excision at the shoulder is a little in excess of ablation of the limb at the joint. Thus, in our experience, the fatality of excisi-.ns was P, 31X6, I. 46.4, S. 29.3; cf amputations, P. 24.1, I. 43.8, 5. 2S.7. M. OlIE.Ni; tApercu hist, etc., Pans. 1674, T. I, p. 4!»2) reports 3.5 exarticulations at the ►houlder with 207 deaths, or 63.69 per cent., and Sl'J ex.-isions with 226 or 70.85 per e»nt. SECT. iv.J SHOT INJURIES OF THE SHAFT OF THE HUMERUS. 665 exarticulation of the arm at the shoulder is imperative in cases of shot lesions of the upper extremity of the humerus attended by injury of the axillary vessels and nerves, or by very grave injuries of the other soft parts in the vicinity of the joint; and may also be demanded Avhen fractures of the humerus involving the shoulder are conjoined with severe injuries lower doAvn in the limb. Circumstances may also justify primary ablation of the arm when there is little injury to the soft parts and the epiphysis is untouched, if the humerus be so extensively shattered dowmvard as to forbid excision, and fissures extend so near the joint that section of the bone in its continuity cannot be practised without danger of arthritis. Intermediary exarticulation at the shoulder may be required in cases of hemor- rhage, gangrene, or osteomyelitis; and secondary exarticulations for the same causes, and also for complete necrosis of the humerus. Section IV. INJURIES OF THE SHAFT OF THE HUMERUS. It is proposed to consider in this place only injuries inflicted by weapons of war, and to relegate the instances of simple and compound fracture, produced by other causes, to the Chapter specially devoted to those subjects, in the Third Surgical Volume. As there were no reported instances of SAVord or bayonet injuries of the humerus, the Section will be wholly occupied by discussions of the reports of shot fractures of the shaft involving neither joint, and of the operations performed in the continuity of the upper arm. In a statistical point of view, the classification will often seem arbitrary, and the estimates cannot be otherwise than approximative. The summing up of the injuries and of the operations will not accord. It has been seen, in the last Section, that excisions and amputations at the shoulder joint were not infrequently practised for injuries attended by fractures strictly limited to the diaphyses. In this Section, many examples will appear of amputations through the shaft of the humerus for shot lesions of the elbow joint or of the forearm. This explanation is essential to a just appreciation of the discrepancies in the numerical statements of the shot fractures and operations involving the shaft of the humerus. Although much labor has been expended in the analysis of the cases of this group, their number and complexity is such, that precision in presentation could only be attained at the cost of long and tiresome iterations. At least eight thousand two hundred and forty-five cases are comprised in the category, the shot fractures of the shaft complicated by fractures of the shoulder or elbow joints being excluded. Of this large number, many were attended by flesh or penetrating wounds of the thorax, or by grave, and sometimes by multiple, injuries in other parts of the body. Through tabular statements, an effort is made to indicate the distribution of these instances of multiple injuries, which have been, or will be, referred to elsewhere. The Section is naturally divided into enquiries regarding the nature and extent of the fractures, the operations undertaken, and the complications of the injuries and operations, and will be subdivided into analyses of cases dealt with on the expectant conservative plan, of those treated by excision, and of those subjected to amputation. A general summary will be premised. 8-1 666 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. Taule LV. Tabular Statement of Eighty-two Hundred and Forty-jive Shct Fractures of the Shaft of the Humei^us unattended by Primary Injury of the Shoulder or Elbow Joints. SUBDIVISIONS. 1. Treated by Expectation......................................... 2. Followed by Amputation at the Shoulder......................... 3. Followed by Amputation of Upper Arm.......................... 4. Followed by Excision of Head and Portion of Shaft of Humerus.-. 5. Followed by Excision of Shaft of Humerus....................... 6. Followed by Excision of Portion of Shaft, with the Elbow Joint... 7. Followed by Excision in the Shaft and Consecutive Amputation at the Shoulder. 8. Followed by Excision in the Shaft and Consecutive Amput'n of Arm Aggregates...................................... Cases. 3,005 606 3,685 245 632 8 15 49 Duty. 1,055 64 430 28. 87 3 0 Discharged. 1,454 370 2,223 141 353 4 4 30 Undeter- mined. 45 21 259 4 28 0 0 Died. 451 151 773 72 164 1 11 Mortality of Determined Cases. 15.2 25.8 22.5 29.8 27.1 12.5 73.3 32.6 8,245 4,579 1,639 20.7 The results of three hundred and fifty-seven of these cases could not be traced. Of the seventy-eight hundred and eighty-eight cases with ascertained results, above tabulated, it will be observed that little more than one-fifth terminated fatally; and if the cases complicated by grave injuries of the trunk or lower extremity were eliminated, the per- centage of mortality would be yet further reduced. Two hundred and thirty-six cases furnished the Museum with pathological specimens.1 Tavo hundred and forty-five cases, in which excisions of the head or head and upper part of shaft of the humerus were excised, have already been examined, and also six hundred and twenty-one cases treated by scapulo-humeral amputation, leaving someAvhat over seven thousand cases for consideration. These will be analyzed in the following order: Cases treated by 1st, expectant conservative measures ; 2d, by excisions in the continuity; 3d, by amputations in the shaft. Expectant Conservative Measures.—Three thousand and five cases of shot fractures limited to the shaft of the humerus, treated on the expectant conservative plan, are found on the returns. It is probable that many of the cases reported as excisions in the continuity really belong to the category now under consideration; but the indications of the reports have been followed in tabulating the cases. In forty-five instances, it was impracticable to trace the results. Of the remaining twenty-nine hundred and sixty-patients, nearly a third returned to modified duty; nearly half of the whole number were discharged; and somewhat over a seventh, or four hundred and fifty-one, died. The mortality rate is not large; but, obviously, the least severe cases were selected for treatment by expectant measures. The extent of the shot injuries, the varieties they presented in different portions of the shaft, the attendant and consequent complications, the details of treatment, and the causes of fatality Avill all claim attention. Shot Contusions and Partial Fractures of the Shaft of the Humerus treated by Expectation.—According to the reports, injuries belonging to either of these groups, unless ' These are distributed as follows: Thirty-six specimens, 7 from cases of recovery and 29 from fatal cases treated on the expectant plan; 41 instances, 24 successful and 17 fatal, from amputations at the shoulder; 80 specimens from amputations of the arm, 51 successful, 2'J fatal; 37 from excisions of head and part of shaft, 21 successful, 16 fatal; 30 specimens from excisions in the shaft, 19 recoveries, 11 post-mortem specimens; 1 specimen from a recovery after an excision of a portion of shaft with the elbow joint; 4 specimens from fatal cases of excisions in the shaft with ulterior amputation at the shoulder; 7 specimens, 4 from successful and 3 from unsuccessful cases of excision in the shaft followed by amputation of the arm. SECT, iv.] SHOT CONTUSIONS OF THE SHAFT OF THE HUMERUS. 667 they resulted favorably and escaped recognition, were exceedingly rare. Unquestionably, opportunities of demonstrating such lesions after death, or after excision or amputation, were Arcry infrequent. The Museum possesses but two examples in the humerus of those illustrations of the effects of shot contusion, characterized by a thin elliptical exfoliation or by a slight superficial caries, associated with signs in the cancellated tissue of suppurative osteomyelitis, of Avhich instances are not uncommon in the femur, tibia, and cranial bones. It may be remarked also that Surgeon John A. Lidell, U. S. V., Avho made a special study of shot contusions of the long bones, and has published a valuable monograph1 on the subject, does not adduce a single instance of contusion of the humerus. There are several specimens of missiles in the Museum slightly flattened by impact on the shaft of the humerus, from cases of recovery, where it Avas supposed that the humerus was contused or at most only partially fractured.2 It is probable that some cases of necrosis after shot Avounds of the upper arm, in which fractures were not discovered at the date of injury, were instances of grazing shots or contusions of the humerus. The following is an example: Case 1G12.—Corporal A. AL A----, Co. B, lGth Michigan, aged '27 years, was Avounded at Poplar Gro\-e Church, September 30, 1884. From a Fifth Corps hospital he was admitted, on October 7th, to Harewood Hospital. Surgeon R. 15. Bontecou, U. S. A7., recorded: "Gunshot Avound of left arm, upper third. Discharged from service March G, 1863.'" Examiner J. Nichols, of Washington, D. C, on May 2, 1333, certified: "Gunshot Avound of left humerus, with compound fracture; abscesses have formed; limb uoav greatly SAVollen and inflamed; flesh Avound extensive and yet unhealed; gangrene attacked the wound, destroying a large portion of soft tissue." Dr. D. Stanton, of New Brighton, Pennsylvania, late surgeon U. S. V., on March 15, 1333, fonvarded the specimen, represented in the annexed Avood-cut (FlG. 500), to the Museum Avith the folloAving history: "A minie ball passed through the upper third of the left arm and side, grazing the humerus. Hospital gangrene commenced in the Avound ou October 20th, at HareAvood Hospital, Avhich Avas arrested by the use of bromine, turpentine, &c., after having exposed four inches of the bone. The patient Avas admitted to the Massachusetts General Hospital, at Boston, W] in May, and a small scale of bone Avas removed by Drs. Bigelow and Clarke. He reported to me in Detroit, L Michigan, in October, 1865. I made an incision four inches in length, enlarged the sinus in the new bone, broke f ^ off about an inch from the upper end of the sequestrum, when I Avas enabled to remove the remaining portion, *j| \ .n three and a half inches in length. At last report (February 5th), the Avound had almost healed and the arm Avas >'''' improving rapidly." The pensioner, in his application for increase, on July 9, 1868, states "that his arm is completely disabled, it being impossible to straighten his-elbow, and that his shoulder joint is also stiff and he Wj cannot use it." In another application, on October 3, 1871, he states: " The Avound is now a running sore; four inches of bone Avere taken out soon after the reception ofthe wound, and last year a piece of bone Avas discharged." Drs. G. K. Johnson and S. R. AVooster, of the Examining Board at Grand Rapids, Michigan, January 3, 1372, lmdrical seques- certify: " AVounded by a musket ball in upper third of left arm, causing a flesh wcrtind. Gangrene followed, * f"]"*?'^"1 shaft Avith destruction of soft tissues and death of bone, three and a half inches of shaft of humerus being removed, after necrosis There is noAV a slight union by the formation of new bone, Avith positive evidence of dead bone still remaining, ,sw.S2434in''Ury the wound never having been entirely healed. The bone at the place of injury is covered only Avith skin for a space of three inches, Avhich is adherent to the bone. No muscular or cellular tissue. There is inoreased disability because of the extent of death of bone, Avhich still continues. Applicant can use his arm a little in feeding and dressing himself," &c. The same Board, Avith the addition of Drs. Z. E. Bliss and E. Boice, reported, September 12,1873 : " Ball entered upper third of left arm, injuring the bone, and, passing around, Avounded back just below posterior border of left axilla. Gangrene folloAved, Avith destruction of soft tissues aud death of bone. There is now complete continuity in shaft of liumerus, with extensive adhesions of skin to bone, and loss of muscular tissue." Tlie disability Avas rated total, and the pensioner Avas paid December 4, 1873. Dr. R. B. Bontecou states that he has "observed several cases of death from pysemia resulting from shot contusions of the humerus and the femur, and, in looking over a mass of manuscript, found a history of a case." Dr. Bontecou also contributed to. the Museum the beautiful specimens (Nos. 6309, 6312) of shot contusion of the humerus represented l Lidell (J. A.), On Contusion and Contused Wounds of Bone, with an Account of Thirteen Cases, in the Am. Jour. Med. Sci., 1865, Vol. L, p. 17. 'Namely: Spec. 4571, "a wafer-like fragment of a spherical ball extracted after flattening against the left humerus" (Cat. Surg.Sect, 1866, p. C0I); case of Pt. J. Stephens, 2d Massachusetts. He was wounded August 9, 18G2, at Slaughter's Mountain, and died September 7, 1832, at Annapolis, of pyaemia. Spec. 4416, "a buckshot flattened against the humerus without fracture" (Cat. Surg. Sect, 1833, p. 597); case of Pt. J. Franel, 45th Pennsyl- vania, who recovered without complications. Spec. 4424 (see CASE 1514). Spec. 453, ,-a conoidal ball laterally flattened; the side next the bone is com- paratively smooth, and retains a fragment of fascia or periosteum " (Cat Surg. Sect, 1866, p. 615); it was lodged in the middle of the arm without fracturing the humerus. Spec. 2751, "a conoidal ball with two portions smoothly cut off the body and base at an obtuse angle to each other" (Cat. Surg. Sect, 1833, p. 016); Pt. C. C Cole, 33th M.m.i.-.husetts. This bill was found lying between the brachial aud the middle of the right humerus, in contact with the b:>ne, but no apparent fracture was delected. l)l)*5 INJURIES OF THE UPPER EXTREMITIES [CHAP. IX. in Plate L, opposite. The specimens are from soldiers who died in Harewood Hospital, in 1861, from pysemia, a feAV weeks after shot perforations of the right arm by musket balls, which must have grazed the humerus.1 We are indebted to the veteran Professor Louis Stromeyer for the first clear account of shot contusions of long bones.2 Since this form of injury was described by him, it has received much attention from writers on military surgery.3 Partial Shot Fractures.—Specimens of partial fractures from small projectiles, though unusual, since such injuries are ordinarily reparable, are less infrequent in cabinets than illustrations of the effects of contusions. The Museum has a few examples: Cash 1(513.—Private Albeit C----, Co. K, 6th Cavalry, aged. 28 years, Avas wounded at Petersburg, April 1, 186"). On April 8th, he was admitted into Lincoln Flospital. Surgeon B. B. Wilson, U. S. V., reported: "The jiatient Avas a man of strong, plethoric habit, and in good condition; his mind was inclined to despondency, lie had received a gunshot wound of the right shoulder, the ball entering in front of the joint, passing through, and was cut out posteriorly; the missile was a mini6 ball. Exploration with the finger discovered shattered frag- ments of bone, being either the head, or near the head, of the humorus. The soft parts were very much inflamed, and the whole arm Avas sAvollen; tin* discliarge was healthy pus, slightly tinged with blood at first, but soon resumed its natural color and floAved freely. The arm Avas bandaged, and cold- water dressings Avere applied. At a consultation of surgeons to consider the propriety of resection, it was decided to Avait for the inflammatory action to subside bef jre operating. The patient continued to do well, the swelling subsiding, and the Avhole system becoming more comfortable until May 10th, when erysipelas set in and spread rapidly, going nearly to the median line both on the breast and back, and down the arm half Avay to the elbow. It was ushered in by a chill and accompanied by severe constitutional symptoms. Tincture of chloride of irou in doses of twenty drops was administered every two hours, and linament of linseed-oil and lime-Avater applied locally. The inflammation ceased to spread twelve hours after the administration of the first dose of iron, and in a week the complications had disappeared. The discharge Avas suppressed during the attack. On April 29th, pysemia Avas ushered in by a severe chill, folloAved by an exhausting sweat, the latter continuing with intermissions up to the time of the patient's death. One, tAvo, or three of these chills occurred every day; the face and entire body became icteroid; there was pain in the right lung, with dyspnoea; the mind Avas dull, and the prostration was very great. The treatment consisted of the administration of quinine to the extent of forty grains per day, Avith capsicum and brandy freely, and beef essence. The diarrhoea and vomitings were treated Avith morphia. The patient died on the 4th of May. Autopsy eleven hours after death : Itigor mortis slightly marked; icteroid Pic 501—Upper appearance of the Avhole body. There Avere small pyaemic abscesses at the apex of the riadit lunar, Avhich extremity of the right ' r J Z. on' humerus partially frac- Avas also considerably collapsed by pressure of an effusion in the right pleural cavity, consisting of serum, S»«?■!«io7 mils,5et bal1' fibrin, and pus intermixed. In the left pleural cavity four ounces of a similar effusion were found. In the middle lobe of the left lung Avere seventeen sm dl pyaemic abscesses. The heart Avas normal, but contained fibrinous clots. The liver was honey-combed Avith pyaemic abscesses, one of which, in the superior portion of the right lobe, contained eight ounces of pus The left kidney contained small abscesses in its substance, which opened into its pelvis Avhen incised; there was a small abscess in the areolar tissue around the right kidney; the kidney was otherwise normal. The shoulder joint was not opened as had been anticipated, the ball having made a groove through the shaft of the humerus joint at the internal insertion of the capsular ligament, partially dividing that insertion and laying open the cancellated structure of the head. The joint was healthy, as Avas also the medullary canal of the humerus.'" The fractured portion of the humerus (FlG. 501) Avas contributed to the Army Medical Museum by Dr. Wilson. i Dr. BoNTECOU's reported case was one of shot contusion ofthe femur, and will appear in the next Chapter; but his recollection of examples of contusions of the humerus resulting iu fatal pyaemia is important. Of the case which furnished Specimen 6309, nothing more has been learned than is stated in the text: Specimen 6312 is from the case of Corporal N. J. E------, Co. H, 8th Xew York Artillery (Case 5, Table XIAT, p. 468). The fact of a bullet grazing the humerus was undiscovered when the case was classified as a flesh wound. "Stromeyeu (L.), Ueber die bei Schusswunden Vorkommenden Knochen- Verletzungen, Fieiburg, 1850, Sa3 : " Sie trifft den Knocken," u. s. v.; or, as .Air. S. F. Statham translates: " They strike the bone without breaking it, and flatten themselves against its surface; the bone struck becomes necrotic from the destruction of its periosteum. In crowded hospitals such injuries of the larger long bones cause suppuration ofthe medullary canal, which, extending itself, at last, by the passage of pus into the veins, gives a fatal termination. In the autopsy (the bone being sawn in its long axis) the marrow is found filled with pus from the wounded part upward, and the same morbid product in the neighboring large veins; as in the femoral vein after contusion ofthe femur. The spot struck by the ball is colorless and exsanguine; in its circumference appears the commencement of a line of demarcation. Contusions of this kind, which, up to the present tirrie, have been little attended to in the long bones, are well known in the bones of the skull, where caused bya blow or fall; they liave the same dangerous consequences if nut properly treated, as suppuration occurs in the diploe and purulent inflammation in the sinus, with its usual results. Such contusions also occur in the cranial bones, if a bullet strikes at a right angle, of which I have seen many examples, where it could be deter- mined, from the character of the wound in the soft parts, that the same had been so struck, without causing fracture or depression of the bone." " BECK (B.) (Chirurgie der Schussverletzungen, Freiburg, 1872, p. 66) cites two cases of shot contusions of the humerus: In one case the wound licaled without complication and without necrosis, but the arm was still emaciated and powerless at an examination ten months after the injury, invaliding the patient; in the other case, the missile passed through the upper third and contused the bone. The wound healed well, but free motion of the arm in the shoulder joint remained impaired and the bone remained puffed up; the patient was also inA'alided. SOCIX (A.) (Kriegschir. Erf., If7^», S. 106) tabulates fhree cases of contusion ofthe shaft ofthe liumerus. Two were treated on wire splints. The patients recovered in 15, 40, and 82 days, respect- ively, with enlargement of the bone in every instance. In two eases, the functions of the arm and forearm remained normal; in the third case, extension i)f the wrist joint and the three last fingers became impossible. &'*•. ■■■* >&■■■ . •*^ >*J. ' -V+y. ■■"«■"■. '«¥"*■;>A .** >»*/, • :*v W/r •.,■-■•>> ;fe\';' :.*• A' *.*"]» • ■^ jth •';.■■*:.■ ,i. 1833. "The patient can use the arm pretty Avell; can flex the foreann to a right angle to the humerus, and can straighten it. There is considerable deformity, hoAvever, at the point of fracture, the arm being crooked, but this does not materially affect the use of the limb. April 2, 1883, the wound is noAV healed." This soldier Avas discharged June 11, 1863. sect. IV.! SHOT FRACTURES OF THE SHAFT OF THE HUMERUS. 673 Pseudarthrosis was infrequent after shot fractures of the shaft of the liumerus, although, after simple fractures, this diaphyses may be considered as almost the seat of predilection of that complication.1 Six examples are recorded among the twenty-nine hundred cases treated by expectant measures, and a somewhat larger number among the excisions in the continuity. Two instances of the former category are detailed:2 Case 162;i.—Private J. Eggerstedt, Co. G, 2d United States Cavalry, aged 29 years, was Avounded in the right arm, at A'alverde, February '-'1, 1882. Dr. B. Norris, U. S. A., medical director ofthe troops engaged, reported on his list of casualties: "Gunshot fracture of humerus." The wounded man Avas conveyed to a hospital at Fort Craig, a distance of about five miles, Avhere he Avas treated for a time. Subsequently he Avas transferred to the general hospital at Hot Springs, near Las Vegas, New Mexico, whence he Avas discharged on July IIS, 1802, his term of service having previously expired. May 19, 1882, Assistant Surgeon B. Norris stated, in the certificate for pension, dated May 10, 1832, as follows: "A musket ball Avound in right arm above elboAV, fracturing the bone and permanently impairing the use of tho arm." Examiner G. AV. Mears, of Indianapolis, on October 3, 1882, certified: " Shot by a rifle ball passing through right arm near middle of humerus, having broken the bone, which never again united, leaving an artificial joint. In other respects, health good. * * In order to have a very imperfect use of his hand he is obliged to keep splints and a bandage upon his arm, &c." In another examination, for increase of pension, Dr. Mears reports the disability increased in consequence of "several efforts having been made to produce reunion ofthe fractured ends of the liumerus without success, and the arm becoming someAvhat painful." Examiner J. Phillips, of Washington, D. C. April 21, 1869, certified: " Ununited fracture of right arm. * * There is no discoverable defect of the system to account for his condition, &c." Examiner J. O. Stanton, on September 12, 1873, certified: "Ununited fracture. There is about two inches shortening of the limb, some atrophy of muscles of right forearm, and evident loss of strength. Can use the hand when the elboAV is supported, and has then a good grasp of the hand, &c." The disability Avas rated total. Pensioner has been paid to June 4, 1865. This man visited the Army Medical Museum in the summer of 1837, Avhen a photograph of him Avas taken. (Surgical Series of Photographs, No. 189, A. M. M.) Case 1627.—Private G\ T. Abbott, Co. I, 4th Vermont, aged 21 years, Avas wounded at the Wilderness, May 5, 1834. From a field hospital he was received into Mount Pleasant Hospital on May 13th. Assistant Surgeon C. A. McCall, U. S. A., reported: " Gunshot wound of right arm. Transferred to Philadelphia, May 30th." Assistant Surgeon T. C. Brainerd, U. S. A., in charge of Broad and Cherry Streets Hospital, reported: "Gunshot fracture of right humerus. Water dressings and splints applied." On February 3, 1865, the wounded man Avas transferred to the Brattleboro' Hospital, Vermont, and on June 15th to Central Park, NeAV York City. Acting Assistant Surgeon C. E. Phelps, from the latter hospital, reported: "Gunshot Avound of right arm. A minie ball passed through middle third from within outward, producing oblique fracture of humerus. Missile cut out next day, in the field hospital. Fracture treated with right-angular splint. A month after reception of Avound gangrene appeared, small in extent, but persistent. Result of injury, ligamentous uuion. On July 24th, an apparatus Avas furnished by Dr. E. D. Hudson, of Ncav York, who reported: "Arm shortened one inch; some atrophy; false joint; fractured ends nearly iu apposition; considerable enlargement about fractured part; functions of forearm good; arm useless." The patient Avas, on August 29th, admitted to Sloan Hospital, Montpelier, Vermont. Surgeon H. Janes, U. S. V., contributed a photograph of the patient (Card Photos, Vol. II, p. 113) with the folloAving history: "Ball entered about the middle of arm on inner side, frac- turing the humerus, and lodging under the skin on the posterior and outer side, where it Avas cut out. No bone Avas taken out with the ball, but a fragment, three-fourths by one-fourth of an inch, came out on the fourth day after the injury. Another fragment, one inch by one-fourth, and a small piece of the bullet, came away Avhile he Avas at home on furlough, five months after the injury. No other pieces of bone have come away. No retentive apparatus Avas applied the first Aveek after the injury. After that an angular curved splint Avas used for about two months, and aftenvard a pasteboard splint. About six Aveeks after the injury the wound became gangrenous, and nitric acid Avas freely used twice. Gangrene Avas arrested in about tAvo Aveeks, and he began to improve very sloAvly, andAvas confined to the house about six Aveeks. The Avound healed about the 1st of July, le55, Avith a false joint. In the latter part of June, he Avas transferred to New York to be fitted Avith Hudson's retentive appa- i Professor F. H. HAMILTON (New Mode of Treatmentof Delayed or Non-Union of a Fractured Humerus, inBuffalo Med. Jour., 1854. Vol. X, p. 142) remarks: " I have observed that non-union results more frequently after fracture of tlie shaft of the liumerus than after fracture of the shaft of any other bone." This result is commonly ascribed to the difficulty of securing immobility in these fractures (XlCAlSE (E.), Article Bras, in Diet Encyc. des Sci. Med., 18G9, T. X, p. 520). Professor Scuillot (Du traitement des fractures des membres par armes a feu, in Arch. gin. de med., Ser. VI, T. XA'II, P. I, p. 401) observes: " Pseudarthrosis, so common in ordinary fractures of the humerus, especially in those of its upper half, because of the difficulty of immobilization of the arm, are very rare after gunshot wounds, and an explanation is found in the extent and activity of the osteogenetic process " in Buch grave injuries. NEUDOltFEit (J.) (Handbuch der Kriegschirurgie, 1872, B. II, S. 1179) remarks: " That in his own practice he has not met with a single case of pseudarthrosis after shot fracture. Only twice he had occasion to observe pseudarthrosis after shot fractures of the epiphysis of the uumerus," and adds: " Pseudarthrosis, as a rule, is an evidence of a constitutional disease of the blood, which, by soldiers generally, and especially at the years in which they take the field, is rarely to be found. But retardation of the consolidation of shot fractures must Hot be called pseudarthrosis." 2The other four instances of pseudarthrosis after expectant treatment were: 1. Pt. J. Jackson, Co. B, 15th AVisconsin, aged 46, wounded at Chick- amauga, September 19, 1863. Surgeon II. CULUEltTSON, U. S. V., at Harvey Hospital, Wisconsin, July 12, 18(14, notes: "Transverse fracture of right humerus below surgical neck; false joint at seat of fracture; external wound healed. Discharged September 20, 18G4," and pensioned. The pension reports which extend to January 2, 1874, make no mention of the pseudarthrosis. 2. Pt. R. II. Miller, Co. A, 25th Ohio, wounded at McDowell, May 8, 1862. Surgeon L. G. Myers, 25th Ohio, reported a "shot fracture of upper third of left humerus; general health good, but the fracture resulted in a false joint." 3. Sergeant J. D. Foulk, Co. A, 7th Iowa. Surgeon M. K. TAYLOR, U. S. V., noted: "Shot fracture of the lower third of the right humerus, resulting in a pseudarthrosis; discharged July 9, 18C3." 4. Private J. AV. Beaver, Co. G, 50th Indiana, aged 31, was wounded at Jenkins's Ferry, April 30, 1864, and taken prisoner; discharged May 30, 1865, and pensioned. Examiner J. Stillson, of Bedford, Indiana, reported, September 5, 1873: "He received a wound from an ounce ball which fractured the humerus in the lower third. The musculo-spiral nerve was severed; all its lower branches are paralyzed. Union has never taken place at the seat of fracture, but he has remaining a false joint with shortening of the liumerus. The arm hangs as a useless appendage." 85 674 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. rat us, which he is iioav wearing. He can Avrite with it, and do any kind of light work; Avithout it the arm is nearly useless. Up to the time that the wound became gangrenous the patient Avas in good condition, and the Avound seemed to do very well. After the gangrene the discharge Avas very profuse; a large abscess formed just above the Avound, and the patient became much debilitated." He Avas discharged from service on September 25, 1835, and pensioned. Examiner G. S. Jones, of Boston, March 29, 1836, certified: "The Avound was in the loAver third of the right arm. The humerus has been fractured and noAV remains ununited, thereby rendering the forearm nearly powerless and useless." Examiner G. T. Gale, of Brattleboro', Ver- mont, September 12, 1867, certified: "The fracture AAras folloAved by gangrene, resulting in large loss of muscle and non-union of bone. Forearm hangs loosely by his side, almost entirely useless. Wounds are noAV closed, but open occasionally. Has very little control over motion of forearm and hand." Examiner H. S. Noble, of Chester, Vermont, reported, on September 4, 1873 : "Nearly an inch of the bone is gone, and the upper and loAver fragments are united by ligament. The arm is practically useless for purposes of manual labor, being entirely flail-like, and capable of being twisted upon itself nearly one and a half turns." The disability Avas rated total. The pensioner Avas paid March 4, 1875. The old doctrine, that shot fracture of the humerus with wound of the brachial artery imperatively indicates amputation, is still earnestly maintained by Dr. Lceffler, though called in question by M. Legouest and others.1 Surgeon A. H. Hoff, U. S. V., warmly advocated attempts to save the limb under these conditions. Case 1628.—Private W. Lay, Co. F, 129th Pennsylvania, aged 21 years, Avas wounded at Fredericksburg, December 13, 1862, and admitted to the 3d division hospital, Fifth Army Corps, where Surgeon D. McKinney, 134th Pennsylvania, recorded: " Gunshot fracture of arm; bone adjusted." On December 17th, he was transferred to Mount Pleasant Hospital, at Washington. Assistant Surgeon C. A. McCall, U. S. A., reported: "Compound fracture of humerus, Avith wound of brachial artery, by conoidal ball. rlasmorrhage from the injured artery occurred on December 19th, 20th, and 21st, and was restrained by mechanical means and persulphate of iron. No ligation Avas performed, and no recurrence of hsemorrhage took place after the 21st." The patient Avas discharged from service on April 16, 1863, and pensioned. Examiner T. B. Smith, of Washington, D. C, April 17, 1833, certified: "Wound still discharging; partial anchylosis of left elbow joint; bone now united; health good; motions of shoulder and hand perfect; limb now useless." Examiner E. SAvift, of Easton, Pennsylvania, certified, on April 13,1864: "The arm can be flexed to a right angle Avith the humerus and extended to an angle of about forty-five degrees, &c." Examiner P. R. Palm, of Allentown, Pennsylvania, reported, on October 14, 1871: " There is considerable deformity of the limb, the arm being curved baclvAvard. The joint is someAvhat stiff, and the arm cannot be straightened, &c." On September 4, 1873, the last examiner again reported: " ElboAV joint partly anchylosed and deformed, &c." The disability was rated three-fourths. Pensioner has been paid to March 4, 1875. I confess that the evidence in this and three other reported cases2 appears to me insufficiently circumstantial and precise to decide affirmatively this controvered point. To avoid iteration, further comments on expectant conservative treatment of shot fractures of the humerus will be reserved for the concluding pages of this Chapter. 1 LOFFLER (F.) (General-Bericht, u. s. w., 1867, S. 179) contends that amputation of the arm is necessary in all cases in which the fracture of the humerus is accompanied by lesion ofthe brachial artery, and censures LEGOUEST (op. cit, p. 529,1st ed., p. 689), who observes: "Nous pensons que dans ci cas l'amputation n'est pas toujours indispensable. Si l'artere brachiale est les6e au-dessous des tendons des muscles grand-road et coraco-brachial, la grande artere collat6rale externe et la grande artere nourriciere de I'humerus restant intactes, retablissent assez facilement et assez rapideinent la circula- tion pour autoriser la conservation du membre. Si, au contraire, l'artere brachiale est ouverte au-dessous de l'origiue de ces vaisseaux, il vaut mieux pratiquer 1 amputation." Generalarzt LOFFLER states: "That up to the present time, as far as I know, the literature of military surgery does not present a single case of preservation of the limb after injury ofthe brachial artery with shot fracture of the humerus," and adds: "Even LEGOUEST does not cite a case; his indication is more the result of a priori calculation, and has the fault, moreover, that it omits a consideration of the highest importance to this class of injuries, the relations of the brachial veins, Avhich, at least in shot wounds, rarely remain uninjured when the artery has been struck. The mere contusion of the A'eins is sufficient to have considerable influence on the result of the injury." BILLROTH (Th.) (Chirurg. Briefe aus den Kriegs Laza- rethen, u. s. w., Berlin, 1872, S. 223) remarks: "Whether shot fractures of the humerus, with injury of the brachial artery, always result in gangrene, I am not able to assert, as the two cases, in which gangrene of the arm supervened, were not carefully examined. That secondary ligation of the brachial for shot fracture of the liumerus neither materially changes the circulation in the extremity nor obstructs consolidation, I have already stated." 2 Surgeon 1KA RUSSELL, U. S. A7., reports, from notes of Surgeon B. O. REYNOLDS, 3d Wisconsin Cavalry, the case of: 1. Lieut. N. Cole, 20th AVis- consin, Avounded at Prairie Grove, Arkansas, December 7, 1862: "Musket ball entered two and a half inches above right elbow joint, passed internally to tbe humerus, and made its exit posteriorly. Did well for seven days, when haemorrhage occurred, and was restrained by the tourniquet. Two days after ■ ward it again bled profusely, and I ligated the brachial artery three-quarters of an inch above its bifurcation, since which time the case has steadily improved." This officer was discharged and pensioned February 27, 1833. In 1868, Examiner L. D. MclNTOSH, of Sheboygan, reported: "Ball entered left arm, anteriorly, five inches below shoulder joint, and passed out opposite its entrance, severing the brachial artery and injuring the nerve. Secondary haemorrhage supervening, the artery was ligated. The humerus was fractured. There is partial anchylosis of the elbow joint, etc." In 1873, Examiner Hall reports: "Arm considerably wasted, with numbness of ulnar border of forearm and hand." 2. Examiner O. MARTIN reports the case of Sergeant F. XN. Briggs, 36th Massachusetts, wounded at Petersburg, June 17, 1864: " Ball hit an inch below coracoid process of right scapula, passed downward and outward, cutting off under side of neck of humerus, through the axilla, and out four inches below shoulder joint, on the back side of the arm. He was under my care for a long time, had gangrene and excessive haemorrhage, and it was thought it would be necessary to amputate at the shoulder. Now (February 1C, 1864) general health is good, shoulder stiff, bone diseased; no use of arm." 3. Pt. N. F. Huntley, Co. F, 5th Vermont, aged 35, was wounded at the AYildemess. May 5, 1864. Surgeon J. E. POMFRET, 7th New York Heavy Artillery, reported: "Severe wound of arm, with lesion ofthe brachial artery. Medical Director A. N. DOUGHERTY." The patient was discharged and pensioned February 22, 1865. Examiner C. PORTER, of Rut- land, certified. March 22, 1865: " Gunshot wound ofthe right arm on the inner side, about three inches above the elbow joint, ball passing obliquely upward and out midway between the elbow and shoulder, destroying the brachial artery and injuring the nerve." Dr. PORTER reported, in September, 1S73: ' 'A musket ball fractured the right humerus about three inches aboA-e the elbow joint." SECT. IV] EXCISIONS IN THE SHAFT OF THE HUMERUS. 675 Excisions in the Continuity of the Humerus for Shot Injury.—The cases returned under this head are very numerous, and probably many mere extractions of fragments have been improperly classified as excisions; but, making every allowance for erroneous returns, the number of formal operations is unpreccdentedly large; the entire number of operations comprised in the series is six hundred and ninety-six. Primary Excisions of the Shaft of the Humerus.—Oar surgeons evidently did not share the opinion of European authorities regarding primary excisions in the continuity, since nearly two-thirds of the operations belong to the primary group. § Cases of Recovery.—Three hundred and twenty-six such cases are reported. Case 1329.—Private C. AAr. C------, Co. E, 39th Illinois, aged 22 years, Avas Avounded at AVeirbottom Church, June 17, 1834. He Avas removed to the field hospital of tho Tenth Corps. Surgeon C. M. Clark, 39th Illinois, reported: ''Private Carpenter was wounded bya conoidal ball, which entered the right arm near the insertion of the deltoid muscle, passing obliquely backward and doAvmvard, and was cut out at the inner surface of the arm tAvo inches beloAV the point of entrance. The ball had extensively fractured the body of the humerus. Chloroform Ava3 administered and six inches of the bone were taken aAvay (leaving the periosteum) by a longitudinal incision. The bone removed included the portions taken from each end of the remaining humerus. The Avound Avas dressed in the usual manner, and the man put to bed in the provisional hospital, Avhere he remained under my care for the space of three Aveeks, the Avound healing rapidly. He Avas then sent to Chesapeake Hospital, remaining a short time, and subsequently to hospital at Willet's Point, NeAV York, Avhence he Avas discharged from service. Before leaving New York Dr. E. D. Hudson applied a supporting splint, which gave the arm its normal strength and use to a great extent. The case came under my observation again in April, 1867, at Avhich time the man Avas folloAving the occupation of ' expressman," and stated that he could use the arm about as Avell as ever. On examination of the arm after removal of the splint, I found the space formerly occupied by bone to be filled Avith a dense rounded mass of cartilage with some ossific deposits. He stated that the arm Avas not as firm as formerly because of an accident that he met with while leaping a fence, at Avhich time he fell, striking the elboAV of the injured arm and disrupting the tissue, which had become sufficiently firm to alloAV the raising of the arm from the shoulder without the appearance of any false joint, but noAV, on raising the arm, there Avas some bending. It Avas, however, groAving stronger, and he thought that he could soon dispense Avith the splint. He is at the present time, December, 1839, folloAving the occupation of a gardener, and makes good use of the arm." Dr. E. D. Hudson, of NeAV York,1 published the folloAving memoranda of the case: " Five months after the operation he was sent from De Camp United States General Hospital to me for final treatment. His arm Avas shortened one inch. Nature had reproduced about oue and a half inches, leaving a space of nearly tAvo inches. Arm very flexile, uncontrollable, someAvhat atrophied, and useless except to hold things Avhen the forearm Avas extended. With sustaining apparatus applied as a representative shaft of bone, and auxiliary straps of rubber Avebbing, he was able to control his arm and forearm, flex his forearm, lift Avith the forearm flexed, and Avill do good service. The appliance was efficient, and his arm Avill recuperate to a high and gratifying degree of usefulness." Examiner J. P. Lynn, of Chicago, February 27, 1863, reported: "He was struck by a ball in front, just beloAV the surgical neck of the humerus. It passed through, shattering the bone, four inches of Avhich were exsected. By an apparatus he wears he has a little use of the forearm." The Chicago Board, September 6, 1873, report: "Exsection of upper third of right humerus and anchylosis of Avhat remains at shoulder joint. Loss of muscular structure of upper arm equal to loss of limb." This pensioner Avas paid March 4, 1874. Case 1630.—Lieutenant J. Egan, Co. C, 2d United States Cavalry, aged 27 years, Avas Avounded at Cold Harbor, June 1, 1834. Assistant Surgeon J. W. Williams, U. S. A., reported: "A mini6 ball entered the upper third of the right arm, frac- turing the humerus to the extent of three inches. Resection was performed and all the pieces of bone Avere removed, Avith the exception of a large piece on the internal aspect, Avhich still preserved the length of the arm, and, from its intimate connection Avith the periosteum, Avas not likely to necrose. The operation Avas completed by smoothing the ends of the bone. Amputation Avas the preferable operation in this case, but the decided objection of the patient to losing his arm, and the situation of the internal fragment of bone decided the operation detailed above." The patient Avas transferred to Washington, and admitted into Stanton Hospital on June 4. Surgeon J. A. Lidell, U. S. V., reported: "Gunshot fracture of right humerus. Excision performed on field, of about two inches, by a straight incision through biceps muscle; ball extracted through place of entrance. Ice dressings and splints applied; tomes, stimulants, and saline cathartics prescribed." Surgeon B. B. AVilson, U. S. V., who was subsequently in charge of Stanton Hospital, performed an operation on March 14,1865, in connection Avith Avhich he reported the folloAving: " Entire bony union of humerus. A cloaca, one inch in diameter, formed on the external edge of the biceps and on a level with and just below the insertion of the deltoid. Cut down on the external edge of the biceps, enlarged the cloaca Avith bone forceps to the extent of three inches, and removed the necrosed portion of the humerus, three inches long. Cold-Avater dressings applied." The patient was, on April 20th, transferred to Annapolis Hospital, whence he returned to his command for duty on May 25,1865. In February, 1868, Lieutenant Egan Avas promoted captain. 'Hudson (E. D.), Save the Arm. Remarks on Exsection, with Cases and Plates, New York, 1865, p. 13. FIG. 505.—Apparatus in a case of excision of the shaft ot the humerus. [After Hudson.] 676 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX Table LVI. Condensed Summary of Three Hundred and Twenty-six Cases of Successful Primary Excisions in the Shaft of the Humerus after Shot Injury. 18 20 23 Name, Age, and Military Description. Abbott, J., Pt., I, 8th Ala- bama, age 23. Abbott, L. D., Corp'l, K, 38th Massachusetts. Ainsworth,M.V.B., Serg't, I, 74th New York. Albright, F., Pt., B, 20th Alichigan, age 28. Alberts, B., Pt., E, 10th New York Cavalry. Allen, AV. L., Pt., H, 1st Maine H. A., age 18. Amos, 1\, Lieut., H, 31st Iowa, age 34. Andrew, H., Corporal, K, 116th Ohio, age 22. Andrews, W. H., Pt., K, 13th Virginia. Ault, J., Pt.. C, 101st In- diana, age 28. Bachelor, T. C, Lieut., I, Tilth Indiana. Bagley, A., Pt., A, 19th Maine, age 36. Baker, J., Pt., I, 125th Ohio, age 18. Baker, L. S., Brig. Gen., age 31. Baldwin, AV., Pt., G, 8th Michigan. Ball, AV. M., Pt., H, 22d Kentucky. Banks, J. H., Corp'l, E, 13th Maine, age 27. Barber, A. D., Pt., K, 19th Ohio, age 19. Barnett, AV. B., Lieut., B, 97th Ohio, age 28. Barnhizer, J. D., Pt., E, 7th Michigan, age 18. Bausinger, C, B, 149th New York, age 20. Barnwell, B. T., Lieut. Confed. Navy, age 23. Bell. S. T., Pt., Co. K, 111th Penn., age 19. Oct. 27, 28, '64. Sept. 19, 19, 'C4. June 17, 17, '64. June 2, 2, '64. April 9, 9, '65. June 4, 4, '64. Aug. 24. 24, '64. June 1, 1, '64. July 3, 3, '63. Nov. 25. 25, '63. May 27, 27, '64. May 6, 6, "64. June 18, 18, '64. Aug. 1, 2, v63. Aug. 19, 19, '64. May 16, 16, '63. May 18, 21, '64. Sept. 2, 3, '64. June 22. 22, '64. Mav 12 12,"'64. July 2, 2, '63. Feb. 6, 7, '65. July 3, 4, "63. Bett, G., Pt., K, 5th New May 5, Jersey, age 25. 6, "62. Bennett, J., Pt., B, 23d May 22, AVisconsin, age 18. 22, '63. Jan. 15, 17, *65. 26 Berk. J. O., Pt., Co. A, 7th Connecticut, age 31. 27 Berrigan, E.. Pt., I, 32d Massachusetts, age 40. May 31 31, '04. Operations, Operator, Result. Left; three inches middle third. February 28,1865, union; entire recovery. Retired. Left. Discharged June 30, 1865; not a pensioner. Right; three inches lower third. Disch'd May 17, 1865. Limb shortened two inches. Right; four inches middle third; Surg. A\r. B. Fox, 8th Michigan. Discharged May 4, 1865. Right; two and a half inches middle third. Disch'd June 30, 1865. Arm shortened one inch and atrophied. Left; portion lower third. Dis- charged November 19, 1864. Right; two inches of upper third; Surg. G. L. Carhart, 3lst Iowa. Discharged February 2, 1865; good union. Left; two and a half inches lower third. Disch'd Feb. 14, 1865. Left; upper third. Nov. 12,1863, sent to City Point for exchange. Left; two inches. Dec. Sth, arm amputated one and a half inches below shoulder joint, by Surg. C. Sollheim, 9th'Ohio. Discl/d June 1, 1864. Left, Disch'd October 4, 1864. Artificial joint at upper third. Right; three inches: by Surg. G. Chaddock, 7th Mich. Disch'd March 1, 1865; no union. Left; middle third; by Surg. F. AV. Lytle, 36th Illinois. Duty April 10, 1865. Right; three iuches. Recovered.. -----; fragment at lower third. Discharged June 8, 1865. An- chylosis of joint. Right; upper third; by Surgeon B. F. Stevenson, 22d Kentucky. Duty November 28, 1863. Right; five inches middle third July, 1866, amputation at junc tion of upper and middle third by Dr. AV. H. True, of Freeport Maine. Right; two inches lower third by Surg. D. C. Patterson, 124th Ohio. Disch'd June 5, 1865. Right; lower third; Surg. E. B. Gliek, 40th Indiana; July 2Qth, amputation at upper third, by Act. Asst. Surg. L. E. Kelley. Resigned March 9, 1865; pen- sioned. Left; upper third; three inches; by Surg. G. Chaddock, 7th Mich. Discharged October 4,1864; pen- sioned; arm useless. Right; upper fourth; four inches; by Surg. J. V. Kendall, 149th N. Y. Vols. To V. R. C. Oct. 16, 1864, pensioned. Left; middle third; two inches excised. Released June 29,1865. Left; middle third; Surg. Geo. P. Oliver, 111th Penn. Mustered out February 27, 1865. Right; middle third; by Surg. C. AV. Horner, U. S. V.; April 11, 1863, amputated at upper third. Disch'd Oct. 1. 1863. Left; two inches of middle third; by Surg. J. AV. Angell, 23d Wis. Discharged August 19, 1865. Right; two inches; by Surg. G. C. JanMs. 7th Connecticut. Dis- charged July 6, 1865. Left; three inches excised. Dis- charged Jan. 18, 1865; pensioned. NO. 37 42 46 Name, Aoe, and Military Description. 50 Bishop, A. J., Pt., A, 27th Ohio, age 25. Bixby, C. F., Pt., M, 2d Cavalry, age 19. Blanchard, J., Pt., B, 10th Vermont, age 23. Book, E., Pt., D, 57th In- diana, acre 31. BohnsacW; H., Pt., F, 3d Mass. Cavalry, age 32. Boice, A., Corp'l, B, 91st Ohio, age 21. Bolger, M. J.,Pt., D,10th Ohio. Bostwick, E. M., Corp'l, H, 2d New York Cav- alry, age 19. Bratscher, G. AV., Pt., D, 19th Colored Troops. Brelsford, H. AV., Serg't, H, 80th Ohio. Bresler, H., Pt., E, 45th Pennsylvania, age 19. Brown, C. B., Pt., F, 3d New York, age 23. Brown, F., Pt., G, 114th Illinois, age 21. Brown, G. D., Pt., A, 184th Penn., age 21. Brown, J. R., Corp'l, A, 101st Illinois, age 20. Bryan, L. V., Corp'l, E, 8th Kansas, age 30. Bunker, n. AV., Lieut., H, 10th Iowa, age 23. Burroughs, H., Corp'l, I, 1st U. S. Sharpshooters. Burroughs, S. L., Capt., A,2d New York Cavalry, age 26. Bush, J. A., Serg't, D, 154th New York, age 30. Bymer, AV. H., Pt., H, 5th New York, age 21. -, J.B., C. S. A.. Sept.25, 25, '64. July 22. 23, '64. June 12, 12, '64. Nov. 27, 30, '63. Dec. 22, 22, '64. May 9, 11, '64. Aug. 24, 24, '64. Oct. 8, 11, '62. April 1, 1, '65. July 30, 31, '64. May 14, 14, '63. Oct. 11, 11, '63. Oct, 27, 27, '64. July 14, 17, '64. Nov. 26, 26, '64. July 24, 24, '64. Dec. 16, 16, '64. Nov. 25, 25, '63. July 2, 2, *G3. May 31 June 1, 1864. July 2, 2, '63. June 27, 27, '62. Operations, Operator, Result. Camp, J., Pt., E, 12th AVisconsin, age 30. Campbell, J. L., Pt., C, 9th New York Cavalry, age 26. Cantrell, J. L., Pt., A, 7th Texas, age 27. July 21 21, '64. May 8, 8, '64. N*ov. 29, 29, '54. Left; four inches of upper third excised. Disch'd May 12,1865; pensioned; arm useless. Left; five inches of middle third excised. Disch'd Jan. 12,1865; pensioned. Left; two and a half inches of mid- dle third excised. Discharged February 22, 1865. Left; three inches of upper third excised. Disch'd May 17,1865. Left; four inches of upper third; by Asst. Surg. C. H. Andrews, 128th New A'ork. Disch'd Jan. 30, 1865; pensioned. Right; four inches of middle third; bv Asst. Surg. J. B. AVarwick, 91 st Ohio. Discharged May 29, 1865; pensioned. Left; three inches of middle third excised. Discharged March 17, 1863; re-enlisted; mustered out August 28, 1866; pensioned. Left; three inches of middle third; by Surg. S. F. Kingston, 2d New York Cavalry. Disch'd Nov. 24, 1865; pensioned. Spec. 2431. Left; two and a half inches of up- per third; by Surg. J. S. Ross, 11th New Hampshire. Disch'd June 28, 1865; pensioned. Left; lower third; bvSurg. E.P. Buell, 80th Ohio. Discrfd Ooi 26, 1863; pensioned. Left; four inches of upper third excised. Disch'd Sept. 14,1864; pensioned. Right; three inches excised. De- serted April 28,1865; not a pen- sioner. Right; middle third; by Acting Asst. Surg. AV. D. Hall. Re- covered ; not a pensioner. Left; three inches of lower half; by Surg. G. Chaddock, 7th Mich. Disch'd June 19,1865: pensioned. Right; two inches of middle third; by Surg. H. K. Spooner, 61st Ohio. Discharged June 22,1865; pensioned; hand useless. Right; two and a half inches at middle third; false joint; arm useless. Disch'd April 18,1865; pensioned. Right; fourinches of middle third; by Surg. R. J. Mohr, 10th Iowa. JIustered out Oct. 11,1864; pen- sioned. Right; excision at middle third; by Surg. II. F. Lyster, 5th Mich. Discharged June 7, 1864; not pensioned. Left; middle third; by Surg. L. P. AVoods, 5th New York Cav. Disch'd Sept. 10,1864; pension'd. Right; fourinches of upper third; by Surg. H. A'an Aernam, 154th New A'ork. Discharged Jan. 30, 1865; pensioned. Right; four inches of upper third; by A. A. Surg. J. Swinburne. Discharged May 25, 1863: arm useless. Four inches of middle third; by Dr. A. Thompson, of Humboldt, Tenn.; "far better than no arm." Left; three inches of upper third; by Surgeon J. S. Reeves, 78th Ohio. Disch'd Sept. 20, 1865; pensioned. Left; four inches of upper half. Disch'd Jan. 30,1865; pensioned. Left; thieeinchesof middle third; by Surg. J.R.Crain, 7th Texas. To Provost M irshal Jan. 7, I860. SECT. IV.] EXCISIONS IN THE SHAFT OF THE HUMERUS. 677 Name, Age, and Military Description. Carpenter, C. AV., Pt., F, 39th Illinois, ago 22. Carpenter, AV. P., Pt., D, 101st Indiana, age 21. Carrtr, A. R., Lieut., B, 56th N. Carolina, age 36. Carroll, M., Corp'l. C, Sth A'irginia. Carter, H. AV., Pt., D, 8th N.Y. Hea\'yArtillery. Cary. M. L., Serg't, C, 1st Rhode Island Cavalry, age 25. Carver. B., Serg't. -A, 142d New York, age 27. Childs.H.F.,Pt.,G, 95th IUinois, age 22. Chrispin. G., Pt., C, 10th Pennsylvania Reserves, age l'J. Churchill, AV. S„ Pt., C. 20th Connecticut, age 20. Clark, C. AV., Lieut., I, 6th Iowa. June 17, 17,'64. June 27, 27, '64. May 13, 13, 'CI. Mav -, -, '61. Juno 3, 3, '64. Sept. 14 14, '63. Sept. 29, 29, '64. June 17 18, '64. Mav 8, 8, '64. July 20, 20, '64. Aug. —, 18b4. Clements. D., Pt.. F. 11th May 16. Connecticut, age 22. Coffman, F., Pt., I, 20th Massachusetts, age 21. Cole. A. A*., Corp'l, G, Gth Michigan Cavalry, a^e 22. Collins. N. B., Serg't, A, 11th New Hampshire, age 33. Col well. W.,Pt., A, 146th N ;w A'ork, age 25. Conklin, L. D., Pt., C, 137th Xew York, age 35. Conway, M., Lieut., E, 173d New York. Cox, C, Serg't, G, 39th Illinois, age 27. Cox, J., Pt., H, 26th Illinois, age 21. Crandall, B., Pt., K, 81st New York, age 25. Crossman, S. H., Pt., D, 15th Michigan, age 18. Culbertson, S., Pt., XI. 3d Penn. Cavalry, age 22. Daily, R. H., Pt., G, 63d Pennsylvania, age 17. Davis, C, Pt., G, 1st X. York Dragoons, age 2.3. Davis, J. £., Pt., B, 18th South Carolina, age 34. Davidson, H., Pt., B, 12th Mass. April 26 26, '64. May 28, 28. '64. Mav 12. 12,*'64. May 1, 1, '63. Oct. 29, 29, '63. June 14, 1863. Oct. 27, 28, '64. Nov. 25, 63. Pri mary. July 2, 2, '64. July 22, 22, '04. Sept. 13, 13, '63. May 8, 8, "64. May 31 31, '64. Mar. 29, 29, '65. Sept. 17, 17, *62. Operations, Operator, Result. Right; four inches of middle third; by Surg. C. M. Clark, 39th 111. Discharged December 8, 1864. Left; three inches: bv Surg. C. X. fowler, 11151 Ii Ohio. Disch'd June 12,180.7. 1 Hed.AIuv '.8,1*70. Two inches of middle third. Fur- loughed July 29, 1864. Four inches of middle third; by Surg. Kennedy, C. S. A.; doing well .May 24, it>IM. Left; three inches of upper third; by Asst. Surg. F. P. Casey, 8th N. Y. Heavy Artillery. Disch'd June 13, 1865: pensioned. Four and a half inches of upper half. Discharged December 24, 1863; pensioned. Right; two and a half inches; by Surg. 1). McFulls, 142d N. York. Disch'd Jan. 4, 1865; pensioned. Left: two inches of lower third; by Acting Ass't Surg. S. S. .les sop. July 23d, amputated at middle third, bv A. A. Surg. It. AV. Clark. Diseh'd Jan. 26, 186.7. Kiirht: middlcthird: livAss't Sur-. I!. Howard. V. S. A*. Mistered out July 18. i860; pensioned. liight: portion of the upper third. Disch'dJunelJO, 1865; pensioned. Left; two and a half inches of middle third: by Surgeon J. II. Hutchison, 15th*Mich. Disch d Dec. 24, 1804 ; not a pensioner. Right; one and a half inches of lower half. To V. It. C. April 23, 1865; not a pensioner. Left; two and a half inches of mid- dle third; by Ass't Surg. J. G. Perry, 20th Mass. Disch'd July 16, 1865; not a pensioner. Left; three inches of upper third. Disch'd July 6,1865; pensioned. Left; five inches of middle and lower third; by Surg. J. S. Ross, 11th Xew Hampshire. Disch'd July 3, 1865; pensioned; hand useful. Right; three inches upper third; by Ass't Surg. B. Howard, U. S. A. Diseh'd July 4, 1863; pen- sioned; arm useless. Left; two inches at middle third; by A. K. Fifield, Surg. 29th Ohio. Disch'd May 8,1865; pensioned. Right; three inches lower third. Disch'd October 18, 1865; arm useless. Left; eight inches upper third; by Surg. C. M. Clark, 39th Illinois, and N. Y. Leet, 76th Penn'a. Disch'd JuneS, 1865; pensioned; arm serviceable. Right; four inches lower third. Disch'd July 8,1864; pensioned. Left; upper end of shaft turned out and sawed off square; by Surg. A. D. Palmer, 9th Maine. Disch'd April 1,1865; pensioned. Left; two inches of shaft; by Surg. J. H. Hutchinson, 15th Michigan. Disch'd June 7,1865; not a pen- sioner. Left; three inches upper third. Mustered out August 24, 1864; pensioned. Left; one inch upper third; subse- quent excision, May 26th, of head and portion of upper third, by Surg. It. B. Bontecou, U. S. V.; cannot elevate arm or use shoul- der in any way. Phot. Arol. 2. p. 9. Left; four inches of shaft, middle third. Discharged Jan. 5, 1865; pensioned. CardPhot.Vol.Q,p.9. Right: three inches of shaft, mid- dle third; by Ass't Surg. T. E. Nott. 18th S*. Carolina. Sent to Fort Mcllenry May 9, 1865. Left: twoinches: by Brigade Sur- geon A. L. Cox, U. S.A". Diseh'd Jan. 11.1863; pensioned; ''arm in very bad condition. ' Name, Age, axd Military Descru'tion. Daw, J., Pt., K, 22dMich- igan, age 24. Delp, E. J., Lieut., I, 5th Indiana Cavalry, ago 23. Demo, M., Pt., A, 14th New York Heavy Artil- lery, ago 16. Divine, AV., Pt., F, 62d Pennsylvania, age 20. Doner, J., Pt., C, 40th New York, age 21. Donehoo, II. M., Captain, 15,17th Pa. Cav., ago 29. Donnelly, J., Corp 1, D, 20th Mass. Dorsoy, E., Pt., C, 1st Colored Troops, age 32. Drake, D. T., Pt.. E, 100th Indiana, age 47. Drake,.!.. Pt., B, 2d N.Y. Mounted Rifles, age 31. Drake. R. P., Corp'l. K, 59th Illinois, age 22. Earle, F. W., Pt., G, 3d Arkansas, age 26. Egan, J., Lieut., C, 2d Cavalry, age 27. Eislinger, F., Pt., A, 40th New Jersey, age 20. Ellis, L. S., Pt., G, 105th Illinois, age 22. Engle, C. V., Serg't, K, 82d Ohio, age 23. Ent, M. R., Serg't, B, 79th Ohio, age 19. Entler, D. M., Pt., B, 2d Virginia, age 28. Evans, A. H., Pt., C, 44th Illinois, age 39. Farrington, G. M., Lieut., H, 35th Mass., age 30. Fernan, J. F., Corp'l, E, 63d Ohio. Finley, J. H., Pt., G, 2d Illinois CaA'alry, age 19. Flemming,E.,Pt,,A,152d New York, age 10. Flynn, II. J., Pt., M, 1st Vermont Cav'y. age 18. Force, C. A., Pt., K, 60th New York, age 20. Foss, G. A., Serg't. A, 1st AVis. Cav., age 29. Foster, J. M.. Corp'l, F, 37th Mass., age 23. Fowler. T. S., Lieut., D, 77th New York, age 23. Fox, J., Pt., B, 8th Ver- mont, age 24. Frazier, I., Pt., C, 24th Texas, age 23. Fred, AV. H., Pt., G, 70th Indiana, age 22. Sept. 20 20, '63. Dec. 14, 14, '63. July 30 30, '64. May 5, 5, ,64. April 6, 7, '65. April 1, 1, '65. May 18, 18, '64. Sept. 29, 30, '64. Sept. 3, 3, '64. June 1, 1, '64. Dec. 16, 16, '64. Sept. 1, 1, '64. June I, 1, '64. April 2, 2, '65. July 3, 3, "64. July 20, 21, '64. July 23, 23, '64. July 2, 3, r63. Mav 27, 27,*'64. Sept.30, 30, '64. Aug. 16, 16, '63. May 29, 29, '64. Aug. 25, 26, '64. Nov. 22, 22, '64. July 25, 25, '64. May 24, 24. '64. April 6, 6, '65. May 10, 10, '64. June 14, 14, '63. Nov. 30, 30, '64. May 15, 15, '64. Operations, Operator, Result. Left; four inches middle third. Disch'd June 2,1864; pensioned, false joint. Left; portion at upper third. Re- signed Aug. 1, 1864; pensioned. Left; two and a half inches at middle third; by Surgeon T. F. Oakes, 56th Mass. Disch'd Nov. 9, 1864; pensioned. Left; two inches: bv Surg. J. Kerr, 62d Penn. Disch'd July 13,1864; pensioned; arm useless. Left; one and a half inches upper third. Disch'd Dec. 4, 1865; pensioned. Right; middle third. Duty May 10, 1865; pensioned. Right; one inch middle third: by Surg. N. Hayward, 20th Mass. Disch'd June 9,1805; doing well. Left; three inches upper third. Disch'd April 1,1865; pensioned. Right; three and a half inches at middle third; by Ass't Surg. D. Halderman, 46th Ohio. Disch'd Feb. 25, 1865; pensioned. Left; four inches of middle third. Disch'd Mar. 30.1805; pensioned. Right; three inches middle third. Disch'd Sept. 14, 1865; loss of use of arm. Left; portion of shaft at upper third; by Surg. Gold, C. S. A. Sent to prison at St. Louis. Right; portion of upper third: by Ass't Surgeon J. AV. AViliiams, U. S. A. Duty May 12, 1865. Left; excision at middle third. Disch'd Sept. 7,1865; not a pen- sioner. Right; excision at upper third. Disch'd June 7,1865; pensioned. Right; four inches at junction of lower and middle thirds; by Surg. C. AV. Myers, 82d Ohio. Disch'd Dec. 27, 1864 ; false anchylosis; pensioned. Right; three and a half inches up- per third. Disch'd Feb. 17,1865; pensioned; anchylosis of elbow joint. Left; three inches in lower third. Exchanged Sept. 22, 1863. Right; one and a half inches at lower third; bv Surgeon AAT. P. Pierce, 88th Illinois. Disch'd Feb. 15, 1865; pensioned; arm useless. Left; four inches of upper third; by Surg. G. AV. Snow, 35th Mass. Disch'd Jan. 13,1865; pensioned; arm unfitted for manual labor. Left; four inches and twelve frag- ments of upper third. Disclrd October 29, 1863. Right; four inches of middle third; by Surg. J. B. Cutts, 2d Rlinois Cavalry. Disch'd Oct. 6, 1864; pensioned: arm useless. Right; portion of upper third. Discharged January 7, 1865. Left; two and a half inches of middle third. Disch'd Aug. 24, 1865; not a pensioner. Right: three inches middle third; by Surg. J. Reily, 33d Xew Jersey. Disch'd Aug. 31, 1865; ann amputated, by Dr. J. S. Greene,of Pottsville, Iowa; pen- sioner. Spec. 1805. Left; excision lower third. Mus- tered out Sept. 1,1864; pensioned. Left; two inches at upper third. Diseh'd Oct. 14,18G5; pensioned; arm powerless. Left; three inches at junction of upper and middle thirds. Dis- charged Aug. 12,1864; pensioned. Left; two inches middle third. Disch'd Dec. 28,1863. Died 1871. Left; excision of two inches of the shaft, by Dr. Lawrence. To Pro- vost Marshal January 3. 186-7. Right; resection at middle third; by Surg. J. Reily, 33d N. J. Discharged March 18, 1835. 678 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. NO. Name, Age, and Military Description. 112 114 115 116 117 118 119 121 122 123 124 125 126 127 128 129 130 131 132 133 135 136 137 138 Fulton, AV. J., Serg't, H, 2d Penn. Reserves. Furber,F.B.,Pt., H,19th Maine, asre 39. Gallagher,AV.,Pt.,K, 6th Iowa, age 25. Gardner, H., Serg't, I, 1st Rhode Island CaA'alry, age 22. Gardner, S. A., Pt., B, 124th Ohio, age 22. Gear, S., Corp'l, H, 49th Ohio, age 19. Gibbs, It. J., Pt, E., 6th Penn. Cav., age 21. Giffard, O. F., Pt., I, 83d Penn., age 22. Giles, R. S.. Serg't, K, 146th N. Y., age 23. Gilman, S. T., Pt., A, 5th Maine, age 30. Ginther, S., Pt., D, 88th Indiana, age 17. Gcebel, C. H., Captain, D, 73d Penn., age 23. Gordan, J. U., Pt,, K, 55th Penn., age 17. Gore, J. M. L., Serg't, C, 13th Ohio Cav., age 28. Gould, C. M., Corp'l, E, Cist Penn., age 27. Graham, C. E., Pt,, G, 141st New York, age 22. Graham, J. M., Major, 7th Illinois Cav., age 38. Grant, A. H., Pt., K, 5th Iowa, age 21. Griffin, A., Pt,, D, 62d Pennsylvania, age 25. Griffin, J., Pt., A, 3d N. A'ork Artillery, age 19. Griffith, R. C, Pt., C, 117th New York, age 23. Haley, E., Pt., K, 69th N. Y'ork, age 31. Halsey, C. A., Pt,, A, 36th Illinois, age 26. Hann, II. IL, Pt., E, 1st Maine Cav., age 19. Harding, T., Pt., K, 38th AAlsconsin, age 25. Harrison, AV. IL, Serg't, K, 28th Penn., age 23. Hart, J. G., Pt., I, 20th Illinois, age 18. Harvey, AI., Pt., G, 9th Mich. Cav., age 44. Dates. Sept. 17, 20, '62. May 6, 6, '64. June 27, 27, '64. Oct. 14, 17, '63. May 27, 30, '64. Dec. 16, 16, '64. May 31, 31, '64. June 27, 30, '62. June 1, 1, '64. June27 28, '62. May 13, 14, '64. Nov. 25, 25, '63. Mar. 31, 31, '65. April 9, 9, '65. May 12, 12, '64. July 20, 21, '64. Dec. 16 16, '64. Nov. 25, 25, '63, May 5, 6, "64. Mar. 10 11, '65. Sept. 29 29, '64! June 16 16, '64. May 26, 26, '64. May 7, 1864. Mar. 4, 4, '65. July 20 20, '64. May 12 12, '63. Sept. 13 15, '64. Operations, Operator, Result. Left; four inches at middle third; by Surg. B. A. A'anderkieft, U. S. V. Disch'd Dec. 20, 1862; pensioned; arm useless. Right; three inches of lower third; by Surg. S. H. Plumb, 82d N.Y. Discharged May 15, 1865; disa- bility three-fourths. Left; fourinches of shaft; by Surg. J. II. Hutchinson, 15th Michigan. Amputation, by Surgeon M. K. Taylor, U. S. V. Disch'd July 26, 1865; pensioned. Left; excision at upper third, by Surg. Edwin Bentley, U. S. V. Discharged February 16, 1864. Right; one and a half inches of upper third; by Surgeon D. C. Patterson, 124th Ohio. Disch'd March 27, 1865. Right; two and a half inches at middle third. Disch'd June 27, 1865; pensioned; died March 2, 1870. Left; three inches at middle third. Duty Oct. 24, 1864; pensioned. Left; resection two inches from shoulder, by A.A.Surg. J. Swin- burne. Disch'd Jan. 16, 1863; " arm useless for labor." Right; two inches of lower third; by Surg. T. M. Flandrau, 146th N. Y. Disch'd Jan. 9,1865: arm amput'ed four years after injury. Right; excision of lower third, by Surg. G. E. Brickett, 5th Maine. Amputation at shoulder joint, by A. A. Surg. B. B. Miles, Aug. 17th. Disch'd Oct. 6, 1862. Left; one and a half inches at the lower and middle thirds. Dis- charged Feb. 21, 1865. Left; three inches of middle third. Returned to duty; mustered out July 14, 1865. Left; five inches at middle third; by Surg. C. M. Clark, 39th Illi- nois. Disch'd July 22, 1865. Right; two inches at junction of middle wit h lower third; by Surg. F. LeMayne, 16th Penn. Cavalry. Disch'd May 31,1865. Right; excision of portion at lower third. Disch'd Sept. 7, 1864. Left; twoandahalf inches middle third, by Ass't Surg. M. T. Bab- cock, 141st N. Y. Disch'd July 15, 1865. Right; four inches at upper third; by A. A. Surg. J. A. Hall; arm very useful. Disch'd Nov. 4,1865. Left; excision of fractured portion at upper third, by Surg. E. J. Buck, 18th AVisconsin. Disch'd July 30, 1864. Right; three and a half inches of shaft. Disch'd Feb. 25, 1865. Left; two inches of fractured por- tion ; amputation at middle third, by A. A. Surg. T. L. Van Nor- den. Disch'd Oct. 21,1865. Left; two inches of upper third. Disch'd April 26, 1865. Right: portion of humerus excised, by Surgeon P. E. Hubon, 28th Mass. Disch'd Nov. 15, 1864. Left; three inches of middle third; by Surg. B. G. Pierce, 96th Illi- nois, and H. E. Hasse, 24 th Wis. Returned to duty Sept, 22,1864. Left; four inches at lower third. To V. R. C. April 13,1865; pen- sioned ; died Oct. 17, 1874. Right; one inch at upper third. Disch'd June 19, 1865. Phot. Left; five inches in middle third. Disch'd Aug. 21, 1865; arm use- less; died Sept. 17, 1866. Left; two inches middle third; bv Surg. A. H. Brundage, 32d Ohio. Disch'd Nov. 22, 1863; limb useless. R ight; three inches at middle third; bv Surg. J. H. Rodgers, 104th Ohio. Disch'd Sept. 1, 1865; arm useless; died. 165 Name, Age, and Military Description. Heard,AV.,Pt.,A,40thUl. Heath, C. AV., Pt., H, Cth Indiana, age 28. Heck, H., Pt., I, 5th N. Y. Cavalry, age 29. Hedrick, T. H., Capt,, K, 15th Iowa, age 23. Heller, D., Pt., H, 51st Indiana, age 38. Henry, N., Corp'l, F, 24th N. Y. Cavalry, age 31. Hess, V., Serg't, A, 5th Ohio, age 22. Hetts,C.,Pt.,B, 7th Mich. Hiestand, I. H., Sergt., C, 23d Indiana. Hillman, A., Pt., I, 16th Penn. Cav., age 23. Hinspeter, J. G., Pt., C, 59th New Y'ork. Hintz, 0.,Pt.,A,lstTexas Cavalry, age 23. Hilton, F, I., Pt., M, 13th Penn. Cav., age 20. Hoadley, J. J., Pt,, K, 14th Conn., age 29. Bookings, J., Pt., M, 1st Mo. Engineers, age 48. Hodgdon, T. F., Corp'l, B, 20th Maine, age 23. Hodgman, J., Pt., E, 15th New Hampshire. Hally, L., Pt., E, 42d Ohio, age 20. Holly, R. B., Pt., D, 39th Indiana, age 30. Hoover, J., Pt., F, 2d Penn. Reserves, age 25. Hopkins, E., Pt., H, 14th New York Heavy Artil- lery, age 18. Hopkins, G.F., Cerp'l, H, 19th Maine, age 26. Homing, G., Pt., II, 8th Penn. Cav., age 23. Howard, D. D., Corp'l, B, 48th Miss., age 41. Humphreys, T., Pt., D, 5th Michigan, age 23. Hunter, J., Pt,, A, 12th AVisconsin, age 45. Hutchinson. S. A., Serg't, Nov. 25, D, 93d Illinois, age 23. Prim'ry, 1863, Dates. June27, 27, '64. May 27, 29, '64. Oct, 19, 20, '64. July 22, 22, '64. Dec. 6, 6, '64. June 21, 21, '64. May 3, 3, "63. June 22, 22, '64. May 1, 1, "63. April 22, 22, '64. May 12, 12, '64. June 6, 9, '64. May 30. 30, '64. Mar. 25, 25, '65. July 30, 30, '64. May 5, 6, "64. June 14, 14, '63. May 25, 25, '63. July 19 19, '63. Jan. 24 24, '64. July 30 30, '64. May 6, 8, "64. Oct. 12, 14, '63. July 3, 3, '63. July 2, 2, r63. Julv 28 29, "'64. Operations, Operator, Result. Left; two inches at junction of the middle and lower thirds; by Surg. AV. Graham, 40th Illinois. Discharged August 14, 1864. Excision of three inches at middle third, by Surg. H. B. Tuttie, 89th Illinois. Mustered out Sept. 22,1864; no power to flex forearm. Left; excision of portion of shaft at middle third. Disch'd Jan. 10, 1865 ; not a pensioner. Right; two inches of upper third. Discharged Feb. 8, 1865; arm shortened two inches. Right; four inches at upper third. Disch'd May 24,1865; pensioned; arm useless. Left; three inches of middle third. Discharged Jan. 30, 1805; false joint; good use of hand. Left; excision of most of surgical neck, by Surg. J. E. Herbst, U. S. V.; remoA-al of half inch of bone and nearly whole circum- ference of humerus subsequently. Disch'd July 1,1864. Spec. 1154. Right; excision of lower third, by Surgeon G. Chaddock, 7th Michigan; amputation of arm July 29th. Discharged June 16, 1865; pensioned. Right; resection at upper third. Discharged November 25, 1863. Right; excision at middle third. Disch'd Feb. 1, 1865; pension claim rejected. Left; excision of middle third, by Surg. S. H. Plumb, 82d N. Y.; amputation of arm May 21,1834. Mustered out August 27, 1804; pensioned; died Mar. 10, 1871. Right; four inches just below sur- gical neck; by Asst. Surg. A. E. Carothers. Disch'd Nov. 26, 1864 ; arm very useful. Right; one inch at lower third; amp., July 6th, upper third, by Surg. N. R. Moseley, U. S. V. Disch'd Sept, 24,1864; pension'd; died Sept. 1,1871. Spec. 2817. Left; fourinches at upper third; by Surg. S. H. Plumb, 82d N. Y. Discharged August 4, 18C5. Right; excision of portion at lower third. Mustered out February 6, 1865; not a pensioner. Right; fiAfe inches at upper third; by Surgeon J. Kerr, 62d Penn. Disch'd June 14,1865. Left; resection at middle third. Mustered out August 13, 1863. Excision of four inches from mid- dle and upper thirds, by Surg. B. F. Stevenson, "2d Kentucky. Returned to duty Jan. 24, 1864; perfect motion of joint. Left; two and a half inches at middle third. Discharged Oct. 14,1863. Drowned Mar. 12,1864. Excision of one inch in middle third. Feb. 12th, amputation of arm. Disch'd July 14, 1864. Left; two and a half inches at mid- dle third; b'y Surg. J. Oliver, 21st Mass. Disch'd Oct. 21, 186.7. Right; four inches of lower por- tion of upper and upper portion of middle thirds; by Surg. G. Chaddock, 7th Mich. Disch'd Feb. 20, 1.805; some atrophy. Left; one inch excised, by A. A. Surg. A. Hartsuff. Discharged Sept. 4, 1864. Left; four inches remoA'ed four inches from the shoulder. Fur- loughed Oct. 12, 1863. Left; excision at middle third. Disch'd Oct. 1, 1864. Left; two inches at upper third; by Surg. H. McKennan, 17th AVisconsin. Discharged May 26, 1865; pensioned; arm partially useless for manual labor. Right: four inches of upper third. Disch'd Aug. 18. 1864; arm en- tirelv useless. Died Mav 17,1869. SECT. IV.] EXCISIONS IN THE SHAFT OF THE HUMERUS. 679 Name, Aoe, and Military Description-. 16GI Israel, J.,Pt., B,62dPenn., I age 23. A"il i Ives, A.. Corp'l, K, Cth I Penu. Reserves, ago 19. 173 J------,JohnA.,C.S..\. J-----, -,C. S. A--- John. Z. AV., Pt., A, 7th Iowa, age 20. Johnson, AV. S, Capt., M, 1st Arkansas Cavalry. Jones, A., Pt., F, 112th New York, age 24. Jones. H. T., Serg't, H, 6th 111. Cav., age 22. Jordan, S., Pt., M. 62d Pennsylvania, age 18. Judd, M., Pt.. B, 13th Kentucky, age 22. Kanouse, L. C. Lieut., D, 6th Michigan Cavalry. Keller, J., Pt., C, 1st Tex. Cavalry, age 40. 178 Kelley. J., Pt., G. 5th U. S. Cavalry, age 33. 179 Keleher. S.. Pt., K, 28th Kentuckv, age 24. Kellum, I., Ft., B, 97th Indiana, age 25. Kemp, J., Lieut., G, 66th Indiana, age 35. Kibler, J. E., Pt., C, 76th Ohio, age 20. Kilbourne, L., Pt., C, 8th Michigan, age 30. King, L. A., 2d Lieut., F, 16th Kentucky, age 25. Kline, L. E., Pt., C, 33d Missouri, age 21. Klngh, J., Capt., 1, 209th Pennsylvania, age 47. Knapp, A., Pt., B, 137th New York, age 25. Lacy, H., Pt.. I. 4th Geor- gia, age 21. Lake, H., Pt., B, 1st New Jersey Cav., age 28. Lanies, W. E , Pt., K, 3d North Carolina. Laughran, P., Pt., C, 35th New Jersey, age 33. Lauson, G., Pt., A, 28th Massachusetts, age 38. Leed, T. F., Pt., A, 99th Pennsylvania, age 23. Legacy, J., Pt., G, 9th Maine, age 30. Lemmell, J., Pt., I, 5th AVisconsin, age 40. July 2, 3, '03. July 3. 3, '63. July 20, 20, '64. May 15, 19, '64. Aug.lt), 10, '04. April 18, 19, '03. June 1, 1, '64. Aug. 13 16, W. Jlav 13 14,"'64. May 13, 13, '64. Sept. 19 19, '64. June 6, 9, '64. Sept. 19 20, '64. June 27, 27, '(14. July 16, 16, '63. May 27 27, '64. May 14 14, '64. Aug. 3, 4/64. June 6, 6, '64. Mar. 25, 26, '65. Oct. 28, 30, '63. Sept. 19, 19, '64. May 5, 5, f64. Sept. 19 19, '64. Oct. 23, 28, '63. May 6, fi, f64. Dec. 13 13, '62. Sept. 29 30, '64. April 2, 3, '65. Oteuations, Operator, KKS6I.T. liight; one and n half inchcslowcr third. Disch'd July 13, 1864 ; union of parts firm. Left; four inches middle third; by Surg. ('. Bower, 6th Penn. Reserves. To V. K. C. Nov. 19, 1863; ligamentous union. Six and a half inches upper third; by Dr. Roan. Arm serviceable. Three inches lower third; arm of no service. Right; five inches middle third ; by Surg. AA'. K. Marsh, 2d Iowa Diseh'd Jan. 20, 186.7; paralysis. Right; four inches upper third; by Asst. Surg. J. V.. Tcil't, 1st Ark. Cav. To V. R. C. Sept. 30, 1863. Phot. Series, No. :i.73. Right; four inches upper third. Disch'd Oct. 21, 18G5; did well. Spec. 289. Right; three inches upper third; by A. A. Surg. H. \V. Coale, U.S.A. Disch'd April 7, 1865; arm powerless. Left; small portion lower third; by Surgeon J. Kerr, 62d Penn. Disch a July 24,1865; pensioned; bone ununited; false joint. Right; five inches middle third; by Surg. J. AV. Lawton, U. S. V. Discharged February 16, 1865. Left. Mustered out; recovered. Left; three and a half inches at junction of the middle and lower thirds ; by Asst. Surgeon A. E. Carotheis, U. S. V. Discharged July 14,1865; arm firmly united. Right; four inches upper third ; by Asst. Surg. AAr. S. Newton, 91st Ohio. Discharged April 17, 1865; no union. Left; three inches upper third; by Surg. E. B. Gliek, 40th Ind. Discharged May 27,1865. Right; four inches upper third; by Surg. AV. H. Leonard, 51st N. Y. Disch'd May 31, 1864 ; loss of use of forearm; pensioned; died July 12, 1874. Left; four inches; by Surg. A. F. Marsh, 56th III. Disch'd Jan. 13, 1865; no union; arm useless. Left; three inches lower third; by Surgeon G. L. Carhart, 31st Iowa. Disch'd Oct. 4, 1864 ; no bony union. Right; five inches middle third; by Surg. S. S. French, 20th Mich. Disch'd Nov. 14,1864; arm useful. Left; two inches middle third; by Surg. AV. H. Mullen, 12th Ken- tucky. Disch'd March 9,1865. Right; two inches middle third. Disch'd Dec. 11,1865; pensioned; arm useless; necrosis. Right; two inches middle third; by Surg. AV. G. Hunter, 211th Penn. Disch'd May 15, 1865. Right; two inches lower third. Disch'd Dec. 3, 1864. Left; four inches; by Surgeon A'oung, 4th Georgia. To Fort McIIenry Feb. 16, 1865; favor- able. Right; three inches upper third; amp. Disch'd Sept. 24, 1804. Four inches. Deserted October 25, 1864. Right; at upper third. Disch'd Aug. 27, 18G5; pensioned; arm useless for manual labor; died Feb. 15, 1870 ; cause unknown. Right; five inches middle third. Disch'd April 1,1865; pensioned. Left; three inches. Discharged April 22, 1863; false joint; died Oct. 26, 1865. Left; four inches middle third. Discharged February 8, 1805, andpensioned; partialuseof arm. Left; two inches middle third; by Surg. G. D. AVilber, Sth AVis. Disch'd Oct. 16,1865; interspace one inch. Name, Ace, and Military Description. Leonard, C. A., Pt., A, 20th Massachusetts. Lcrmond, F. B., Adjutant, 103d Illinois. Lillard, 77. C, Pt., (I, 45th N. Carolina, age 20. Linthurst, J. P., Pt., B, 12th Penn., ago 2ii. Locker, H. E., Serg't, G, 190th Penn., ago 20. Love, C., Pt., A, 20th Maine, age 19. Luther, F. C, Pt., F. 1st N. Y. Dragoons, age 25. Lynch, C, Pt., G, 73d New York, age 20. Mack, C. L., Pt., H, 89th New York, age 40. Marsh, H. A., Pt., B, 32d Iowa, age 20. Marshall, D., Lieut., E, 3d N. Hampshire, age 24. Mason, W. A., Pt., C, 2d Arkansas, age 24. Massey, AV. T., Pt., I, 7th Illinois. McCue, J. D., Pt., E, 8th Illinois, age 22. McDonald, A.D. J.,Lieut., C, 108th N. Y., age 33. McGarrity, J., Pt., F, 96th Pennsylvania. Mclntyre, J., Pt., G, 2d Michigan, age 33. McLachlan, E., Pt., K, 89th Illinois, age 39. McNaughton, P., Lieut., H, 151st N. Y., age 23. Meisner, C, Pt., B, 7th N. Y. Heavy Artillery, age 22. Merrill, E. J., Capt,, G, 17th Maine, age 37. Metzler, G. M., Pt., H, 30th Iowa. Miller, J. H., Serg't, C, 36th Mass., age 32. Mills. A.R., Pt., E, 39th Iowa, age 35. Moffat, R., Serg't, K, 121st Pennsylvania, age 23. Montairue, B. ]L, Serg't, F, 36th Mass., age 3'J. July 3, 4, '63. Mar. 21 21, '6.7. Mar. 26, 6, '63. Sept. 17, 20, '62. Feb. 6, 6, '6.7. July 2, 2, '63. Sept. 19. 19, '64. May 6, 7, *64. April 2, 3, '65. May 18 18, '64. Jan. 15, 15, '65. Nov. 30 Dec. 1, 1864. Oct. 5, 5, '64. April 9, 9, '65. July 2, 5, '63. June 27, 27, '62. Nov. 24, 24, '63. June 25, 26, '63. Julv 9, 12, "'64. May 12 15, '64. Mav 3, 3. '63. June 15, 15, '64. June 3, 4, '64. Oct. 5, 6, '64. July 15, 15, '64. June 3, 4, '64. Operations, Operator, Result. Left; portion of the upper third. Discharged July 25, 1864, and pensioned; arm nearly useless. Right; two inches lower third; by Surg. R. Morris, 103d Illinois. Disch'd June 21, 1865; use im- paired. Left; three inches middle third; by Surgeon T. F. Oakes, 56th Mass. Released June 11, 1865; favorable. Three inches middle third. Dis- charged April 7,1863; no union. Right; three inches middle third; by Surg. H. Bendoll, 86th N. Y. Discharged October 13, 1865. Right; three inches middle third. Discharged March 21, 1865. Right; two inches lower third. Discharged March 21, 186.7. Right; at upper third; by Asst. Surgeon B. Howard, II. S. A. Discharged Nov. 9, 1864, and pensioned; partial anchylosis. Left; three inches at junction of upper with middle thirds. Dis- charged Nov. 25, 1865; satis- factory. Right; twoinchesofmiddlethird; by Surgeon J. Robarts, U. S. V. Discharged April 20, 1865. Right: four inches at upper and middle thirds; by Asst. Surg. H. C. Merryweather, 5th TJ. S. C. T.; amputation July 4, 1865. Disch'd July 20, 1865; tender stump. Right; about three inches at mid- dle third. To Provost Marshal March 23, 1865. Left; entire upper third; by Asst. Surg. G. AV. Crossley, 57th HI. Discharged Mar. 12, 1865; pen- sioned; nearly normal. Left; fractured portion upperthird; by Surgeon J. B. Dicker, 47th Indiana. Disch'd June 5,1865; pensioned ; no union. Injured Oct., 1865; Dr. J. H. Stanway, late Asst. Surg. 102d Illinois, brought the bones together and applied friction to roughen the ends; union took place March 1, 1866; a good and useful limb. Left; portions of middle and lower thirds; by Asst. Surgeon Fred. AVolf, 39th New York. Disch'd Nov. 21. 1863. and pensioned; arm useless; died Mar. 21,1871. Right; injured part of upperthird; by A. A. Surg. J. Swinburne. D'isch'd January 20. 1863. Right; upper third; by Surg. A. M. AVilder, U. S. V. Duty Mar. 23.1864 ; amputated Mar., 1865. Left; both ends in upper third. Discharged Mar. 30, 1864; liga- mentous union. Left; three inches middle third; by A. A. Surg. T. J. Dunott, U. S. A. Disch'd Feb. 18, 1865; good condition. Left; three inches middle third; by Asst. Surg. B. Howard, TJ. S. A. Disch'd June 6, 1865; union perfect; passive motion. Left; five inches of upper third. Diseh'd Dec. 15, 1863; condition good. Right; by Surg. B. N. Bond, 27th Missouri. Furloughed July 30, 1864. Left; four inches of lower third. Returned to duty Dec. 18, 1864; partial paralysis; forearm useful. Left; three inches middle third; by Asst, Surg. G. AV. Crossley, 57th Illinois. Disch'd July 6, 1865; cartilaginous union i an- chylosis. Left"; fourinches upperthird; by Surg. F. C. Reamer, 143d Penn. Discharged June 29, 1865. Right; three inches upper third. Discharged May 19, 1865, and pensioned; non-union. 680 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. Name, Age. and Military Description. Moran, P. J., Serg't, I, 59th New A'ork, age 26. Moran, T., Pt,, F, 29th Pennsylvania, age 38. Morton. AV. J., Serg't, H, 209th Penn., age 23. Moulton, E. C, Pt., D, 13th N. H., age 43. Mullen, T., Corp'l, B, 61st Ohio. Murphy, P.E., Lieut., E, 9th Mass., age 23. Myers, F. A., Capt., I, 72d Penn., age 34. Myers, I., Pt., D, 100th Indiana, age 32. Myers. O. C, Capt., G, 2d Georgia, age 30. Myers, T., Pt., F, 124th Indiana, age 20. Naylor, Samuel, Pt., E, 78th Illinois, age .27. Nicholson, O., Pt., M, 3d AVisconsin CaAr., age 18. Nipper, R., Pt., E, 10th East Tenn. Cav., age 20. Nobles, W. M., Pt.,K, 31st North Carolina, age 35. Northrop, J., Pt., F, 103d Ohio, age 20. Ostron, J. G., Pt., A, 3d Tenn. Cav., age 35. On, B., Pt., B, 26th Ohio, age 26. Overmire, S., Pt,, D, 14th Ohio. Parker, C.AAr.,Pt.,F, 45th Pennsyh'ania, age 22. Patchin, A. J., Pt., E, 20th Ohio, age 27. Pease, I., Pt., D, 19th Maine, age 38. Pelton, Alfred, Serg't, I, 3d Michigan. Perkins, J. S., Serg't, G, 14th Va. Cav., age 25. 245 Peters. F., Pt., L, 14th N. Y. Heavy Artillery, age 18. 246 Peters. J., Corp'l, C, 33d Missouri, age 34. Dates. May 6, 6, "64. Mav 25, 25,"'04. Mar. 25, 25, 'C5. Sept.30, 30, '64. June 1, 1, '64. May 5, 5, "64. June22 22, '64. May 13, 13, '64. Dec. 16 17, '64. Nov. 26. 26, '64. July 19, 19, '64. Oct. 20, 20, '63. Aug. 1, 1, p64. May 31. June 1, 18C4. Nov. 25 25, 'C3. May 24 25, '64. May 10, 10, '64. Sept, 19 19, '63. May 6, 6, '64. July 27. 27, '64. Mar. 31. 31, '65. Mav 12. 12,"'64. Julv 9, 12, *'64. Sept.30. 30, '64. Dec. 16, 16, '64. Operations, Operator, Result. Right; two inches middle third; by Surg. S. II. Plumb, 82d New A'ork. Disch'd June 12. 1865; non-union ; died April 28, 1873. Right; injured portion. Duty Aug. 1, 1864; rejected as pen- sioner. Right; three inches middle third; by Asst. Surg. J. A. Hayes, 11th N. II. Disch'd June 20, 1865: false joint. Right; three inches upper third. Disch'd Aug. 11,1865; functions good. Spec. 4363. Right; two inches. Disch'd Dec. 13, 1864; pensioned. Left; upper third; by Surg. D. F. Sullivan, 9th Mass.; ampu- tated at upper third May 9th. Disch'd June 25, 1864, and pen- sioned ; stump sound. Left; two inches lower third; by Surg. G. Chaddock, 7th Mich. Mustered out Aug. 24,1864, and pensioned; entirely disabled. Right; two inches at junction of middle and lower thirds; by Surg. AV. Lomax, 12th Indiana; non-union; secondary excision Dec. 10,1864. Disch'd June 17, 1865; anchylosed elbow; chronic ulceration. Right; two inches middle third. To Prov. Marshal June 14,1865. Right; two inches middle third. Disch'd May 15, 1865; unhealed. Left; three inches middle third. Disch'd May 2,1865; partial use. Right; two inches upper third; by Ass't Surg. A. C. Van Duyn, U. S. V. To V. R. C. Aug. 2, 1864; useful arm. Right; two inches lower third; by Surg. L. C. Fouts, 2d Tenn. Mounted Infantry. Disch'd Mar. 21, 1865; pensioned; anchylosed elbow; arm of no use. Right; four inches upper third. Furloughed Aug. II, 1864. Re- ported by Surg. AV. L. Baylor, P. A. C. S. Right; fractured ends, upperthird; by Surg. G. B. Coggswell, 29th Mass. Disch'd July 30, 1864; pensioned. Arm useless. Died March 4, 1872. Left; three inches upper third; by Surg. R. L. Stanford, U. S. V. Deserted Oct, 4, 1864. Right; one and a half inches up- per third ; by Surg. J. Chapman, 123d N. York. Disch'd May 27, 1865; pensioned; partial union; loss of power. Died September 8, 1868. Left; two inches upper third. Duty Feb. 24, 1865; arm weak; necrosis still continues (April, 1873). Left; in upper third. To V. R. C. Jan. 18,1865. Disch'd April 14, 1865; pensioned. Right; three inches upper third. Discharged February 27, 1865; favorable. Right; three inches at junction of lower and middle thirds; by Sur- geon D. AV. Maull, 1st Delaware. Disch'd Aug. 24, 1865; no con- trol of forearm; pensioned. Right; in upper third; by Surg. H. F. Lyster, 5th Mich. Disctfd January 15, 1865. Left; four inches middle third; by A. A. Surg. T. J. Dunott, U.S.A. Paroled Nov. 22,1864; non-union. Specs. 3937, 1480. Right; two inches upper third. Discharged August 4,1865; can use arm but little. Left; two and a half inches at junction of middle and lower thirds ; by Surg. A. T. Bartlett, 33d Mo. "Disch'd June 3, 1865; no use of arm. 270 271 272 273 274 275 Name, Age, and Military Description. Pettijohn, C, Pt., E, 50th Ohio. Phillipsen, P., Pt., G, 26th AVisconsin, age 32. Pickett, C, Pt., E, 20th Michigan, age 18. Pineo, J. H., Serg't, K, 12th Maine. Piper, J., Pt., D, 73d HI., age 37. Porter, J., Pt., L, 1st New Jersey Cavalry, age 19. Porubsky, E., Pt., B, 46th New York, age 25. Price, J., Pt,, E, 139th New York, age 32. Quickel, J., Pt., E, 87th Pennsylvania, age 32. Redding, G. AV., Pt., L, 22d New York Cavalry, age 28. Reid, T. E., Corp'l, C, 69th New York, age 21. Rice, B. F., Corp'l, 1,26th Hlinois. Riffles, D. J., Pt., B, 10th West Virginia, age 19. Riley, W. H., Pt., A, 59th A'irginia, age 28. Roberts, B. F., Pt., I, 138th Penn., age 18. Roberts, G. M., Pt., B, 13th Georgia, age 26. Roberts, S. G., Lieut., B, 17th Mass., age 25. Robinson, D., Pt., D, 5fith Massachusetts, age 35. Robson, J.,Pt..E, 32d-9th Massachusetts, age 26. Robinson, J. Y., Pt., I, 8th Kansas, age 22. Robe, G. A., Corp'l, H, 97th New York, age 33. Rosenthal, L., Pt., F, 69th New York, age 32. Ross, G. M., Lieut., 77th New York. G. Rowley, E., Pt., I, 8th Iowa Cavalry, age 18. Ruddock, AV., Corp'l, C, 117th New York, age 21. Russell, J. M., Pt., F, 12th Mississippi. Rutherford, C. E., Pt., A, 66th Hlinois, age 31. Rykert, G. AI., Corp'l, C, 154th N. A'ork, age 22. Saunders, J.. Pt., B, 31st Maine, age 18. May 31 31, '64. July 20. 20, '64. June 18, 19, '64. June 19, 19, '63. May 14, 14, '64. Mav 28, 28,"'64. April 2, 2, '65. July 5, 5, f64. Nov. 24 24, '63. Nov. 6, 7, '64. June 3, 3, '64. May 13, 13, '64. Mar. 31, 31, '65. June 17, 17, '64. Nov. 27, 27, '63. Oct. 19, 19, '64. April 9, 11, '63. May 18, 18, '64. May 7, 8, ;64. July 21, 22, '64. May 7, 7, "64. June 16, 16, '64. Sept. 19, 20, '64. May 13, 14, '64. Oct. 27, 27, '64. July 20, 21, '64. May 16, 16, '64. Julyl, 3, fe. May 12, 13, '64. Operations, Operator, Result. Left; three inches lower third; by Surg. C. K. Crawford, 5Cth Ohio. Duty Aug. 25, 1864; not a pen- sioner. Left; three and a half inches up- per third. Discharged May 25, 1865; pensioned. Left; four inches middle third; by Surg. S. S. French, 20th Mich. Discharged June 10, 1865. Left; in upperthird; by Surg. J. H. Thompson, 12th Maine. Dis- charged June 16,1864; pensioned; necrosis. Left; two and a half inches upper third; by Surg. H. E. Hasse, 24th AVis. Disch'd Aug. 5,1865, and pensioned; no use of arm. Right; three inches upper third; by Surg. AV. B. Rezner, 6th Ohio Cavalry. Duty April 26, 1865. Disch'd June 6,1865; pensioned. Right; two inches upper third; by Surg. D. C. Roundy, 37th AVis. Disch'd Nov, 27,18*65, and pensioned; no union. Left; three inches upper third. Disch'd June 1, 1865; entirely disabled. Three inches upper third; ampu- tated Dec. 12, 18G3. Disch'd February 15, 1864. Left ; three and a half inches mid- dle third. Discharged June 12, 1865; false joint. Left; three inches lower third; by Surg. J. A. Spencer, C9th N. Y. Diseh'd Feb. 6,1865; pensioned; arm flexile; necrosis. Died Jan. 27, 1871. Right; three and a half inches upperthird; by Surg. A. Goslin, 48th Illinois. Discharged July 20, 1865. Left; three inches middle third; by Surg. C. M. Clark, 39th 111. Duty July 26, 1865. Right; in lower third. Furloughed July 28, 1864. Left; two inches of lower third. Disch'd May 5, 18C5; necrosis and ulceration. Left; in middle third. Transferred to Fort McHenry Jan. 5, 1865. Right; two inches middle third; by Surg. C. A. Cowgill, U. S.V. Disch'd August 3, 1864; perfect recovery. Left; three inches middle third; by Surg. T. F. Oakes, 55th Mass. To V. R. C. May 4, 1865; liga- mentous union; useful arm. Right; in lower third. Disch'd June 23, 1865; loss of use of forearm. Left; two inphes upper third. Duty Jan. 18, 1865; osseous union. Left; portion in the upper third. Discharged September 11, 1865. Right; portion in middle third; by Surg. S. H. Plumb, 82d N. Y. Discharged March 29, 1865. Right; upper third; by Surg. G. T. Stevens, 77th N. Y. Duty Nov. 4, 1864; perfect recoA-ery; arm nearly as useful as the other. Left; two inches middle third; by Surg. AV. II. Finley, Sth IoAva Cavalry. Disch'd July 10,1865. Left; three and a half inches lower third; by Surg. II. AV.Carpenter, 117th N. Y. Discharged May 4, 1865: useful arm. Left: four inches. Furloughed Sept. 10,1864; suppuration when furloughed. Right; three and a half inches middle third; by gurg. AV. R. Marsh, 2d Iowa. Disch'd June 13, 1865; no bony union. Right; four inches upper third. Disch'd Jan. 11,1864; no control of arm. Right; middle third; by Surg. L. AV. Bliss. 51st N.York. Disch'd May 18, 1865. SECT. IV.] EXCISIONS IN THE SHAFT OF THE HUMERUS. 681 Name, Age, and Military Description. Operations, Operator, Result. Name, Age, and Military Description. Operations, Operator, Result. Scanlon, J., Tt., A, 111th Ohio, ago 21. Scott, F., Serg't, B, 23d Wisconsin, age 27. Scott, J., l't., E, 29th Col- ored Troops, age 27. Shaffer, H., Pt., G, 12th Indiana, age 19. Shattuek, N., Pt., F, 5th Michigan, ago 23. Sheffrey. J. J. L., Corp'l, K, otli N. York, age 25. Shumway, D.,Pt, K, 19th Ohio, age 2o. Sigler, J. AV., Capt,, I, 150th Penn., age 31. Smead, L. B., Ft., A, 9th New York Cav., age 35. Smith, A. H., Pt., A, 7th Indiana, age 26. Smith, H. T., Pt., C, 28th Georgia, age 20. Smith, R. A.Pt., B, 67th New A'ork, age 45. Sommars, J. B., Pt., I, 12th Wisconsin. Spencer, J.. Pt., G, 103*1 Ohio, age 23. Stewart. J. F., Pt., B, 110th Penn., age 20. Stewart, AV., Pt., C, 23d Indiana. Stiles. J. R., Pt., G. 145th New York, age 28. Stone, A. E., Pt., H, 115th New York, age 21. Stone, G. H., Serg't, A, 8th N. Y. H. A., age 21. Stone. J., Pt., D, 92d Xew York, age 24. Strathdee,G..Pt., A, lOCth Illinois, age 28. Stout, F., Pt., C, 48th New York, age 18. Tarbell, J., Pt., K, 6th New Hampshire, age 36. Tathwell, E. E., Pt., A, 96th Ohio, age 18. Taylor, J. H„ Pt., G, 8th Alabama, age 28. Thompkins, C. H., Pt., B, 38th A'irginia. June 2, 2, '64. Xov. 3, 3, "63. July 30, 30, '64. Mav 13, 13," 64. Oct. 27, 27, '64. June 27, 27, '62. June 17, 18, '64. May 10, 10, '64. Mav 7, May 25, 27, '64. Julv 3, 4, '*03. June 27 27, '62. July 21, 22, '64. June 29, 29, '64. May 6, 6, '64. May 12, 12, '63. June 18, 18, '64. Jan. 15, 15, '65. June 16, 17, '64. June 1, 1, '64. Nov. 25, 27, '63. Feb. 21, 21, '65. June 28, 28, '64. Xov. 3, 3, '63. June 23, 24, '64. Jan. 19, 20, '63. Left; five inches upperthird; by Surg. C. AV. McMillcn, 1st Tenn, Disch'd Feb. 10, 1865. Left; in upper third. Discharged March 10, 1864. Left; two and a half inches upper third; by Surg. D. Maokay, 2Jth U. S. Colored Troops. Disch'd Juno 8, 18j5; arm useless. Left; two and a half inches at junction of lower and middle thirds; by Surg. A. Goslin, 48th Illinois. Disch'd Juno 14, 186,7. Right; portion of upper third. Disch'd Feb. 18, 186.7. Left; injured portion, middle third; by A! A. Surg. J. Swinburne, U. S. A. Diseh'd Sept. 10,1862; no bony union; arm useless. Right; one and a half inches. Dis- charged Nov. 24, 186.7; ununited. Three inches lower third. Duty July, 1864; bone united; arm weak. Died Jan. 12, 1869. Right; two inches upper part of middle third; by Surg. B. G. Strecter, 4th N. Y. Cav. Disch'd Oct. 11,1864 ; no bony union; arm of some use. Phot, No. 2. Right; three and a half inches up- perthird. Disch'd May-5, 1867, Left: six: inches upperthird; by Sur?. XV..I. Arrinsrton, C. S. A. Exchanged Mar. IT, If64; bone united; motion imperfect. Right; three inches lower third. Ann useless; amputated Feb. 22,1863. Disch'd April 14", 1863. Right; one and a half inches lower third: by Surg. O. B. Ormsby, 45th niinois. To V. R. C. April 24, 1865. Left: four inches middle third; bv Surg. C. AV. McMillen, 1st Tenn. Disch'd April 27, 1865. In upper third. Disch'd June 28, 1865. Right. Disch'd July 28, 1864. Right; three inches upper third. Disch'd June 24, 1805; elbow anchylosed. Left ; portion in upper third; by Surg. G. C. Jarvis, 7th Conn. Discharged June 4, 1865. Left; three inches middle third. Disch'd Mar. 2, 1865; did well. Left; two inches of upper third. Disch'd Jan. 12,1865; useful arm. Died Jan. 25, 1874. of pyaemia. Left; one and a half inches mid- dle third; amputated Feb. 9, 1864. Disch'd Feb. 5, 1865. Right; four inches middle third; by Surg. A. D. Palmer, 9th Me. Dis. June 6,1865; not a pensioner. Right; injured portion. Duty September 15, 1864. Right; about two inches lower third; by Asst. Surg. S. McClel- lan, 13th Conn. Disch'd March 10, 1864; favorable. Right; fractured ends in lower third; by Surgeon of 8th Ala- bama. Retired September, 1864; good motion of joint. Left; four inches of lower third. Furloughed March 21, 1865. Totten, ('., Corp'l, E, 4th Iowa Cavalry, age 25. Toynton, AV., Pt., E, 6th Michigan Cavalry. A'an Brunt. A., Pt., C, 49th New Vork, ago 22. VanA'alkenlnirg.E., Corp'l. F, KMh N. A ., age 32. Wall, G. W., Capt,, C, 24th Mississippi, ago 24. AA'atkins, AV. II., Serg t, E, 12th Miss. Cavalry, age 30. Watson, S., Pt., E, 184th Pennsylvania, age 24. Welch, J., Pt., B, Oth U. S. Infantry, age 26. AVells, J., Pt., F, 19th TJ. S. Colored Troops. AVentz, IL, Pt., F, 112th New York, age 36. Westmoreland, J. E., Pt., I, 59th Virginia, age 25. Wheatley, T., K, 13th Georgia. AVheeler, AV. M., Pt., A, 6th Vermont, age 43. Wilson, J., Pt., D, 185th New York, age 36. AVinchell, S., Pt,, I, 142d New York, age 30. Winslow, J., Pt., G, 16th Maine, age 19. Wood, F. V., Pt.,A, 14th Ohio, age 18. Woodman, S. AV., Pt., C, 2d Mass., age 24. Woods, E. D., Corp'l, K, 25th Indiana, age 27. Young, B. F., Corp'l, A, 1st Maine Cav., age 27. Young, E., Pt., D, 59th Illinois, age 20. Young, IL, Pt, K, 20th Connecticut, age 29. Zerther, C, Pt., I, 62d Pennsylvania. Zimmerman, C, Serg't, H, 6th Conn., age 30. Zimmerman, S., Lieut,H, 81st N. Y., age 24. Oct. 25, 25, '04. Nov. 15, On field 1863. May 10, 11, '64. May 12 13, '64. April 6, 7, '65. Dec. 16, 16, '64. June 3, 3, '64. Mar. 18, 20, '65. July 30, 30, '64. Jan. 15, 15, '65. April 9, 9, '65. Slay 4, 4, '63. Mav 5, 6, !64. Mar. 29, 30, '65. Jan. 15, 16, '65. June 18 18, '64. June 2, 3, '64. July 3, 5, '63. Oct. 15, 16, '64. Oct. 27, 28, '64. Dec. 16, 17, '64. Mar. 19, 19, '65. June 3, 3, '64. Aug. 14 14, '64. June 3, 3, '64. Right; two inches upper third. Disch'd June 1, 1865; arm en- tirely useless. Right; about three inches upper third. Disch'd Aug. 23, 1864; motion restricted. Left; three inches upper and mid- dle thirds ; by Surg. J. A. Hall, 49th N. Y. Discharged July 14, 186.7; ligamentous union. Left; two inches middle third; by Surg. S. S. French, 20th Mich. Diseh'd October 3, 1864; some mobility of elbow. Right; three inches middle third. To Fort McIIenry May 9, 1865. Right; five inches; by A.A.Surg. A. Rolls, U.S.A. Disch'd April 14, 1865; not a pensioner. Right; at middle third; by Surg. M. Rizer, 72d Penn. Disch d Feb. 20,1865; motion recovered, strength net. Left; live inches upper third; by Act. Asst. Surg. J. E. Semple; amputation at the shoulder joint. Disch'd June 3,1865; pensioned. Right; four inches middle third; by Surg. G. R. Potts, 23d U. S. C. T.; arm amputated August, 1804. Disch d June 12, 1865. Right; three inches upper third; by Asst. Serg. F. B. KimbalL 3d New Hampshire. Disch'd Sept. 6, 1865. Left; three inches upper third; by Surg. Hopkins, C. S. A. To Fort McHenry May 9, 1865. Two and a quarter inches lower third; recovering rapidly. Right; two inches upper third; by Surg. G. T. Stevens, 77th N. Y. Discharged May 6, 1865. Left; five inches upper and mid- dle thirds. Discharged J une 29, 1865, and pensioned; interspace two inches. Left; four inches middle third. Disch'd May 23,1865; pensioned; arm useless; no bony union. Died September 5,1873. Left; one inch lower third. Dis- charged Jan. 2, 1865; no bony union. Right; three inches middle third. Discharged January 23, 1865. Left; two inches middle third. Disch'd April 19,1864, and pen- sioned : can use hand and rotate forearm. Right; four inches middle third; amputation. Disch'd May, 1865. Right; two inches upper third. Discharged June 10, 1865, and pensioned. Right; middle third. Discharged July 13, 1865. Left; between upper and middle thirds. Disch'd Nov. 7, 1865; non-union; limb useless. Left; injured portion. Duty July 20, 1864. Left; four inches of upper third; amputated August 21. Disch'd November 18, 1864. Right; five inches upper third. Discharged September 21,1864; no bony union. Of the foregoing list of three hundred and twenty-six operations, two hundred and twenty-six were practised on Union and thirty-one on Confederate soldiers. Two hundred and seventy-six of the men were discharged and pensioned, nineteen returned to duty, thirty-one were exchanged or paroled. Seventeen of the pensioners have died since their discharge—one by drowning, two from phthisis, one from general anasarca, one from pysemia, and the rest from causes not stated. Unfortunately, no autopsy is recorded in any case. The injuries are reported to have been inflicted by shell-fragments in ten instances, 86 Gs2 INJURIES OF THE UPPKR EXTREMITIES. [Chap. ix. by grape or canister shot in two, and by small projectiles in three hundred and fourteen cases. The left arm was interested in one hundred and sixty-five, the right in one hundred and forty-seven, and this point was unnoticed in fourteen instances. In two hundred and ninety-four cases in which the seat of excision was precisely defined, the excised portion belonged chiefly to the upper third of the diaphysis in one hundred and twenty-two, to the middle third in one hundred and fourteen, and to the lower third in fifty-eight. The extent of bone excised is specified in two hundred and forty-nine instances, as enumerated in the foot-note.1 Twenty-seven cases were complicated by other wounds; and, in one case, a leg Avas amputated, in another, an exsection of the ulnar nerve practised, and, in six, missiles extracted, at the time of excision. Later, exarticulations at the shoulder were thrice resorted to, and amputations of the arm were practised in twenty-four cases. In thirteen instances, consecutive operations for the removal of diseased bone were required: Case 1631.—Private E. P------, Co. B, 46th NeAV York, aged 25 years, Avas Avounded at Petersburg, April 2,1835. He Avas admitted into tho field hospital of the Ninth Corps. Surgeon M. K. Hogan, U. S. V., recorded "a gunshot fracture of the right arm; resection of tAvo inches of the humerus, by Surgeon D. C. Roundy, 37th Wisconsin." On April 8th, he Avas transferred to Stanton Hospital, "Washington. Surgeon 13. B. Wilson, U. S. V., noted: "Compound comminuted fracture of the upper third of the right humerus." On September 19th, he Avas transferred to Douglas Hospital, Avhence Assistant Surgeon W. F. Norris, U. S. A., reported: " Gunshot fracture of the right humerus, upper third, by a minie ball. Primary resection of four inches of the shaft of the right humerus. Incision three inches long on the external aspect; chloroform administered. Present condition: All closed except a fistulous opening which leads to the necrosed end of the upper portion of the loAver fragment; no union; operation performed on the field; still under treatment." On November 2d, he Avas transferred to Harewood, Avhence Surgeon R. B. Bontecou, U. S. Y., fonvarded a photograph of the patient, which is copied in the Avood-cut (FlG. 503), and reported the Avound as then healed, but with no bony union." Porubsky Avas discharged, on certificate of disability, November 27,1835, and pensioned. Examiner J. H. Clark, of NeAvark, NeAV Jersey, July 31, 1837, reported: " Has resection of the right humerus at the upper third of about three inches. The arm, forearm, and hand are of very little service; so little that his inability to perform manual'labor is equivalent to the loss of the hand." Examiner C. M. Chamberlain, NeAV York, reported, February 10, 1868: "Six inches ofthe shaft of the humerus has been resected, and the bone has not been restored. The forearm dangles from the false joint and is atrophied, being of less use than if the injury had been the loss ofthe hand; disability total." The pensioner has not been heard from since 1870. Case 1632.—Corporal S. Gear, Co. H, 49th Ohio, aged 19 years, Avas wounded at Nashville, December 16, 1864. He Avas admitted into the hospital of the 3d division, Fourth Army Corps, and on the folloAving day Avas transferred to Hospital No. 1, Nashville. Surgeon B. B. Breed, U. S. V., reported: "Gunshot fracture of right humerus. Ball entered on anterior aspect of arm in middle third, passed through the humerus, and lodged in the tissues behind it. Resection Avas performed, on December lGth, of tAvo and a half inches of shaft of liumerus, middle third, through an incision three and a half inches long over anterior aspect of arm. Anaesthetic and operator unknown. AA'ound doing well. Water dressings used, and tonics and stimu- lants and nutritious diet administered. Patient transferred to Hospital No. 2 on December 22d." Surgeon J. E. Herbst, U. S. V., in charge of the latter hospital, reported: "Gunshot fracture of right humerus. Haemorrhage from posterior circumflex artery, to amount of ten ounces, occurred on December 23th, caused by gangrene of the wound. The bleeding Avas discovered early, and the artery was ligated by Acting Assistant Surgeon S. W. BlackAVOod. Constitutional condition of patient healthy, and improvement rapid." The patient was discharged from service on June 27, 1865, and pensioned. In the certificate of disability for discharge Surgeon Herbst reports : "Gunshot fracture of right humerus, middle third, producing pseudarthrosis and extensive injury of nerves." Examiner J. H. Hair, of Fostoria, Ohio, July 15, 1865, certified: "Ball entered right arm, fracturing liumerus, middle third. About three inches of said bone was resected (Avhich Avound is still discharging), from Avhich he has lost fully three-fourths the use of right arm." The disability was rated three-fourths. The pensioner died on March 2, 1670. Tlie cause of his death is not known. %,Fatal Cases.—One hundred and forty-five, or about one-third of the primary excisions in the continuity, terminated fatally. 1 A'iz: An inch in 7 seAren cases; an inch and a half in 9 oases; two inches in 55 cases; two and a half inches in 19 cases; three inches in 71 cases; three and a half inelies in 11 cases; four inches in 56 cases; four and a half inches iu 1 case; five inches in 16 cases; six inches in 1 case (No. 286); six and a half inches in i case (No. lb'?): eight inches in I case (No. 71). In seventy-seven cases this point was not explicitly defined. -Dangling arm after excision in the [From a photograph.] SECT. IV.l EXCISIONS IN THE SHAFT OF THE HUMERUS. Table LVII. 683 Condensed Summary of One Hundred and Forty-five Fatal Primary Excisions of the 6haft of the Humerus for Shot Injury. Name, Age, and MILITARY DESCRIPTION. Arbuckle, R. A., Pt., A, 32d Ohio. Barker, L., Pt., E, 4th Indiana Cavalry. Barnard, J. AV., Pt., K, llth A'irginia. ago 56. Batchcldcr, C.AV.. Corp'l, D. lilth X. Hampshire. Battle, W. L , Lieut.. D, 31th X. Carolina, age IS). Beckelshymer, H., Pt., A, 103d Illinois. Bennet, A. S., Pt., C, 2d Ohio Cavalry, ago 22. Black, J., l't., 11,1st Penn- sylvania Reserves. Boswell, B. M., Corp'l, E, 111th Illinois. Boynton, H. E., Pt., 1st Mass. Heavy Artillery , age 18. Brooke. J., Pt., I, 16th Connecticut, age 19. Buckley, J., Corp'l, G, 9th Mass.. age 27. Burke, J., Pt., H, Cth Penn. Cavalry, age 20. Burress, E. B , Pt., G, 2d South Carolina. Butterfield. S. AV., Corp'l, E, 111th Pennsylvania. Byers. W. F., Serg't, A, 57th Indiana. Campbell, G. AV., Pt., K, 36th AA'iscousin. Carman, G.. Corp'l, E, SJth Illinois. Charles, II., Pt., A, 19th Maine. Chapman, E., Pt., I-D, 7oth Xew Vork, age 48. Charter, AV. S., Pt., D, 145th Pennsylvania. Chestnut, J. W., Pt., D, 63d Alabama, age 18. Childers, T. B., Pt., E, 38th Georgia. Coggins, J. B., Lieut., D, 50th North Carolina. Coker, W. C, Pt., A, 4th South Carolina Cavalry. Collins, J., Pt., B, 2d Michigan. Cunningham, H. C, Pt, A. 95th Penn., age 19. Dailey. P., Pt., D, 5Cth Ohio, age 40. Davis, J. A., Corp'l, C, 32d U. S. Cold Troops. Donaldson, AV., Pt., I, 1st A'irginia, age 32. Dougherty, J., Pt., D, 52d Ohio. Downs, T., Pt., G, 20th Indiana Cavalry. Drum, E., Pt., G, 97th Ohio. Dudley, M. N., Pt., D, 106th Pennsylvania. Julv 21. 21," 61. Jan. 16, 19, '64. July 2, 3, '63. May 13, 13, '04. July 2, 3, '63. July 22, 22,"'64. June 1, 1, '64. July 2, 2, r63. May 15, 15, '64. May 19, 22,*'04. Sept. 17, 17, '62. May 12, 12, '64. May 8, 9, '64. May 23, 24, '64. July 23, 20, '64. June 27, 27, '64. June 18, 18, '64. Prim'ry. —, '64. Feb. 5, 5, '65. June 14, 14, '63. May 12, 12, '64. April 9, 9, '65. Dec. 13, 14, '62. June 17, 17, '64. May 28, Prim'ry, 1864. Nov. 29, 2J, '63. Mar. 25, 25, '65. Aug. 3, 3, '64. Nov. 30 30, '64. July 7, 7, '64. June 27 27, '64. June 4, 4, '63. June 22, 22, '04. May 6, 6, '64. Operations, Oferator, Result. Right; two inches middle third; by Surg. A. C. Brundagcr, 32d Ohio. Died July 19, 1865, of dropsy. Right; three inches upper third. Died April 26,1864. Right. Died July 26, 1863, of pyiemia. Right; at tho middle third. Died JulyS, 1864. Left; three inches upper third. Arm amputated Aug. 23, 1863; died thrco hours afterward. Left; two inches middle third; by Surg. It. Morris, 103d Illinois. Died Aug. 23, 1864. Left; fractured, portion. Died July 2, 1864. Left.; three inches. Died Aug. 15, 1863. Left; at lower third; by Surg. A. C. Messenger, 57th Ohio. Died May 22, I8.il. Right; two inches middle third; by Surg. N. 11. Moseley, U. S. V. Died June 22, 1864. Spec 2322. Left; six inches upper third; by Surg.N.Mayer, 16thConn. Died Oct. 11, 1832. Right; eight inches. Died May 28, 1864. Left; amputation June 4, 1864. Died June 5, 1864, of pyaemia. Spec. 3550. Middle third. Died July 12,1864. Right; in lower third. Died Sept. 5, 1864. Right; by Surg. E. B. Glick, 40th Indiana. Died July 12, 1864. Left; in upper third; by Surgeon AV. J. Burr, 43d N. V- Died June 27, 1864. Died June 8, 1864. Left; in upper third; by Surgeon S. H. Plumb, 82d N. Y. Died February 14, 1865. Left; greater portion of the shaft. Died July 17, 1663, of pyaemia. Left; portion in upper third ; by Asst. Surg. B. Howard, U. S. A.; arm amputated October 7, 1864. Died Oct. 21, 1864, of tetanus. Left; by Surg. O. G. Hunt, llth 111. Died June 20, 1865, from exhaustion. Died January 7, 1863, of pyaemia. Left; one inch middle third. Died August 20, 1864. Left; two inches of lower third. Died June 19,1864, frorh exhaus- tion. Three and a half inches upper third; by Surg. A. M. AVilder, U. S. V. Died Nov. 29, 1863. Right; two inches middle third. Died July 11, 1865. Left; two and a half inches mid- dle third; by Surg. AV. H. Mul- lens, 12th Kentucky. Died Nov. 9, 1864. from exhaustion. Right; four inches upper third. Died Dec. 14, 1864. Spec 3701. Left; portion of shaft. Died July 28, 1864. Right; lower third. Died July 12, 1864. Left; three inches; by Surg. I. Moses, U. S. A. Died July 6, 1863, of pyiemia. Spec. 1749. Right; at middle third; by Surg. AV. B. McCiavoau, 2Gth Ohio. Died July 21, 1864, of pya'iniii. Left; pen-lieu of lower third; by Sur-r. AV. .1. Burr. 4 .'d N. V. Hied May 20, 1861. Name, Age, and military description. Edgcrly, H. F., Pt., II, 4th New Hampshire, ago 26. Finch, J., Pt., I, 3d Mich- igan. Freeman, W. S., Serg't, D, Kith Virginia, ago 31. Gladding, J., Pt., 1, 7th Rhode Island, age 20. Goff, J., Pt., D, 142d New York, age 28. Harrington,L., Pt., G, 1st N. CarolinaCav., age 34. Harrowls, C, Pt., L, 3d New Jersey Cavalry. Hampton, J. K. P., Pt., 36th Tennessee, age 17. Hamilton, B., Corp'l, C, 1st Maryland. Hanson, B., Pt., B, 5th New Hampshire. Hartz, J., Pt., F, 23d Illinois. Henderson, S. S., Pt., F, 32d Maine, age 28. Herdendorf, E. E., Pt., F, 136th New York. Herrick, M., Pt., D, 49th New A'ork, age 21. Hickey, T., Capt., A, 164th New York, age 25. Highman, R., Pt., K, 6th Penn. Cavalry. Hinton, T., Pt., E, 6th Iowa. Hoggard, J., Corp'l, E, 137th Illinois, age 20. Hooper, AV. H., Lieut., D, 7th Maine. Hollis, II. S., Pt., H, 35th Massachusetts, age 26. Hoyt, C, Serg't, G, 10th New Hampshire, age 24. Houtz, I, Pt., K, 50th Pennsylvania. Huffman, H., Corp'l, H, 65th Ohio, age 20. Hull, D., l't., C, 81st Indiana. Humphrey, E. D., Pt., C, 6th Tennessee, age 22. Hudson, J. E., Capt., D, 53d Illinois. Ingalls, L., Pt., G, 17th Vermont, age 19. Kelsey, G., Pt., I, 4th N. York Artillery. Kinsey, AV. H., Serg't, II, 2*tith Illinois. Kletchner, J., Pt., H, 2d Penn. Heavy Artillery, age 18. July 24, 24, '64. May 12, 12, '04. July 30, 30, '64, June 3, 3, '64. Oct. 29, 29, '64. April 2, -'65. Sept. 19, 20, *64. Feb. 16, 18, '62. July 3, 3, '63. June 16, 16, '64. July 7, 7, '64. June 5, 64. May 15, 15, '64. May 5, 5, *64. June 3, 3, '64. Aug. 28, 28, '64. June 27, 27, '64. Aug. 21 —, '64. May 5, 5, '64. July 12, 12, '63. May 14, 14, '64. June 3, 3, '64. July 20, 21, '64. June 27, 27, '64. June 16 16, '04. July 12, 12, '63. May 6, 6, '64. June 18 18, '64. July 12 12, '63. July 5, 5, '64. Operations, Operator, Result. Left; three inches of upper third; by .Surg. G.P. Grueby, 4th N. II. Died August 2, 1864, from ex- haustion. Fractured portion upper third; by Surg. II. F. Lyster, 5th Mich. Died May 20, 1804. Right; in lower third. Died Aug. 9, 1864, of erysipelas. Right; two and a half inches mid- dle third; by Surg. J. Harris, 7th R. I. Died July 3, 1864, of pyaemia. Left; portion of shaft; by Surg. McFalls, 142d N. Y. Died Dec. 17, 1864, from exhaustion. Left; four inches. Died May 18, 1865, from exhaustion. Right; portion of lower third; by Surg. R. Curran, 9th N. Y. Cav.; arm amputated Sept. 22, 1864. Died Sept. 29, 1864, from con- cealed haemorrhage in back. Left; three inches middle third; by Dr. Madden; amputation Mar. 25, 1862. Died March 29, 1862. Right; by Surg. AV. H. Tusford, 27th Ind. Died July 22, 1863. In upper third; by Surgeon G. L. Potter, 145th Penn. Died June 27, 1864. Left; inlowerthird; by Asst.Surg. J. S. Taylor, 23d Illinois. Died July 15, 1864. Left; two inches. Died July 3, 1864. Right. Died July 28, 1864. Left; three inches; amp. at shoul- der May 26,1864. Died May 26, 1864, of asthenia. Spec 3595. Right; four inches; by Surg. M. F. Regan, 164th N. Y.; arm am- putated June 22, 1864. Died July 0. 1864, of pyaemia. Left; injured portion. Died Sept. 2, 1864. Left; two inches; by Surg. J. C. Hutchinson, 15th Mich. Died July 21, 1864. About half an inch of each end in upper third; amputated at shoul- der joint Sept. 9,1864. Died Sept. 12, 1864, from haemorrhages. Right. Died May 14, 1864. Two and a half inches lower third; bySurg.G.B.Coggswell. Died Aug. 7, 1863. Left. Died June 27, 1864. Right; at middle third; by Surg. II. E. Smith, 27th Mich. Died June 12, 1864. Left: upper third. Died August 1,1864. Upper third; by Surgeon C. J. AVnlton, 21st Kentucky. Died July 1, 1864. Left; three inches middle third; by Surg. E. D. Moore, 13th Ky. Died July 6, 1864, of pyiemia. Right; by Surg. AV. S. Edgar, 32d 111. Died Aug. 6, 1863. Right; three inches; by Surg. J. T. Milhau, U. S. A. Died June 12. 1864. Right; amputation at shoulder ioint July 3, 1864. Died July 7, 1864, of pyaemia. Left; upper third; by Surg. C Carle, 41st Illinois. Died July 27, 1863. Left; five inches middle third; by Surg. F. F. Oakes, 56th Mass.; arm amputated Aug. 9th. Died Aug. 11, 1864. Spec. 3667. 684 INJURIES OF THE UPPER EXTREMITIES. [CHAP. ix. 89 90 91 92 93 94 95 9C 97 98 99 100 Name, Age, and Military Description. Klahro. II. F., Corp'l, A, 184th Penn., age 22. Klitze, G., Pt., D, 19th Ohio. Lampkin, H. T, Corp'l, K, 34th Virginia, age 28. Leaphart, T. E., Serg't, C, 15th South Carolina. Lewis, Ii. J., Pt., K, 1st Michigan Cav., age 27. Liflins, J., Drummer, F, 29th Mass., age 15. Mall, AV. M., Pt., E, 117th New York, age 19. Mapes. A. II.,"" Serg't, C, 9th Illinois Cav., age 28. Martin, J., Pt., B, 2d Pa. Artillery, age 30. McNabb, AV. P., Pt,, D, 62d Penn., age 31. McNulty, J. U.,Pt., H, 1st N. Jersey Cav., age 32. Merrill, A. C, Pt., I, 1st Maine H. Art., age 30. Merrille, A., Pt., G, Sth Ohio. Merchant, A. L., Pt.. F, 17th Vermont, ago J 9. Miller, C.M.,Pt.,G, 105th Illinois. Masher, G. II., Pt., II, 13Gth New York. Moat, C, Corp'l, E, 6th New A'ork CaA'alry. Monuhan, J., Corp'l, E, 22d Mass., age 38. Mooney, J., Pt., G, llth U. S. Infantry. Moore, AV. K., Pt., I, 57th Mass., age 23. Mulke, J.. Pt,, A, 7th New A'ork, age 23. Newton. J. JI., l't., C, 6th Indiana Cavalry. Nelson, H., Pt., B, 31st U. S. C. Troops, age 27. Oliphant, D., Capt.,B, 5th Mich. Cavalry, age 36. Ollis, L., Corp'l, K, 2d U. S. Cavalry. Ourish. P., Serg't, E, 32d Jlass., age 19. Owens, J., Pt, C, 1st Ver- mont CaA'alrA', age 24. Paddock, R., Pt., K, 81st New A'ork, age 19. Parliament, J., Pt.,C, 13th New JerseA'. Pan-is, II. S., Pt., D, 1st Delaware, age 26. Peasly, H., Pt., F, 58th Penn., age 21. Pendar, F., Pt., G, 6'lst Penn., age 25. Perdue, I.E., Pt.,B, 5th A'irginia, age 44. Perkins, M., Sergt, B, 7th Mieliisran Cavalry. Pl>ht. H..*Pt.. I. 15th N. A'ork Artillery, age 22. Potts. J.. Pt., A, 17th Penn. Cavalrv. Dates. June 22 22, 'C4. June 20, 20, '64. Aug. 5, 5, '64. Sept. 19. 19, '64. May 28, 28, '04. June 19, 20, '64. Oct. 27, 27, '64. Aug. 13, 16, V4. June 17, 17, 'C4. May 12. 12. '64. May 28, 28, '04. June 18, 19, '64. July 3, 4, '63. June 17, 1864, On field May 25 25, '64. July 3, 3, 63. Aug. lb- Hi, '64. May 5, 6, '64. Mav 12, 12,*'64. Oct. 8, 8, '64. Dec. 13, 14, '62. July 14, 14, '64. July 30, 31, '64. May 28. 28, '64. Sept. 19, 19, '64. May 30 30, 'G4. June 13, 13, '64. Aug. 15. 15, '64. July 3, 4, '63. Aug. 25, 26, '64. Sept. 30, 30, '64. May 5, 5, '64. Sept. 3, 4, '64. Mav 28, 28," 64. May 6, 8, '64. June 1, 1, '64. Operations, Operator, Result. Right; one inch at upper third; by Surg. G. Chaddock, 7th Mich. Died July 23.1864; haemorrhage. Spec. 3334. Upper third. Died July 11,1864. Left; one and a half inches mid- dle third. Died Sept. 5, 1864. Three inches middle third. Died Oct, 12, 1864, of pyaemia and dj-sentery. Right; three inches middle third. Died June 15, 1864, of pA'aemia. Right, Died June 26, 1864. Left; two-thirds of shaft. Died Oct. 31,1864, from exhaustion. Right; one and a half inches; by A. A. Surg. B. AV. Coale. Died Sept. 8, 1864, of typhoid fever. Left; three inches of upper third. Died July 5, 1864, from exhaus- tion. Left. Died June 8, 1864, of pyaemia. Right; middle third; arm ampu- tated. Died June 9, 1864. Right; portion of the shaft. Died July 5, 1864, from haemorrhage. Left; three inches middle third; by Surg. H. E. Goodman, 26th Penn.; arm amputated Julv 10, 1863. Died July 13, 1863, of pneumonia. Right; three inches upperthird. Died July 12, 1864, from gan- grene. Right; middle third; by Surg. I. M. Himes, 73dOhio. DiedJune 18, 1864. Left; fractured portion. Died August 1, 1863. Died September 12, 1864. Right; three inches middle third; arm amputated Sept. 17, 1864. Died September 26, 1864, from exhaustion. Spec. 3331. Right; two inches lower third; arm amputated June 7, 1864. Died June 7, 1864. Right; of shaft; amputated at shoulder joint Nov. 11, 1864. Died Nov. 27, 1864. Left; of shaft. Died December 29, 1862, of traumatic tetanus. Right; two and a half inches mid- dle third; by Surg. S. K. Craw- ford, 50th Ohio. Died July 26, 1864. Right; middle third. Died Sept, 21, 1864. Right; at upper third. Died June 4, 1864, from exhaustion. Left; three inches middle third. Died Oct. 13, 1864, of typhoid pneumonia. Left; upperthird; amputation at shoulderjointJune8,1864. Died June 8, 1864, from shock. Left; fractured portion. Died July 21, 1864, of pyaemia. Right; fractured portion upper third. Died Sept. 3, 1864. Right; portion of middle third ; by Surg. J. A. Freeman, 13th N. J.; arm amputated July 18, 1863. Died July 28, 1863. Left; part of lower third. Died Jan. 31,1865, of pyaemia. Spee. 3652. Left; four inches upper third; by Asst. Surg. J. AV. Gray, 98th N. Y. Died Oct. 9, 1864, from exhaustion. Right; three inches. Died June 2, 1864. Right; portion of shaft; by A.A. Surg. J. R. Uhler. Died Sept. 13, 1864. Died May 30, 1864. Left: three inches of upper third. Died June 9, 1864, of pyaemia. Right. Died. NO Name, Age, and Military Description. Pritchard, AV. H., Pt., F, 149th New York. Quinlan, J., Pt., B, 90th New York. Ramsdell, G. A., Serg't, K, 20th Maine. Ralston, H., Pt,, D, 8th Maryland, age 24. Remmington, A. O., Cor- poral, H, 75th N. York. Reeves, M., Pt., G, 9th New York Cavaln'. Richard, AV. H., Pt., I, 93d Illinois. Rich, G. H., Pt., B, 42d Massachusetts, age 21. Roach, J., Pt., A, 5th N. Jersey, age 16. Reese, J., Corp'l, K, 2d New A'ork Cav., age 20. Roberts, J. IL, Pt., 1,17th Maine, age 46. Rowley, A., Pt,, H, 86th New York, age 19. Rutherstine, G., PL, K, 76th Ohio. Scott, H. M., Corp'l, B, 100th Indiana. Scott, AV. H., Capt., D, 1st Ohio Cav., age 25. Shank, D., Pt., I, 44th Ohio. Sharp, J., Pt., H, 100th New York. Shickle, J., Corp'l, D, 52d Ohio. Smith, I., Pt., G, 60th Ohio, age 19. Smith, J. I., Pt., D, 1st Mass. Heavy Artillery. Snyder, M., Pt., G, 69th Penn., age 19. Stover, AV. L., Pt,, D, 4th N. Y. Heavy Artillery, age 21. Strickland, A. P., Pt., K, 24th N. Carolina, age 46. Stropes, A. J., Pt., E, 53d Illinois. Tarby, J., Pt., I., 82d U. S. Cl'd Troops, age 30. Templeman, J. AV., Pt., E,' 10th Mass., age 16. Thomas, E., Pt., G, 31st Maine, age 19. Tinkham, F. L., Pt., H, 33d AVisconsin. Vontaine, J. R., Commis- sary Serg't, A, 8th N. York Cavalry. Walker, J. AV., Pt., K, 9th Maine, age 34. Walker, W., Pt., C, 18th Georgia. AVentworth, M. R., Pt., F, 20th Maine. AVelch, AV. C, Pt., E, 184th Penn., age 22. AVebb. C. C, Capt., E, Llth Michigan. AVhalen, M., Pt., I, 90th Illinois. Dates July 20 20, '64. June 14, 14, 'dX Oct. 1, 1, '64. Mav 12, 12, "'64. June 14, 14, '63. Julv 28, 28, ''64. Nov. 25, 25, '63. Aug. 3, 3, '64. Mav 5, 5, '64. Aug. 25, 26, '64. Mav 14, 16,''64. May 12, 12, '64. Aug. 19, 19, '64. May 14, 14, '64. Aug. 20, —, '64. Nov. 29, —, '63. June 1, 1, '62. June 27, 27, '64. June 23, 23, '64. Juno 23, 23, '64. Oct. 27, 27, '64. May 19, 19, '64. Aug. 15, 15, '64. July 12, 12, '63. April 5, 5, '65. May 5, 6, '64. July 30, 30, '64. April 24, 24, "64. June 13, 13, '64. Oct. 27, 27, '64. Nov. 25, 25, *63. June 3, 3, '64. June 22, 22, '64. Dec. 31 31, '62. July 28 28, '(il. Operations, Operator, Result. Left; four inches upperthird; by Surg. J. A'. Kendall, 149th N. Y. Died July 27, 1864. Left; portion of upper third: by Surg. C. Robertson, 159th N. Y. Died July 6, 1863. Right; fractured portion of upper third. Died October 17, 1864. Left; upper third. Died June 5, 1864. Right; lower third. Died Juno 17, 1863. Left; of shaft. Died September 2, 1864. Left; fractured portion; by Surg. E. J. Buck, 18th AVis. Died January 4, 1864. Right; two inches upper third; by Surg. E. Bentley, U. S. V. Died Aug. 14,1864, from haemor- rhages. Left; upper fourth. Died June 25, 1864, of pyaemia. Left; three inches; bv A. A. Surg. J. R. Uhler. Died Aug. 29, 1864, of typhoid fever. Right; six inches upper third. Died Aug. 15, 1864, of asthenia. Spec. 3589. Right; six inches. Died May 30, 1864, from exhaustion. Right; three inches upperthird; by Surg. A. Sabine, 76th Ohio. Died August 24, 1864. Right; two and a half inches; by Surg. R. Morris, 103d 111. Died June 6, 1864. Right; three inches; arm ampu- tated Sept, 17,1804. Died Sept. 27, 1864, from exhaustion. Right; middle third; by Surgeon G. A. Collamore, 100th Ohio. Died January 18, 1864. Injured portion. Died June 9, 1862. Left. Died June 30, 1864. Left; lower portion : amputation July 11, 1864. Died July 13, 1864. Fractured portion. Died June 28, 1864. Right; fractured portion at middle third; by Surg. S. H. Plumb, 82d N. Y. Died Nov. 5, 1864, from exhaustion. Right; portion of shaft. Died June 13, 1864, of pysemia. Left; three inches middle third. Died Sept. 19, 1864, from ex- haustion. Right; in upper third; by Surg. AV. S. Edgar, 32d Illinois. Died Aug. 10, 1863, of pyaemia. Right; five inches; by Surg. H. Osborne, 51st U. S. C. T.; arm amputated April 12,1865. Died April 19, 1865. Left; three inches. Died June 6, 1864, from exhaustion. Left; in middle third; arm ampu- tated. Lied Aug. 13,1864, from exhaustion. Spec. 2974. Left; fractured portion and ampu- tation of right arm. Died April 25, 1864. Right; fractured portion of upper third; amputation at shoulder joint July 5, 1864. Died July 5, 1864. Left; portion of shaft; by Surg. P.arlow, 62d Ohio. Died Dec. 5, 1864, from exhaustion. Arm amputated, by a Confederate surgeon, Dec. 10, 1863. Died December 11, 1863. Left; injured portion. DiedJune 8, 1864. Right; two inches middle third; by Surg. G. Chaddock, 7th Mich. Died July 5, 1864, of pyaemia. M i ddle third. Died February 14, 1863. Right; by Surg. Halderman, 46th Ohio. Died Aug. 21, 1864. SECT. IV.] EXCISIONS IN THE SHAFT OF THE HUMERUS. 685 NO. Name, Age, and Military Dr.SCUUTION. Dates. Operation, Operator., Result. No. Name, Age, and Military Description. Dates. Operation, Operator, Result. 136 137 138 139 140 Williams. T. G., F, 31st North Carolina, age 25. AVilliams, S., Pt., E, 140th Pennsylvania. AVilson,' AV., Pt., K, 15th New Jersey, age 23. AVilburn, 1., Pt., A, G8th U. S. Colored Troops, aire 30. AVilliams, J. J., Pt., K, 72d Indiana. May 16, l(i.*'64. Oct. 14, 14, '(13. Aug. 18, 19, '64. April 2, 3, '65. June 19, 19, '64. Died June 14, 1864, of pyasmia. Right, Died November 1, 1863, of pyaemia. Left; three inches lower third; by Surg. IL Fearns, 175th N. Y. Died Septomber 4, 1864. Left; portion of lower third; arm amputated April 13,1865. Died April 28, 1865, from hectio fever. Left; in middle third; by Surg. A. T. Hudson, 26th Iowa. Died July 26, 1864. 141 142 143 144 145 Wilburn, G., Pt., G, 111th Illinois. Woodbridge, AV. 0., Pt., C, 4th New Hampshire, age 35. AVyatt, A., Pt., IL, 83d New York, age 26. Young, J., Pt., F, 13th Illinois. Zonna, J., Pt., F, 44th Illinois, age 29. May 14, 14, '64. June 24, 24, '64. May 8, 8, '64. Nov. 27. 27, *64. Nov. 25, 27, '63. Upper third; by Surgeon S. 0. Bonner, 47th Ohio. Died May 22, 1864, of erysipelas. Two inches upper third; by Surg. D. Mackay, 3!)th U. S. C. T. Died July 13, 1864, of tetanus. Left; two inches. Died June 3, 1864, of pyaemia. Right; in middle third; by Surg. S. C. Plummer, 13th 111. Died Jan. 14, 1865. Left; injured portion lower third. Died December 6, 1863, from secondary haemorrhage. Some further details are appended of the cases numbered 38, 94, and 108, in the foregoino- tabular statement. Case 1633.—Private IT. S. P------, Co. D, 1st DelaAvare, aged 26 years, was Avounded at the Weldon Railroad, August 25, lS-j-1, and Avas sent to AVashington, entering Lincoln Hospital August 28th. Assistant Sur- geon J. C. McKee, U. S. A., reported: " Shot fracture of tlie left liumerus, lower third, severe. Excision on the field." Acting Assistant Surgeon A. N. Sherman reported: "Gunshot fracture of left humerus. When the patient Avas admitted to AArard 14, about January 1st, he Avas much emaciated, with very irritable stomach. The discharge from the Avound was of a dark sanious color, indicating extensive necrosis of bone; his general health would not admit of an operation. Pysemia appeared to develope itself about fifteen days previous to death, which occurred January 31,1865." Acting Assistant Surgeon H. M. Dean contributed the specimen (FlG. 507), and reported: "Post-mortem January 31,1385, at 10 a. m. : Body very much emaciated; skin of a salloAV color; height five feet five and a half inches; rigor mortis not very well marked; oesophagus, larynx, and trachea healthy; both lungs appeared normal; pericardium normal; heart contained a clot—very pale, otherwise appeared normal; liver very fatty; spleen appeared normal; both kidneys very pale; lining membrane of intestine very pale; right lung Aveighed nine ounces, left nine and a half ounces; spleen six ounces; heart nine ounces; right kidney six ounces, left six and a half ounces; liver eighty-eight ounces. The left humerus was found to be badly comminuted and necrosed in its middle third, and the tissues surrounding it were of a black color." The specimen, of which a wood-cut (FlG. 507) is annexed, consists of "the left humerus six months after fracture in the lower third. The entire shaft of the bone is occupied by a sequestrum. That in the lower fragment is heavy and nearly detached. The involucrum is wanting on the anterior surface, where it appears to have been absorbed after deposit. The new deposit on the upper fragment is irregular and sparse." Case 1634.—Private G. H. Rich, Co. B, 42d Massachusetts, aged 21 years, was, on August 3, 1834, accidentally shot while on guard duty at the Government docks in Alexandria. He was admitted into Old Hallowell Hospital. Surgeon E. Bentley, U. S. V., recorded: "Gunshot, fracture of right humerus by miui6 ball. Patient was put under the influence of chloroform, and an incision having been made through the deltoid muscle, the fragments of the humerus Avere taken out and the ends of the bone saAved off, removing altogether about two inches. Operator, Surgeon E. Bentley, U. S. V. Patient reacted and progressed well until August 13th, Avhen, at 3 P. m., he was taken with a chill, and bleeding commenced immediately from the wound. The loss of blood amounted to sixteen ounces before it Avas arrested by pressure on the subclavian artery. The pulse after this was small and very indistinct at the Avrist; stomach rejecting everything intro- duced. Patient continued to sink, and died at 4 p. M. on August 14, 1834." Case 1635.—Private J. N. Gladding, Co. F, 7th Rhode Island, aged 20 years, was wounded, at Bethesda Church, June 3, 1834. He was admitted into the 2d division hospital, Ninth Army Corps. Sur- geon J. Harris, 7th Rhode Island, recorded: "Gunshot fracture of arm; resection; transferred to White House." On June 7th, the patient reached Washington, where he was admitted into Mount Pleasant Hos- pital. Assistant Surgeon C. A. McCall, U. S. A., reported: " Gunshot Avound, causing comminuted fracture of middle third of right humerus. Resection of about two and a half inches of the shaft at middle third performed on day of injury, through an incision four inches long. Operator, Surgeon J. Harris, 7th Rhode Island. On admission the arm was much swollen and erysipelatous. Muriated tincture of iron Avas prescribed in doses of fifteen drops every four hours. By June 15th, erysipelas had disappeared and the Avound was suppurating freely. On June 18th, pyaemia began to develope, of which the patient died, on July 3, 1864." The excisions were practised on one hundred and thirty Union and fifteen Confederate soldiers. Of one hundred and twenty-seven operations, sixty-one were on the right and sixty-six on the left side, this point being unspecified in eighteen cases. Thirty-six excisions were mainly in the upper, thirty-four in the middle, and sixteen in the lower third; in fifty-nine cases, the extent and situation of excision could only be surmised. Fifteen of the patients had other serious wounds, one undergoing amputation of the right great toe, Fig. 507.—Necro- sis of left humerus after shot fracture of the lower third. Spec. 3652. oso INJURIES OF THE UPPER EXTREMITIES. |CHAP. IX. another amputation at the ankle by Syme's method, a third exarticulation of the opposite arm. Twenty-five were subjected to consecutive major operations, nine to exarticulations at the shoulder, fifteen to amputations of the arm, and one to excision in the fibula. Pysemia was by far the most frequent cause of death, although there were twenty-two instances of consecutive hsemorrhage. Eleven pathological specimens are preserved. § Primary Operations, in which the Results could not be definitely ascertained.— Sixteen cases could not be traced to their termination; although there is reason to believe that a majority of them progressed favorably. Table LVIII. Condensed Summary of Sixteen Cases of Primary Excisions in the Shaft of the Humerus after Shot Injury, in which the Results could not be determined. Name, Age, and Military Description. Bcahan, B. F., Pt,, H, 33d Virginia, age ID. Byers. ept. 2). icuj. May 3, 10, '63. Sept. 20 Oct. 7, 1863. June 27. July 11, 1864. June 21. 25, '64. Aug. 18 28, '64. June 25, !9, '63. June 26. 30, '63. OrKUATioxs, Oi'kuator, Result. Right; three inches of middle third. Discharged May 14,1863; pensioned. Uight; three inches of middle third. Discharged April 29,1864; pensioned. Left; three and a quarter inches upperthird; considerable union of bone. Resigned April 11, 1864; pensioned. Left; two inches at middle tliird. Sent to Fort Mcllenry May 9, 1865. Right; two inches of lower third; A. A. Surg. J. C. Lee; shortened two inches; bony union; little powerinann. Mustered out Nov. 8, '64; pension'd; died Sept. 3, '66. Left; excision of ends of bone in middle third, by Surgeon E. A. Clark, 37th 111. Resigned Aug. 15, 1865; pensioned. Left ; excision of injured portion in middle third ; perfect union of bone. Paroled. Right; two and a half inches of upper third; by A. A. Surg. J. C. Lee; continuity above condyle removed, by A. A. Surg. Fergu- son. Discharged July 15,1864; pensioned. Two false joints; elbow joint anchylosed; com- plex arm and forearm with ap- paratus. Right; four and a half inches in upper third; by Asst. Surg. J. H. Frantz, U. S. A. Discharged June 22, 1865; pensioned. A. M. M., Spec. 2416. Left; one and a quarter inches of middle third; by A. A. Surg. T. B. Upham. Duty March 27, 1863; resigned as lieutenant Sept. 20, 1864; pensioned. Right; three and a half inches at junction of upper with middle thirds; false joint but useful limb. Discharged Feb. 25,1865; pensioned. Left; three inches of shaft; by Surg. H. Palmer, U. S. V. Dis- charged June 22, '65; pensioned; arm amputated at upper third, by Dr. A. R. Gleasou. Left; two and a half iaches at middle third; by Surg. A. Ball, 5th Ohio. Discharged Nov. 13, 1862; pensioned. Left; two and a half inches at junction of lower and middle thirds. Disch'd March 11,1863; pensioned. Spec. 145. Right; four and a half inches of shaft one and a half inches from elbow joint. Disch'd Oct. 18, 1863; pensioned. Left; resection in lower third; gangrene, Oct. 29th. Nov. 30th, doing well. Right; two inches of upper third; by A. A. Surg. J. AV. Digby. Disch'd Dec. 26,1864; pensioned. Right; three inches middle third; by O. A. Judson, U. S. V. Dis- charged June 23, '65; pensioned. Right ^ four inches at upper and middle thirds, by A. A. Surg. AV. C. Mulford; ends of bone firmly united. Disch'd Oct. 2, 1864; pensioned. Spec. 3554. Left; fragments removed and frac- tured ends sawn off, by Surg. I. Moses, U. S. V.; bony union. Duty Aug. 1,1864; disch'd Oct. 11, 1864; pensioned. Spec. 1754. Left; two inches of upper third; by Surg. J. S. Reese, 68th Ohio. Disch'd Oct. 27,1864; pensioned. Name, Age, and Military Descru'tion. Fausel, C, Corp'l, A, 50th Illinois, age 27. Franz, AV., Pt., F, 132d Penn., age 20. George, J. N., Serg't, E, 7M Illinois, age 27. Gleason, P., Pt., H, 5th New York, age 21. Gleeson, J., Pt., G., 14th Infantry, age 28. Glenn, D. M., Corp'l, K, 1st Penn. Rifles, age 21. Hall, J. H., Pt., A, 9th Maine, age 23. Hance, I., Pt., F, 14th New Jersey, age 18. Herman, A., Pt., C, 48th New York, age 42. Horton,E., Pt., 1,1st Wis., age 29. Jarvis, W. D., Pt., D, 98th Ohio, age 23. Johnston, D., Pt., F, 103d Penn., age 23. Keeney, Alexander, Pt., F, 141st Penn., age 30. Kinsley, T., Pt., C, 107th Penn., age 17. Landgrove, J. M., Pt., A, 15th AVisconsin, age 18. Long, G. B., 2d Lieut., F, llth Virginia, age 24. Loyd, M., Pt., F, 100th Pennsylvania, age 23. Maynard, H., Pt., C, 7th New Hampshire, age 31. McAllister, J. A., Pt., I, 149th New York, age 24. McCully.A. S., Corp'l, C, 2d Penn. Reserves, age 20. McCullough, D. G., Pt., A, 54th Penn., age 24. April 6, 10, '62. Sept. 17, 27, '62. Nov. 30, Dec. 10. 1864. Aug. 31, Sept. —, 1862. June 27, July 23, 1862. Dec. 13, 17, 'C2. Sept 29, Oct. 3, 1864. May 30, June 6, 1864. Feb. 20, Mar. 9, 1864. May 26, June 9, 1864. Oct. 8, 16, '62. Dec. 14, 1862, Jan. 13, 1863. Julv 2, 8, ''63. Sept. 17, 26, '62. May 27, June 3, 1864. July 3, 15, '63. Mar. 25, April 24, 1865. Feb. 20, Mar. 9, 1864. Nov. 24, Dec. 7, 1863. Dec. 13 19, '62. May 15, 22, '64. OrERATIOXS, OrEUATOR, Result. Left; four inches; by Surg. H.AV. Kendall, 50th 111". July, 1862, ends tf bone sawn off. Disch'd Oct. 13, 1862; pensioned. Left; six inches of shaft of upper third; by Surg. G. Grant, U. S.V. Disch'd Dec. 12,1862; pensioned. Spec. 814. Right; three inches of upper third; by A. A. Surg. J. H. Mclntyre. Disch'd June 6, 1865; pensioned. Died July 16,1673, of erysipelas from injury to arm. Right; in lower third, by Surg. T. Crosby, U. S. V. Discharged Dec. 26, 1862. Elbow joint an- chylosed; false joint; pensioned. Died July 6, 1873, of phthisis. Left; four inches; by Dr. Gilfillan. Disch'd Feb. 9,1864; pensioned. Nine operations for removal of bone performed; free use of el- bow joint and shoulder. Right; three and a half inches at middle third; amputation at up- per third, V. R. C. Sept. 9,1863; pensioned. Spec. 1066. Left; two inches middle third. Discharged June 17, 1865; pen- sioned. Right; removal of fragments and ends sawn off, by Surg. N. It. Moseley, U. S. V. Deserted Aug. 24, 1864; not pensioned. Spec. 2505. Right; fourinches of upperthird; by A. A. Surg. J. T. Kennedy; partial union; bids fair to make a useful arm. Discharged Oct. 3, 1865; pensioned. Left; by Asst. Surg. C. C. Byrne, D. S. A. Disch'd April 8,1865, and pensioned. Left; upper third to surgical neck; by A. A. Surgeon A. S. Green. Disch'd Jan. 22, 1863; useful arm; pensioned. Spec. 340. Right; two and a half inches lower third; no union; arm amputated. Discharged Nov. 25, 1863; pen- sioned. Left; three inches middle third; by A. A. Surg. H. Leernan. To V. R. C. Sept. 17, 1864; bone ununited; pensioned. Left; two inches; by A. A. Surg. I. Sweet. To V. R. C. May 3, 1864 ; pensioned. Spec. 821. Left; two and a half inches mid- dle third; by Surg. S. B. Haw- ley, 35th Illinois. Disch'd Dec. 17,1864 ; union. Not a pensioner. Right; three inches upper third; by A. A. Surg. B. F. Butcher. To FortMcHenry Nov. 12,1863; recovered. Right; three inches upper third; by Surg. G. L. Pancoast, TJ. S. V. Discharged July 24, 1865; pensioned. Spec. 4292. Right; five inches lower third; by A. A. Surg. AV. Balser. Dis- charged September 7,1864; pen- sioned. Arm nearly as strong as the other. Died March 15, 1872. Right; three inches middle third; by Surg. I. Moses, TJ. S. Ar. Dis- charged Jan. 26,1865; pensioned; useful hands. Spec. 2143. Right; four inches lower third; by Surg. E. Donnelly, 2d Penn. Reserves. To V. R.*C. Feb. 24, 1864 ; pensioned; anchylosis. Left; two inches of shaft; by Surgeon J. B. Lewis, U. S. V. Discharged Jan. 31, 1805; pen- sioned ; bone united. ass INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. NO. 43 47 48 49 50 51 Name, Ace, and military description. McKeever, J. E., Serg't, G, 101st Ohio, age 22. Miller, R. R., Corp'l, D, 4th Minnesota. Patton, G., Pt., I, 86th Indiana, age 23. Peet, C. C, Corp'l, F, 121st New York. Potter, X. F., Serg't, E, 149th New York, age 36. Rechel, C, Pt., G, 34th Ohio, age 22. Smith, A., Pt., A, 9th N. Y. Heavy Artillery. Sprav, J. C, Serg't, G, 71st Ohio, age 28. Stahl, AV., Pt., D., 150th Penn., age 26. Stevenson, J. V., Serg't, E, 96th Ohio, age 31. Dates. Oct. 8, 21, '62. May 22 June 3, 1863. May 27 June 17 1864. May 3, 11, '63. Nov. 24, Dec. 7, 1863. July 24, 29, '64. July 9, 17, *64. Dec. 16, '64, Jan 10, '65. July 1, 20, '63. April 8, 12, '64. Operations, Operator, Result. Right; four inches lower thirds by A. A. Surgeon N. M. Elrod. Discharged Jan. 1, 1863; pen- sioned ; useful arm. Spec. 339. Right; five inches middle third. Disch'd Oct. 22, 1833, and pen- sioned; arm amp. in Oct., 1865. Left; four inches upper and mid- dle thirds; by Asst. Surg. C. C. Byrne, U. S. A. Disch'd Dec. 7,1864, and pensioned. Right; five aud a half inches from one-half inch below surgical neck to three inches above condyles. Disch'd Dec. 12, 1863, and pen- sioned. Right; three inches upper third; by Surgeon I. Moses, TJ. S. V. Disch'dJuly22,1864; pensioned; loss of use of arm. Spec. 2142. Right; fractured ends at junction of upper and middle thirds; by Surg. J.B.Lewis, U.S. V. Dis- charged Nov. 7,1864; pensioned; bone ununited. Right; fourinches middle third; by A. A. Surg. P. Middleton; arm amputated. Disch'd March 31, 1865, and pensioned. Right; two inches upper third; by Surg. J. H. Grove, U. S. V.; amputated. Disch'd May 16, 1865, and pensioned. Left; two large fragments at junc- tion of middle and lower thirds; by A. A. Surg. AV. V. Keating, Disch'd June 17,1865; pensioned; union firm. Left; three inches lower end of upper third. Disch'd July 31, 1865; pensioned; paralysis. Name, A he, and Dvtfec. 11 27, '62. July 1, 26, '62. Julv 3, •JO. 'ii:!. Mar. 25 April!, 1865. Oct. 19, Nov. 5, 1864. liight; three and a half inches middle third ; by Surgeon C. A. Uougill, (_',. H. A.; disarticulation at shoulder joint Jan. 8, 1863. Died Jan. 8, 1863, of pysemia. Spec. 1327. Left; lower third; bv Ass't Surg. J. M. Study, U. *S. V. Died Jan. 15, 1865, of typhoid fever. Left; one inch upper third; by A. A. Surg. I). Kennedy; four ins. of shaft at .junction of middle and upper thirds removed Jan. 26, 18U3. Died Feb'y 7, 1863, of chronic diarrhoeaand pneumonia. Right; by Surg. AV. S. Heath, 2d Mass. Died July 23. 1863. Right; four inches at middle third; by Ass't Surg. II. Allen. U. S. A. Died April 26, 1865, of pyasmia. Left; two inches middle third; hy Ass't Surg. J. Ilomans, jr., IT. S. A. Died November ID, 1864, from exhaustion. Twenty-six Union and three Confederate soldiers are enumerated in this series. Nineteen of the operations were on the right, and ten on the left arm. The usual predomi- nance of operations in the middle and upper thirds obtained. Pysemia and haemorrhage were the principal causes of death; one patient succumbed from tetanus. Eight cases furnished specimens to the Museum. There were six major consecutive operations, includ- ing two exarticulations at the shoulder. An account of one of them is subjoined: Case 1G37.—Private C. Gallagher, Co. C, IGOth NeAV York, Avas Avounded at Cold Harbor, June 1, 18G4. Surgeon S. A. Richardson, 13th New Hampshire, reported, from the base hospital ofthe Eighteenth Corps: "Shot Avound of right shoulder." On June Sth, he was transferred to the Methodist Church Hospital, Alexandria. Surgeon T. E. Spencer, U. S. V., reported: "Shot wound of right arm, upper third. Ball entered anterior margin of deltoid muscle, fracturing the humerus. Eesection ou field. Transferred to Albany, September 27. 1834. Acting Assistant Surgeon O. H. Young reported: "Wounded June 1, 1334, by a ball passin g through and fracturing the upper third of the humerus. On June Gth, in a hospital at White House Landing, exsection was performed, ahout two and a half inches of the liumerus being removed, beginning about an inch beloAV the surgical neck. A day or tAvo afterward he was removed to the Methodist Church Hospital in Alexandria. HeAvas admitted to this hospital September 27th. At this time he was anaemic, and had a constant and very troublesome cough. There Avere three sinuses in his arm, Avhich discharged large quantities of pus. Exploration Avith the probe shoAved the entire shaft ofthe hone to be carious, and in some places necrosed. His appetite failed; he Avas restless and anxious, and his general health continued to fail until it became evident that he could not recover unless the armAvere amputated. Accordingly, on January 12, lS3o, the operation Avas performed by Acting Assistant Surgeon Henry Pearce. The head of the bone was carefully disarticulated, and, last of all, the inner flap Avas made. Scarcely any blood was lost, and the patient appeared quite as strong as he Avas before the operation. He continued to improA'e daily, and, on January 19th, AA'as in excellent condition. The Avound has apparently healed by the first intention, and his general health is better." Dr. Young also forwarded the specimen (Fig. COD), Avhich consists of " the right humerus amputated at tho shoulder joint for necrosis of the shaft after excision of two and a half inches of the upper third. The upper extremity is someAvhat rounded, but spongy. A large sequestrum, around Avhich there is an exceedingly imperfect' and scanty involu- crum, occupies nearly the entire shaft." (Cat. Surg. Sect., 186 i. p. 112.) Assistant Surgeon J. H. Armsby. U. S. V., subsequently reported that the Avound seemed to do Avell after the operation, but the general health continued to fail. The symptoms of phthisis progressed rapidly until death, Avhich occurred March 3, 1865." Dr. Armsby contributed a cast in the case (FlG. 510). "There is great emaciation, causing remarkable prominence of the anterior border and head oi the scapula. The cicatrix is nearly linear, extending doAvnward from the acromial process into the deep hollow underneath." (Cat, ' . .. r .... ,,i FIG- 510.—Cast from a case of exarticulation op. cit, p. 547.) This is one of many instances in Avhich, could the following a secondary excision of the shaft of the end have been foreseen, primary exarticulation would have been Uumerus. Spec. 38.1. regarded as the preferable and most truly conservative operation. FlG.50!).-Xecrosis ofthe h umerus after excision fur shot in- jur}'- Spec. 3008. (M) INJURIKS OF THE UPPER EXTREMITIES. [CHAP. IX. Secondary Excisions in the Shaft of the Humerus. —■ Forty-one examples were reported in tins category, with a very low rate of mortality. § Cases of Recovery.—Thirty-six of the patients who underwent this operation recovered. A few detailed illustrations will precede the table: Case 1638.—Private P. Murray, Co. H, 70th NeAV York, aged 20 years, Avas Avounded at Williamsburg, May 5,18t*>2, and Avas admitted to Chesapeake Hospital, Fort Monroe, on the 9th. Here the patient states resection Avas performed by Surgeon R. B. Bontecou, U. S. V. He Avas sent north on the 22d, and Avas treated in the Twenty-second and Wood Streets Hospital, Philadelphia, until January, 1863, Avhen beAvas transferred to Sixteenth and Filbert Streets Hospital. Acting Assistant Surgeon A. D. Hall made the folloAving special report: "While not more than fifty yards from the enemy this man avus struck by two minie* bullets, which entered the outer side of the upper third of the left arm about three and a half inches apart, in a line parallel Avith the liumerus; the upper one passed entirely through behind the bone, the other striking and comminuting the bone to such a degree as to render it a comminuted fracture, at the same time that it became arrested among the fragments, Avhere it remained about tAvo months, Avhen it Avas remoA*ed, together Avith eight fragments of bone, the patient being at the time at Fort Monroe, to Avhich place he Avas taken immediately after receiving his Avounds. In the folloAving July he was transferred to Philadelphia and taken to the TAventy-second and Wood Streets Hospital, Avhere he remained under treatment until February 1, IH63. Avhen be Avas brought to this house Avith a number of others. The Avounds of entrance and exit of the upper ball, at this time, were healed entirely, Avhile there Avere tAvo orifices communicating Avith the carious cavity of the loAver Avound, one on the outer side, Avhere the ball entered, the other on the inside, the result of an abscess; from these there aviis considerable discliarge of pus. The Avound Avas dressed Avith simple cerate, and the arm supported by a proper splint and roller. This treatment Avas continued, and the administration of tonics commenced. On exploration Avith a probe, it Avas found that tliere existed in the cavity of the lower Avound considerable dead bone, Avhich, upon consultation, it Avas decided to remove. Accordingly, on the 21st instant, at half past ten o'clock, the patient being in excellent condition, ether Avas given, and the operation commenced. An incision, about five inches in length, Avas made on the anterior and outer side of the arm in the line of the cicatrix; it Avas carried down to the bone and parallel Avith its axis. The fragments Avere found to be imperfectly united, as there Avas fibrous instead of bony union, and, as a consequence, motion existed to a certain extent betAveen them. One piece of bone, three-fourths of an inch in lengtli by half an inch in breadth, Avas removed. The haemorrhage during operation was slight, about four ounces of blood being lost; Avhen it Avas checked the Avound Avas closed by means of pins, with points of interrupted suture intervening between them, and adhesive strips. The limb AA*as placed upon a straight splint and bandaged, and cold Avater was kept applied over the Avhole arm by means of a saturated toAvel. In two hours after the commencement of the operation the patient Avas placed in bed, and Avas comfortable at .-even o'clock in the evening, having been someAvhat affected in the afternoon Avith sickness of the stomach from the effects of ether. The case is progressing favorably." In May, 1833, the patient was transferred to NeAV York City, entering Ladies' Home Hospital, and Avas thence discharged the service and pensioned May 17, 1864. Surgeon A. B. Mott, U. S. X., certified to: ''Ununited fracture of left humerus folloAving exfoliation of bone from gunshot Avound." Examiner G. S. Jones, of Boston, March 3, 1865, reported: "The Avound was in the middle third of the left arm. In conse- quence of necrosis of the bone having taken place, the liumerus is now ununited. Fistulous openings exist about the Avounded parts, from Avhich matter is discharging. The arm is now nearly powerless and useless." This man subsequently entered tbe Boston City Hospital. Dr. H. J. BigeloAV reports the case in the Boston Medical and Surgical Journal, volume 76, page 332, as folloAvs: "* * * In November, 1865, he entered the hospital. The left humerus had a false joint at its middle. There Avas necrosed bone at the bottom of a couple of sinuses in the loAver fragment. An incision was made over the fracture, the perios- teum reflected, and the ends of the bone saAved off. In March, 1866, there Avas no union. March 31st, Dr. Bigelow again operated. The periosteum Avas detached from both fragments for a sufficient distance; about one and a half inches Avas sawed off from the loAver, and one inch from the end ofthe upper fragment. The ends Avere drilled, silver wire inserted, and the frag- ments placed in apposition. The periosteum Avas then replaced and its edges united hy sutures. April 28th, the arm had stiffened at the point of fracture. June 10th, he fell upon the arm and broke it. July 15th, he Avas discharged Avith an ununited fracture, to return Avhen the arm looks and feels better. January 12, 18(17, operation by Dr. BigeloAV. Patient Avas etherized. An incision three inches long Avas made over the outer aspect of the arm aiid carried carefully doAvu to the point of fracture. The two ends Avere found to be much roughened. Great difficulty Avas experienced in everting the ends of the hoav short fragments and in detaching the periosteum. The bone Avas finally separated from the periosteum for a sufficient distance, and a piece one inch long saAved from the upper, and one three-quarters of an inch long from the lower fragment. The loAver fragment Avas tAvo inches in diameter; the upper one Avas of normal size, but Avith fatty degeneration of the marroAV. A hole Avas drilled through the sides of both fragments, a silver Avire Avas inserted, the ends Avere placed in apposition and the wire twisted. The periosteum Avas replaced and its edges united by sutures. The external Avound Avas partly closed by sutures. A folded towel Avas placed in the axilla to lift out the short upper fragment, and the arm secured to the side, the forearm across tlie chest. 13th: There is almost complete paralysis of the extensors of the fingers of the left hand. No nervous Trunk was knoAvn to have been divided in the operation, and the paralysis is perhaps due to a compression of the nerve in very forcibly everting the shortened fragments. 21st: The arm Avas placed in an apparatus, Avhich consists of a firm cap about the shoulder, secured by a strap around the chest; this is made firm by two steel bridges to a splint that invests the forearm like a coat sleeve. 27th: The arm remains in excellent position. The poAA'er of extension is returning to the fingers. February 3d, the wound is contracting by healthy granulation. 6th : Slight stiffening at point of fracture. 16th : Phosphate of lime ordered, ten grains, three times a day. March 4th, alloAvedto Avalk about. April 16th, the humerus is quite firm at the point of fracture. He Hexes the forearm and raises the humerus from the side freely. 22d: Discharged, probably Avell, although sufficient time lias not elapsed to determine the fact. As will be readily inferred, this humerus Avas materially shortened hy these consecutive si-.ot. iv.i EXCISIONS IN THE SHAFT OF THE HUMERUS. cm operations—tAvo before entering the hospital, and three subsequently by Dr. Bigohnv. In fact, by measurement, it Avas seven inches shorter than its felloAV, yet the biceps and triceps Avere fulfilling their functions, and the patient Avas regaining excellent, motion. There can be no comparison in the value of an arm of this sort, however short, and an ununited humerus. In the first operation, and during the existence of undefined necrosis, the bony tissue of tlie substance ofthe lower fragment Avas of a reddish hue, and of a dense, brittle, and amorphous texture, sometimes to be observed in the denuded walls of the cavities of sequestra Avhen chiseled. At the end of about a year, at the next operation, Avhen the probe no longer detected dead bone, the operator Avas agreeably surprized to find that this tissue had given place to a comparatively healthy one, Avith cancellated interior." The fragments of bone removed at the two first operations of Dr. Bigelow, Avith one of the Avires, are sbown as specimen No. 100S of the Warren Anatomical Museum, Harvard University. (See Desc. Cut, Boston, IH70, p. 165.) The pensioner Avas paid June 14, 187 1. The next case was also an example of resection for pseudarthrosis following shot injury: Cask 1530.—Lieutenant T. Michener, Co. A, 1st Ncav Jersey Cavalry, aged 27 years, Avas wounded at the Wilderness, M: y 5, 1854. He remained at a cavalry corps field hospital for several days, and was thence conveyed to Seminary Hospital, Coorgctown, on May llth. Surgeon II. W. Diuachet, IJ. S. V., reported: "Gunshot fracture of middle third of left humerus liy a minie ball. Several days after admission tlie patient Avas furloughed. On July 2d, Avhen returning to the hospital, the original wound had nearly healed, but the fracture was found ununited and the end ofthe bone rounded and covered with callus. Constitutional condition very good. On July 7th, chloroform Avas administered and one inch of the humerus excised. Favor- able progress followed the operation. On September 25th, tbe patient again left the hospital on furlough." On October 22d, be was admitted to Division Hospital No. 1. Annapolis. Surgeon B. A. Vanderkeift, U. S. V., noted: '' I'esection of left liumerus." Lieutenant Micbener Avas discharged from service on December 2, 1834, and pensioned. Examiner W. Corson, of N'orristown, Pennsylvania, April 12. 1855, certified: "The avouikI Avas received about the middle of the humerus, left ann; Avas resected about tAvo months after injury, and is now reunited and firm, Avith shortening of not more than half to three-fourths of an inch." The Philadelphia Board, consisting of Drs. .J. Collins, H. E. Coodman, and T. II. Sherwood, certify, on October 13, 1873 : " Cicatrices adherent to bone and three inches long; arm Aveakened, curved, and muscles bulging." The disability Avas rated total. Pensioner has been paid to March 4. 1875. Imperfect consolidation or non-union and pseudarthrosis, unusual after expectant treat- ment of shot fractures of the humerus, were not infrequent after excisions in the continuity. The majority of the cases in this series, however, were of the nature of operations for necrosis, as in the following instance and in the abstract succeeding the tabular statement: Cast. 1640.—Serjeant J. W. Ross, Co. C, 93d New York, aged 25 years, Avas Avounded at Petersburg, June 22. 1~G 1. He Avas sent to Philadelphia, and entered Filbert Street Hospital. Assistant Surgeon S. J. StorroAv, U. S. A., noted: " Gunshot fracture ofthe humerus, not involv- ing the joint." The patient was transferred to McClellan Hospital April 28th, and subsequently entered Ira Harris Hospital, Alabany. Assistant Surgeon J. H. Armsby, U. S. V., contributed the specimen (FlG. 511), with the following history: " Patient Avas Avounded in the left arm, the ball injuring the humerus. Admitted July 20, 1865. The arm continued SAVollen and inflamed, and seA'eral fistulie made their appearance. September 26, 1865 : On exploring Avith the probe, they Avere found to lead to a large sequestrum, Avhich was accordingly removed. A large incision was made, about five inches long, and the dead bone removed Avith the forceps. Ether Avas adminis- tered. Simple dressings applied." The specimen consists of four fragments of a sequestrum, four inches in length, from the left liumerus, three months after gunshot fracture. About one-third of the circumference is involved (Cat. Sjrj. Szct, 1836, p. 137). The patient Avas discharged November 30, 1805, and pensioned. Examiner E. W. Howard, October 3, 1865, certified: "Shot through the left arm near the shoulder, breaking the humerus, followed by extensive gangrene and sloughing ofthe muscles, leaving the entire arm utterly useless for any practical purpose, the remaining flesh having adhered firmly to the bone nearly the Avhole length of the arm." Examiner F. J. Bancroft, of Denver, Colorado, September 13, 1*7 3, certified: "There is atrophy of tbe left arm, and it is entirely useless for manual labor." The disability Avas rated total. The pensioner from a"hUmenis fractured by shot. was paid March 4, 1875. Spec. 40lfi. A. Of the thirty-six operations—thirty-one practised on Union and five on Confederate patients—fourteen were on the right and twenty on the left side, the point being unspecified in two cases. The middle third was chiefly implicated in fourteen, the upper in twelve, the lower in ten cases.1 Twenty-five men were discharged, five paroled or exchanged, six returned to modified duty. Twenty-eight were placed on the pension list, two of whom have died. Troublesome gangrene appeared after three of the operations, and obstinate haemorrhage in one. 'The extent of bone removed is specified, in 23 of the operations, as one inch in 4 cases, two inches in !) cases, two and a half or three inches hi 3 ea>e». three and a half inches in 3 cases, four inches in G cases, five inches in 1 case. INJURIES OF THE UPPER EXTREMITIES. [chap. IX. Table LXI. Condensed Summary of Thirty-six Successful Second try Eecisions of the Shaft of the Humerus for Shot Injury. Namk, A<;k, and Military DrscRirriox. dough, P.. Pt.. G, 88th Indiana, age 28. Boswicre, P., Pt, D, Cth Wisconsin, age 21. Broughton, J., Pt., G, 6th Infantry, age 31. Claffcy, H., Pt., C, 21st Massachusetts. Darby, J., Pt., G, 96th Illinois, age 22. Dusty, P., Pt., I, 31st Maine, age 16. Ezekiel, I. D..Lieut., 10th AA'cst Virginia, age 22. l-'isk, C. A., Pt., K, llth Massachusetts, age 21. Floyed, E., Pt., I, 2d Georgia, age 30. Hill, M.. Pt., 15, Sth Louisiana. Johnson, A., Pt., II, 7th New Jersey, age 21. Kahlmever. AV., Serg't, E, 8th*N. York, age 40. Kanery, J., Pt., A. 9th Massachusetts, ago 37, Linn, C.. Corp'l, II, 15th Ohio, age 31. Marrh, J. H., Lieutenant, Scott's Batter v. 16 i Mieheuer, T.. Lieut., A. 1 st New Jersey CaA'alry, a^c 27. IT Miller. IL. Pt., M, 3(3 i II. Island Art'a*, age 35. Murray. P., Pt.. II, 70th New A'ork, age 22. late Confederate Feb. 23. Dec. 16, 1864. May 8, Dee. 6. 1864. Mav 2, Dec. 20, 1863. Mar. 14. April 15, 1862. Sept. 20, Nov. 26, 1863. May 10, Juno 13, 1864. July 7, Aug. 22, 1864. July 2, —, '63. June 27. Dec. 17, 1862. Sept. 1, 1862, Aug. 20, 1863. July 2, 1863, June 5, 1864. June 8, Aug. 19, 1862. July 1, 1862, Feb. —, 1863. Mav 27, Sept. 4, 1864. Sept. 19. Oct, 21, 1863. May 5. Juiv 7, 1864. Aug. 30, 1863, Feb. 25, 1864. MaAT 5, 18*62. Feb. 21, 1863. Mav 3, 1863, Jan. 9, 1864. Operations, Oi'krator, Result. Left; two inches loAver third; bv Surg. G. Grant, U. S.V. Disch'd March 20, 1865; pensioned; an- chylosis. Right; four inches upper and mid- dle thirds; by A. A. Surg. H. S. Strcetcr. U. >S. A. Disch d June 7. 186."); pensioned; bony union; anchylosis. Right; necrosed bone, lower third; by Ass t Surg. H. E. Brown, U. S. A. Disch d March 29, 1864; pensioned. Left; three inches upper third; by Surg. AV. II. Church, U. S .V. Duty July 10, 1862 ; pensioned; arm useful; atrophied. Left; two inches middle third; by A. A. Surg. M. L. Herr. U. S. A. To V. R. C. Aug. 26, 1864; pro- gressed finely; pensioned. Left; three and a half inches; bA" A. A. Surg. F. G. II. Bradford, U. S. A. Disch'd Jan. 14, 1865: pensioned. Died April 10, 1866. Right; lour and a half ins. lower third; by Dr. AV. II. Mussey. Disch'd Mar.9.1865; bony union; full use of arm; not a pensioner. Left; four inches upper third ; by Dr. Hodges. Disch'd Mar. 15, 1864; necrosis; pensioner. Dead bone to the extent of at least one-half the original; use of arm restored. Left; diseased ends of bone in lower and middle thirds. Re- covered. Right; portion of humerus; by A. A. Surg. M. B. Richardson. Disch'd Oct, 7,1864 ; pensioned; arm useless. Right; nineteen fragments upper third; by A. A.Surg. S.D. Gross. Disch'd'Jan. 28,1863; pensioned. Left; twoinches uppcrand middle thirds; by Dr.Hodges, Soldiers' Home, Boston. Disch'd Nov. 5, 1862; pensioned; no bony union. Right; one inch ; by A. A. Surg. A. Buckingham. Disch'd March 17,1865; pensioned; anchylosis. Left; about fourincheslowerthird. Recovered. Left; one inch middle third; bv Surg. II. AV. Ducachet, U. S. X. Disch'd Noa\ 2,1864; pensioned. Left; portion of shaft; by A. A. Surg. J. XV. dishing, U. S. A. Disch'd Aug. 5. 1864; pensioned. Left; necrosed portion of middle third. Disch'd May 17, 1864; pensioned. Five inches upper third; by Dr. Schmidt; no bony union. 20 Name, Age, and Military Description. Phillips, H. W., Pt., F, 1st Michigan Cavalrv. Pollock, G., Captain. E, 78th, Illinois, age 23. Reeves, P. S., Serg't, G, 23d Kentucky, age 23. Riffle, J., Pt., F, 10th AVest Virginia, age 25. Robbins, L. N., Pt., C, 9th New York CaAralry, age 27. Ross, J. AV., Serg't, C, 93d New York, age 25. Sarbach, D.,Pt., A, 107tb Ohio, age 37. Shultz, E., Pt., I). 102d New York, age 3J. Snider, D., Pt., E, 74th Illinois, age 19. Spinner. J., Corp'l, G, 28th Ohio, age 33. St. Clair, L., Pt,, "M, 2d Ohio HeaA-y Artillery, age 22. Taylor, C. A.. Tt., I, 4th Georgia, age 22. Tucker, AV. A., Pt., E, 49th Ohio, age 22. Ward, J. IL, Pt., C, 36th Illinois, age 25. Wareham. II. IL, Pt.. A, llth Penn'a Reserves, age 20. AVittgenfeld, R., Pt., B, lOtiiOhio, age 21. A\roodward. J.W., Lieut., I, 26th Penn., age 27. Sept. 20, Oct. 22, 1863. May 27, Julv 5, 1864. Nov. 6. Dec. 26, 1863. May 12, 1864, Jan. 27, 1865. June 22, 1864, Sept. 26, 1865. July 1, Oct, 11, 1863. Dec. 18, Mar. 25, 1865. May 17, Mar. 19. 1865. Nov. 6, '63. Op- erat'n in 1864. April 10, June 20, 1865. Mav 10, Ana:. -, 186-1. A piil 15. Julv 14, 18*53. Sept. 20, 1863, Jan. 22, 1864. Line 30, Aug. 2, 1862. Oct. 8, Dee. 10, 1852. Mav 3, 1863. orekations, operator, Result. Right; fragments remoA-ed and ends of bone sawn off three and a half inches above external con- dyles, by Surg.AA*. .Al. Breed, 11. S. V.; fracture united. Disch'd March 13, 1863; pensioned. Right; about two inches of shaft; by Ass't Surg. AV. W. AVvthes, U. S. V. Duty April 19, "l Sol; resigned June 27, 1864; pen- sioned ; arm useless. Right; two and a half inches of middle third; by Dr. A.Mel Irow. Duty Nov. 15, 1864: pensioned: complete bony union; arm of great service. Left; three and three-quarter inches lower third ; by Surg. C. E. Denig, 28th Ohio; arm amp. Feb. 8th ; healed. Disch'd Oct. 24, 1S64; pensioned. Left; two inches at middle third; by A. A. Surg. J. F. Thompson. Discharged May 31, 1865; pen- sioned. Left; four inches cf humerus; by Ass't Surg. J. II. Armsby. Dis- charged Nov. 39, 1865; pen- sioned. Spec. 4016. Left; one and a half inches of hu- merus; by A. A. Surg. E. A. Kcerper. Disch'd April 18,1865; pensioned. Right; nearly one-half inch re- moA-ed from each end; bv Ass't Surg. S. II. Orton. Diseh'd July 14, 1865; pensioned. Left: two inches: by A. A. Surg. R. N. Isham. Disch'd June 12, 1865; pensioned. Left; excision of a large portion of middle third. Disch'd July 23, 1864; pensioned; can use hand well for light work. Left; ends of bone at middle third; by A. A. Surg. T. XV. Baugh. Disch'd Sept. 15, 1865; pen- sioned. Died Dec. 12, 1865. Left; excision of portion of upper third. Transferred to Old Capi- tol Prison Noa'. 1, 1864. Right; three and a half inches at upperthird. Veteran Reserves; not a pensioner. Right; by A. A. Surgeon J. II. CooAer: subsequent remoA'al of extremities of both fragments: no bony union. Mustered out Sept. 13. 1864; pensioned. Right: two inelies middle shaft; by Surg. A. B. Ilasson, U. fi. A.; firm union. A'. R. C. Aug. 30. 1863; not a pensioner. Spec. 434. Left: two inches just below head; by Ass't Surg. B. H. Cheney. Disch'd Jan. 24.1063: pensioned. Right, at upper third: by Dr. Lea- vick. Transferred to V. R. C: disch'd April 1, 1867; pensioned: anchylosis of shoulder joint and loss of power of whole limb. Cask l!>41.—Private H. II. Wareham, Co. A, llth Pennsylvania Reserves, aged 20 years, was wounded in the right arm at "White Oak Swamp, June 30, 18G2. He Avas captured by the enemy and conveyed to Libby prison, at Richmond, at Avhich place he remained until paroled and sent to Baltimore, where he entered Camden Street Hospital on- July 25th. Surgeon A. B. Hasxiti. U. S. A., on August 2d, excised tAvo inches of the middle third of the shaft of the humerus, and subsequently, on Jan- uary 22. 1-33, he removed eleven necrosed fragments, Avhich he contributed to the Army Medical Museum (Cat. Surg. S-ct., lsi;i. p. 133, Spec. 434). On July 2d. the patient Avas transferred to Point Lookout Hospital, Avhere Surgeon A. Heger, U. S. A., recorded: "Gunshot Avound of right humerus." Subsequently the patient Avas transferred to Convalescent Camp at Alexandria, and on August 30, 1S33, he Avas assigned to tlie Veteran Reserve Corps. He is not a pensioner. An account of this ease was published by Acting Assistant Surgeon G. H. Dare, in the American Medical Times, Vol. VI. p. 203, 18o3, as folloAvs: "Private Wareham was Avounded through the middle of the arm. He Avalked a mile to a field hospital, Avhere his Avound Avas bandaged. SECT. IV.1 EXCISIONS IN THE SHAFT OF THE HUMERUS. 693 On July 1st. he was captured by tbe Confederates and sent to Richmond, Avhere he endured the usual hardships at the Lobby prison until he Avas paroled and sent to Baltimore. He was admitted into the United States Army Hospital, Camden Street, Baltimore, July 25th. A musket ball had passed horizontally through the right arm from behind forward, fracturing the humerus in its middle third. Lateral splints Avere applied for the first time, and cold-water dressings. August 2d, union not having taken place, the fractured extremities were resected, about two inches of the bone being removed. The elbow Avas after- ward Avell supported, but it Avas found impossible to keep the ends of the bone in immediate apposition—the finger for a long time could be passed between them. Notwithstanding this dilficulty, Avithin two months, union, at first of a cartilaginous or lymphatic nature, had taken place, and then osseous matter was gradually deposited. A fistulous orifice continued in front, and some dead bone being detected Avith tbe probe, the orifice Avas expanded January 22d, and several small sequestra, entirely detached, Avere removed. Osseous union was ascertained to be perfect. February Gth, there is still a trifling discharge from the anterior opening. The man can take off his cap without difficulty. Some stiffness of the muscles exists, Avhich is rapidly passing away. There is every probability of his regaining almost perfect use of the limb." There were in this series three instances of unsuccessful operations for pseudarthrosis, and one of consecutive amputation of the arm. § Fatal Secondary Excisions.—There were but five instances of fatal results after secondary excision of the shaft; one of them is detailed : Case 1G42—Corporal W. A. Armstrong, Co. B, 31st Maine, aged 23 years, Avas wounded at Petersburg, July 30, 18G4, and Avas admitted into 2d division hospital,. Ninth Army Corps. Surgeon J. Harris, 7th Rhode Island, noted : " Gunshot fracture of left arm; excision of humerus." On the second day after the reception of the injury the patient was transferred to City Point, and thence to Lovell Hospital, Portsmouth GroA'e. August 7th, Surgeon C. O'Leary, U. S. V., reported: " Gunshot fracture of left humerus, upper third. Patient furloughed November 30th, and readmitted on January 24th. At this time there Avas thorough cicatrization of the external Avound; formation of false joint by re-absorption of callus; ligamentous union. On January 31st, resection of two inches ofthe upper third ofthe bone Avas performed, by Acting Assistant Surgeon E. Seyffarth, through a longi- tudinal incision four inches long. Anassthetic: Chloroform and ether. Reaction prompt; considerable loss of venous blood attended the operation, but uo arterial haemorrhage. The arm was lightly bandaged, and the bones Avere brought in contact and secured by an elbow splint. Sutures Avere entirely dispensed with, as the edges of the avouucI were easily held in contact by the bandage and adhesi\'e strips, the muscles having been someAvhat relieved by a cross cut, about half an inch deep, in order to do away Avith the 'pockets' formed after pushing both ends of the bone together. During the first six days progress seemed favor- able; but on the eighth day there Avas a severe chill, which Avas repeated every day or every other day; appetite failed; diarrhoea set in, and patient rapidly sank. On the ninth day several abscesses appeared on the inner surface ofthe arm. These, together with the Avound, Avhich had become partially reopened by the extreme tension caused by the swelling of the Avhole arm, were discharging an ichorous serum mixed Avith pus, and extremely offensive. The treatment consisted of cold-Avater applications in the beginning, and aftenvard of free use of solution of permanganate of potassa, stimulants as freely as could be borne, generous diet, muriated tincture of iron, &c. Death occurred on February 19, 1S35. At the post-mortem, examination of the shoulder and elboAV joints, a small quantity of pus Avas found in the former, but no metastatic abscesses Avere discovered." Table LXII. Condensed Summary of Five Fatal Secondary Excisions of the Shaft of the Humerus for Shot Injury. NO. Name, Age, and Military description-. Dates. Operations, Operator, Result. XO. Name, Age, and Military Description. Dates. Operations, Operator, Result. 1 2 3 Armstrong, W. A., Cor-poral, B, 31st Maine, age 23. Dunn, D., Pt., H, 37th North Carolina, age 29. Markel, J. D., Serg't, F, 56th Ohio. July 30, 1804, Jan. 31, 1865. May 16, June 24, 1863. Left; two inches upper third; by A. A. Surg. E. Seyffarth. Died Feb. l'J, 1805, of pyaemia. It is stated that excision had been per-formed on the field. Onein.fromeachendofbone. Died July28,'63,ofpleuro-pneumonia. Left; upperthird; bv Ass't Surwjoint; pensioned. Right; excision of two inches. Disch'd Sept, 2, 1SG3; pensioned; bone ununited; arm useless. Left; lower third. Diseh'd Oct. 0, 1804; pensioned; partial an- chylosis of elbow joint. Right; resection at middle third. Disch'd Mar. 24,1003; pensioned. Excision of throe inches; false joint substituted; uses arm with great freedom. Left; three inches of middle third. Dischd Dee. 2, 1803; healed; pensioned; little or no use of arm; compelled to carry it in a sling. Left; three inches of upper third. Disch'd Sept. 20,1803; pensioned. Right; two inches at lower third. Disch'd Sept. 17,1804; pensioned. Resection of three inches. Fur- loughed July 14, 1804. Left; three and a half inches. Furloughed. October 15, 1804. Right; middle of fractured por- tion united by shortening one and a half inches; cannot ext endarm. Disch'd Dec. 5,1802; pensioned. Resection near elbaw. RecoA'ered, Avith false joint. Resection uf portion of left hume- rus. Furloughed Aug. 15, 1804. Left; excision in middle third. Retired Feb. 10,1805; permanent disability. Left; about two inches of middle third. Sent to ProA'ost Marshal March 7, 1805. Right; one and a half inches. Re- tired February 9, 1805; partial paralysis; limb useless. Right; resection. Disch'd July 14, 1803; pensioned. Left; excision of a portion. Dis- charged Dec. 6,1802; pensioned. Resection in the upper third. Re- coA'ered. Left; excision; amputation at the shoulder joint. Dec. 1st, promised a speedy recoA'ery. Name, Age, and Milu'auv Description. Martin, J. S., fierir't, K, 93d Illinois, aire 33. Moreover. M.,Pt..B,23d Kentucky, age 35. Mav 14, 1803. May 27 1804. Mickey, T. E.. Tt., I, 33d May 3, X. V.. age 24. j 1803. Miller, J{. P., Pt., G, 7th Sept. 19, X. O. Arty, age 19. 1804.' Xusser, IL, Pt., A, 49th ()hio, age 20. Oglctree, W. D., Pt,, K, 14th Alabama, age 19. Padgel, J. IF.,Pt., F,13th Alabama, aire 22. Patton, J., Corp'l, E, 2d Pennsylvania Reserves. Pojr. W. J., Pt,, II, 19th Mississippi, age 18. Pow, 11, A. S., Pt., D, 0th N. C, age 30. Powell, J. T., Pt., B, Cth X. (J., ;ige 22. Powers. P., Corp'l, B,45th Illinois, age 2J. Quinn,.!., Pt.,C,83dOhio, ajre 20. Reed, A., Pt,, B, llth Missouri, age 19. S------, Capt., K. 31st Tennessee, C. S. A. Shilling, J. J., Pt., B, 4ul A'irginia, age 25. Smith, J. X., Pt., G, 89th Illinois. Stafford, J. S., Lieut., H, 7th Xorth Carolina. Tolson, A., Pt., 1st Mary- land Artillery. Tucker, W. P., General. 17,ry. R. C, Pt., D, 10th Alabama, age 30. Yonst. J. S., Pt., F, 0th Ohio, ajre 19. Sept. 19. 1803. June 23, 1804. May G, 1004. Sept. 17, 1802. Operations, Operator, Result. April 18 1804. July 3, 1803. April 0, 1802. Jan. 11, 1803. May 27, 1803. July 22 18G4. Sept. 19, 1804. Sept. 19, 1803. May 12, 1804. Mav 3, 1803. May 14, 1864. June 0, 1804. Sept, 19 1803. Left; two and a half inches mid- dle third; ATcteran Rescn*es Mar. 2, 1804. Disch'd Mar. 30, 1805; pensioned. Light; two inches at lower third andrcmoA'al of fragments of bone from fractured scapula ; V. R. O. March 10, 18(>5; shoulder A-cry weak; arm shorter. Mustered out August 29, 1800; pensioned. Left; four inches lower third. Re- tired January 28, 1804. Right; three inches at upperthird. Transferred to ProA'ost Marshal February 11, 1865. Left; middle third. Discharged May 14, 1804; pensioned. Left; three inches at middle third; wound healing firmly, by gran- ulation, July 31st. Furloughed August 31, 1804. Left; one aud a half inches: liga- mentous union; wound did not heal. Retired Feb. 16, 1805; disability. Left; upper third. Disch'd Dec. 20, 1802, and pensioned. Left; two and a half inches lower third; also right elbow joint frac- tured. Retired Jan. 27, 1805; partial anchylosis of elbow joint. Left; excision of portion of hume- rus. Retired December 30,1804; disability. Right; three inches at upper third. Exchanged March 17, 1804. Left; resection at upper third: arm not much disabled; one and a half inches shortening. Vete- ran Reserves Xov. 25, 1863; not a pensioner. Left; lower third. V. R. C. Xov. 11,1803. Disch'd May 11,1805; pensioned. Left; excision of upper third; not united; arm shortened about three inches; shoulder joint anchy- losed. Discharged August 5, 1803; pensioned. Three inches of bone removed for fracture of the upper and middle thirds; cannot extend limb but can ilex ; arm healthy. Excision of six inches three inches below shoulder joint. Retired Jan. 20, 1805; disability; arm useless. Right; three inches of upper third. Discharged June 0, 1804; pen- sioned ; arm useless. Resection of two and a half inches. Furloughed May 30, 1804. Right; excision of two inches of shaft. Duty October 30, 1803. Left; three inches, to within three- fourths cf an inch of anatomical neck; by Dr. J. S.Cain; healed promptly; no bony union; limb shortened three inches; can use foreann and hand when rested on a table or supported; is far preferable to jio arm. Left; four inches of middle third. Furloughed August 20, 1864. Right; two inches of upper third: strong callus united the bone; arm shortened oneinch. Disch'd June 21, 1804 ; pensioned. slvt. iv.| EXCISIONS IN TIIK FIIA FT OF THE HUMERUS. 6% To complete the series of six hundred and ninety-six excisions in the continuity of the humerus after shot injury, there remain twenty-four cases, of which the histories arc very imperfect, What has been ascertained is recapitulated in the two succeeding tables: Table LXIV. Condensed Summary of Twelr: Fatal Cases of Excision of the Shaft of the Humerus, in which the Time of Operation was not ascertained. I .. Name, Age. and i MlLI'I'AKY DESCRIPTION. Operations. Operator, NO. Name. Age, and Dates. Operations Operator, RESULT. Military description. Result. 1 Bowles, Jr., Pt.. G. 57th Left; excision of middle third. 8 Sherwood, ().,l't.,K,132d Sept. 17, Excision of portion of humerus. A iiginia. Died Sept. 30, 1863. Pennsylvania. 1862. Died Oct. 13, 1862. 2 Bunnell, D., Pt., II, 93d Left; excision. Died September Illinois. 13, m;.i. !) Squiere, II., Pt., F, 5th Sept. 17, Right; excision of a portion of 3 Garland. B. P., Pt., D, llth Infantrv. Mav -, ISii-l. Right; excision. Died Juno 3,'(i4. Ohio. 1862. humerus. Died Nov. 5, 1862. 4 Grissius. C.. l't., B, llth Alar 31, Right; excision of two inches at 10 Ward, II. IV, Pt.,A, 103d Oct. 15, Left; about seven inches from Pennsylvania. IStio. lower third Died May 21, 1865, of crvsipelas. Ohio, age 19. 1863. surgical neck downward. Died Feb. 17, 1864, of small-pox. 5 Joice, J. A., Pt., II, 42d Excision of a portion of humerus. A'irginia. Died June 8. ISiil, of pva'inia. 11 AV.'urnor, ('., Pt., F, C8th Right; exsection. Died October 6 Moyer. M., Pt., G, 28th Pennsylvania. Sept.l/. 1862. Excision of a portion uf humerus. Died Oct 15, 1862. New Vork. 15, 1862. 7 Seiler,AV..Corp'l. A, 104th June 14, Left; one nnd a half inches excised 12 Westernian, G., l't., F, 3th Sept. 17, Left; excision of a portion. Died Ohio, age 19. 1804. from middle third. Died Aug. 29, 1804. Ohio. 1862. Oct. 27, 1862. 1 Table LXV. Condensed Summary of Twelve Cases of Excisions of the Humerus for Shot Injury, the Result and the Time between Injury and Operation being unknown. \ No. Name. Auk. axd Military Description. Dates. Operations, Operator, Result. NO, Name. Ace, and Military Description. Dates. Opera itons. Operator, Result. 1 3 4 5 6 Behon. J. J., Corp'l, G, 27th A'irginia. age 24. Chasteen, A C. Pt., D, 2d South Carolina. Craig, J., Pt., A. Orr's Ritlcs. Gamble. J. A., Pt., F, 59iu Georgia. Harris, J., Pt., E, 21st fJ eorgia. Hcnnington.L., Corp'l. G, 4Cth A'irginia, age 46. Mav 3, 1863. Sept.30, 18G4. July 28, 1864. Nov. 18, 1863. July-, 1863. June 2, 1864. Three inches of shaft resected. Left; excision. Right; excision. Right; excision. Right; excision. Left; two or three inches at lower part of upper third; progress favorable. 7 8 9 10 11 12 Hunt, B., Pt., K, 57th A'irginia. King, T, Pt., B, 38th Georgia. Land, S. L., Pt., C, 13th South Carolina. Murphy, I., Pt., F, Sth South Carolina. Smoke. J. W., Pt., B, 30th Virginia, age 33. Welch. 11. L , Corp'l, E, Palmetto Sharpshooters. July 3, 1863. Aug. 16, 1864. Aug. 16, 1864. Oct. 13, 1864. Oct. 7, 1864. Left; excision middle third. Left; excision. Left; excision. Right; excision. Right; resection of upper third. January I. 186.3, not doing well. Right; excision. Concluding Observations on Excisions in the Continuity of the Humerus after Shot Injury.—Excluding operations for necrosis, and, possibly, resections for pseudarthrosis, formal excisions in the continuity of the long bones, and especially in the humerus, were generally regarded prior to the war with disfavor by American surgeons.1 They seem now to be less emphatically condemned. But I cannot discern that the experience of the war lends any support to the doctrine of the justifiability of operations of this nature, except in 1 The opinions of American surgeons who have treated, since the war, of the merits of this operation, may be summarized as follows: Dr. J. Ash- hurst, jr. (The Principles and Practice of Surgery, 1871, p. 167) declares: "Excision in the continuity of the humerus * * is more fatal than ampu- tation ofthe corresponding parts; still the difference is not so great but that the operation may be regarded as justifiable in favorable cases." See also this author's remarks on Surgical Cases, in the Am. Jour. Med. Set, 1863, A'ol. XLV, p. 342. Professor F. II. Hamilton (The Principles and Practice of Surgery, 1872, p. 391) observes: "A few fortunate examples in which excisions of considerable portions of the shaft of the humerus have resulted in bony union do not authorize a well-grounded hope that it will generally occur, or a repetition of the practice, except as a last alternative." Dr. S. W. Gross (Military Surgery, in Am. Jour. Med. S:i., 1867, A'ol. LIV, p. 475) regards formal resections of portions of the shafts of long bones "not only as unneces- sary and dangerous, but also as prejudicial, from the fact of the union of the divided extremities being uncertain and imperfect." Professor S. D. Gross (A System, of Surgery, 5th ed., 1872, A'ol. II, p. 10871 thinks "excision of the shaft of tbe humerus is sometimes required on account of gunshot injuries," and that the tabular statement prepared by his son, Dr. S. XV. Gross, "shows much more favorable results" than appeared from the Schleswig-Holstein and Crimean experience. Dr. G. II. Stevens (On Excisions in Cases of Gunshot Wounds, in Trans, of Med. Soc of State, of New York, 1866, p. 138) gives a favorable case, and the opinion that: "Excisions of the humeral shaft, although not often required, yet in some instances are advisable, and the cases were quite as promising as other resections." Dr. AV. GlLFILLAN (Ibid, p. 122. Excision of the. Shaft of the Humerus) cites a partially successful case. and advocates the operation as a secondary procedure. Surgeon D. G. Brinton, U. S. V. (Appendix to Part I of Mid. and Surg. Hist, of the War cf (>% INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. vcrv exceptional cases. The numerical return, and the necessarily abbreviated summaries, may appear, at first glance, to represent the results in a favorable light; but a more precise analysis reveals most lamentable conclusions. The naked figures are as follows : Table LXVL Numerical Statement of Six Hundred and Ninety-six Cases of Excisions in the Shaft of the Humerus for Shot Injury. Operations. Primary................................ Intermediary........................... S ec< mdary.............................. Time of operation unknown............... Aggregate of Exeisions in Continuity Cases. 487 93 41 Recovery. 69G 326 04 36 51 477 Fatal. 145 29 12 191 Result UnknoAvn. 16 12 Mortality Rate of Determined Cases. 30.7 31.1 12.1 19.0 28. The mortality rate is nearly double that observed in the cases treated by expectant measures, and more than 12 per cent, higher than the fatality in a larger series of primary amputations in the upper third of the arm. Moreover, in the four hundred and seventy- seven cases of recovery, there were no less than ninety-nine instances in which " no bony union" was reported, and sixty-five others recorded as examples of "false-joint." There were also among the cases reported as "successful" thirty-seven instances of consecutive amputations of the arm. Recourse was had to ulterior exarticulation or amputation in sixty-four patients, of whom twenty-seven perished. Such evidence warrants the assertion that early excisions in the continuity of the humerus after injury can seldom be justifiable, a conclusion at which European surgeons had already arrived from the experience of the Schleswig-Holstein and Danish wars,1 and which has been confirmed by more recent observations.2 The coaptation of the resected ends of the bone by silver wires was sometimes practised, with few illustrations of favorable the Rebellion, p. 293) states that: "The astonishing success that attended resections of the humerus in its continuity, both here [Chattanooga] and after the battle of Gettysburg, convinces me that the objections urged against this operation are entirely unfounded." His argument in full may be found at the page indicated. Amerman (G. K.) (Chicago Med. Jonr., 1866, A'ol. XXIII, p. 358) reports a primary excision of four inches of the middle ofthe shaft of the left humerus. The patient recovered in three months; but the arm refractured, and the author concludes that "the operation of excision in the continuity of the long bones is still of doubtful expediency." Billings (J. S.) (Appendix to Part I, Med. and Surg. Hist, of the Rebellion, p. 146) remarks, after Gettysburg: " In no ease of fracture of the long bones did I attempt any formal resection. * * From my experience in Cliff bourne Hospital, I am convinced that regular resections in such cases are worse than doing nothing at all." ' Schwartz (II.) (Beitrage zur Lehre von den Schusswunden, Schleswig, 1854, S. 212) declared: "Resection in the continuity ofthe humerus is to be rejected." Stkomeykk (L.) (Maximen der Kriegsheilkunst, Hannover, 1855, S. 077) states: "Already, in the yea-1849, extensive resections in the diaphyses were discountenanced; and, in the campaign of 1850, even limited resections of the diaphyses were not undertaken, and the extraction of splinters was confined to the removal of such as were readily accessible and entirely loose. * * Far be it from me to contend," he adds, "that free incision in eases of shot fracture, and careful remoA'al of all splinters and beveling of fragments, haA-e no rational foundation, and may not lead to favorable results." DEMME (H.) (Militdr-chirurgische Studien, 1861, S. 230) tabulates, from Italian hospitals, 7 cases of excisions in the shaft of the humerus, of which 4, or 57.1 per cent, Avere fatal, and concludes: " We must reject excision of the shaft of the humerus. The unfavorable result of the operation, as compared with resection of the shoulder joint, may be due partly to the greater extent of the operative interference, but especially to the opening of the medullary cavity." Fischer (H.) (Kriegschir. Erf., Erlangen, 1872, S. 145) says: '' Even in case of necrosis of the fractured ends, Ave hesitated to institute operative interference, as in preceding Avars our experience in regard to resection ofthe shaft ofthe humerus in the continuity had been exceedingly lamentable." i KLEiss (E.) (Beitrage zur Pathologischen Anatomie der Schusswunden. Leipzig, 1872, S. 15) gives an autopsy in the case of Notzel, wounded, near Strassbourg, September 4, 1870: " Shot fracture of the shaft of the humerus; resection of the ends of the bone; death October 14,1870, * * * large pus cavity, into which protrude the sawn ends ofthe shaft, denuded of periosteum and necrosed; the medullary cavity filled Avith exuberant granulations." Dr. Klels remarks : " It is true that it cannot be ascertained how far the loss of periosteum of the resected ends is due to the effect of ichorous pus, but, in view ofthe slight disposition toward callus-formation, the removal of larger but yet adherent bone-splinters must necessarily diminish the chances of a definite consolidation, and uny aid toward the separation of the necrosed portions can hardly be expected; on the contrary, any interference before the consolidation might readily lead to fresh necrosis of the sawn ends." Ciiexu (J. C.) (Apcrcu hist, etc., pendant la Guerre de 1870-71) tabulates 'J8 cases of excisions iu the shaft of the humerus, of which 84, or 85.7 per cent., were firtul. SECT. IV.] AMPUTATIONS IN THE SHAFT OF THE HUMERUS. 697 results. Examination of the details of many of the formal primary excisions in the shaft strengthens the impression that they were for the most part unnecessary and injurious. AMPUTATIONS OF THE ARM FOR SHOT INJURY.-The records present fifty- four hundred and fifty-six cases of this nature. Fifty-four have already been particularized on page 469, as practised on account of flesh wounds or their complications. Three thousand six hundred and eighty-five were performed on account of shot fractures of the shaft of the humerus or their consequences, and seventeen hundred and seventeen ampu- tations were done for the immediate or remote results of shot injuries of the elbow joint or of the forearm. The results as to fatality, the period at which the operations were done, and the point at which amputations1 were practised are indicated, as far as known, in the following table: Table LXVII. Summary of Five Thousand Four Hundred and Fifty-six Amputations of the Arm for Shot Injury. Ca *ES. UrrEU Third. Middle Third. Loaveu Third. •Seat kot Recorded. ■6 ■6 -3 ■6 ■g OPERATIONS. ^, p ^ p +j .5 ~ .- £> g a Total. i? ■3 a o 1 i 0> % & g' 3 a > Ki o .g P5» •a 1 S3 a K3j o 1 a 1 1 -3 a « Q p M Q P 1,019 Q i-> « Q a - " '^ 2,657 602 3,259 1,155 183 143 406 106 -7 170 600 302 902 239 108 255 93 94 67 12 34 297 114 411 127 46 127 35 37 24 6 9 Time between injury and operation 473 228 183 884 61 21 12 45 13 9 22 2 345 194 160 not stated. 183 160 4,027 1,246 5,456 1,582 358 12 1,446 284 9 559 197 o 440 407 It will be observed that the results as to fatality were ascertained in fifty-two hundred and seventy-three cases, twelve hundred and forty-six, or 23.6 per cent., terminating fatally. It has been seen (p. 655) that the fatality of the series of eight hundred and forty-one determined cases of amputation at the shoulder joint was in the proportion of 29.1 per cent. The results, therefore, conform to the general rule formulated by M. Legouest, that amputations in the continuity below a joint have less gravity than amputa- tions through that joint,2 and vindicate the precept of amputating always as far as possible from the trunk. Primary Amputations in the Continuity.—In three thousand two hundred and fifty-nine cases, or nearly three-fourths of those in which the precise period of operation was ascertained, the amputations were practised within the forty-eight hours succeeding the injury. Undoubtedly there are cases in which the invasion of inflammatory phenomena takes place earlier or is deferred much later than this period; but, in dealing with statistics of such magnitude, it is necessary to adopt some arbitrary limit, afid in this work, in deal- i The predominance of amputations for shot injury of the upper portion of the arm corresponds with what has been observed in other wars. Thus, M. Chenu (Apercu hist stat. ct clin, sur le service des ambulances ct des hopitaux, 1874, p. 492) tabulating 2026 cases of amputations of the arm with 606 recoveries and 1420 deaths (a mortality rate of 70.09), is able to determine the locality of the operation in 327 of the 606 successful cases ; namely: upper third, 170—middle third, 106—and lower third, 51. 2 LEGOUEST (L.) (Traite de Chirurgie d'Armee, 2. » Fig. 512.—Shot frac- ture of shaft of right humerus. Spec. 1147. SECT. IV.] PRIMARY AMPUTATIONS OP THE UPPER ARM. 699 I'k;. 514.—Part of right humerus amputated for shot fracture. Spec. 2518. Some of the primary amputations high up in the arm, in cases attended by comp; atively little osseous splintering, were probably practised on account of real or apprehended lesions of the nerves, vessels, or other important soft parts: Cask 1646.—Captain M. Rankle, Co. F, 56th Pennsylvania, age 3;> years, Avas wounded in the right arm, at the Wilderness, May 0, 1864, and was operated upon at the field hospital, 4th division, Fifth Corps. Surgeon C. N. Chamberlain, U. S. V., noted: "Gunshot fracture of arm; amputation." Surgeon A. S. Coe, 147th New York, contributed the pathological specimen (I'm. f>14), Avhich consists of "a portion of the shaft of the humerus, nearly transversely fractured near the loAvest third. From the posterior and inferior surface an irregular frag- ment, one by tAvo inches, Avith the base at the line of fract are, has broken, but remains in position. Primary amputation has been performed at the junction of the upper thirds, three inches above the line of fracture, from Avhich it appears the laceration of tlie soft parts must have been excessive." (Cat. Surg. S,ct, \:'>.) On May li'th, the patient reached Washington, Avhere be obtained from Surgeon T. Antisell, U. S. V., a leave of absence for thirty days. On August 6th, he entered the Officers' Hospital, at Annapolis. Surgeon 13. A. Vanderkieft, U. S. V., reported: "Gunshot Avound of right arm. Flap amputation at junction of upper and middle third performed on day after injury." Captain RunkleAvas discharged from service on August 12, 1834, and pensioned. He Avas paid on December 4,18/4. In his application for commutation for artificial limb, dated 1870, he stated the stump as being in a healthy condition; also that Surgeon G. W. Met calf, 70th NeAV York, performed the amputation. A number of examples of painful stumps, from bulbous enlargement of the extremities of the divided nerves, are observed in this series: Case 1647.—Private J. Brien, Co. G, 97th New York, aged 36 years, Avas Avounded in the right arm by grapeshot, at Antietam, September 17, 180:2. On October 4th, he Avas received from a field hospital into Frederick Hospital No. 5, Avhence he AA'as transferred to Patterson Park, Baltimore. On October 9th, Medical Cadet A. T. Piek furnished the folloAving history: "The arm Avas amputated, on the battlefield, near the superior third of the humerus. The patient Avas suffering exceedingly, and on February 18, 1~83, it Avas decided to open the stump, Avhen a bulbous degeneration of the musculo-spiral nerve Avas discov- ered and removed by Surgeon 8. D. Freeman, U. S. V. The patient iioav doing well." In the course of time, hoAvever, tbe tumor formed again, necessitating another operation for the removal of the enlarged bulbous extremity of the median nerve, Avhich Avas performed by Surgeon Freeman, in September, 1863. Both of the specimens (Cat. Surg. Sect. 1886, p. 500, Specs. 1117 and 1790) were contributed to the Museum by the operator. The patient Avas subsequently transferred to the Veteran Reserve Corps, and on October 17, 18(>4, he Avas discharged from service and pensioned. In his application for commutation for an artificial limb, dated 1870, he describes the stump as being "in good condition." This pensioner was paid to June 4, 1875. Laceration of the soft parts by large projectiles frequently demanded amputation high up, in cases in which the comminution of bone was limited to the lower portion of the shaft of the humerus: Case 1048.—Corporal T. W. Stocksleger, Co. H, 47th Pennsylvania, aged 21 years, Avas Avounded at Pocotaligo," October 22, 1862, and admitted into hospital at Hilton Head on the following day. Assistant Surgeon J. E. Semple, U. S. A., contributed the specimen represented in the wood-cut (FlG. 515), Avith the folloAving history by Acting Assistant Surgeon T. T. Smiley: ''Was wounded by a shot, Avhich struck the anterior face of the left arm about two inches above the elboAV joint, and passed obliquely upward and backward, coming out about tAvo inches higher up than the point of entrance. The bone Avas extensively fractured, comminuted, and splintered, and it Avas therefore determined to amputate the limb. The oper- ation was performed by the circular method, immediately above the highest point of the injury, and the patient is doing Avell." The specimen consists of the lower half of the left humerus, greatly comminuted at the loAver third. The patient Avas discharged from service on December 15, 1862, and pensioned. He has been paid to March 4, 1875. In his application for commutation, for artificial limb, dated 1870, the pensioner describes the stump of his left arm as "one and a half inches long from the shoulder, and in healthy condition." Eighty-nine of the eleven hundred and fifty-five amputations were practised on Con- federate soldiers. There was the usual predominance of operations on the left extremity. This circumstance was specified in all but seventeen cases. Five hundred and fifty-five amputations were recorded on the right, and five hundred and eighty-three on the left side. Nine hundred and ninety-two patients were discharged, seventy-four returned to modified duty, and eighty-nine were paroled, exchanged, or furloughed, and subsequently unac- counted for. Two hundred and ninety-three amputations were by the circular, and five hundred and fifty-five by the flap or modified flap method. In three hundred and seven cases the mode of operation was not recorded. FlG. 515.—Grape- shot comminution of the lower third of the left humerus. Spec. G88. 700 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. Table LXVIiI. Condensed Summary of Eleven Hundred and Fifty-five Cases of Recovery after Primary Amputation in the Upper Third ff the Shaft of the Humerus. Name, Age, and Military Description. Ackcrman, T., Corp'l, B, 51st l'enn., age 22. Adams. T. C. 1st Lieut., Ii. 121st N. Y., age 33. Adams, J., l't., A. 3Jth Mass., age 46. Ahlers, A. Lieut.,C, 47th Ohio, age 28. Ailiff, P. C, Pt., G, 28th Virginia. Aisenhood, A., Pt., G, 4th Michigan. Aitken, J. S., l't.. D, 2d N. Y. Heavy Artillery, age 19. Aldrich, J. B., Pt., E, 4th Vermont, age 45. Allen, H. C, Pt., E, 1st Mass. Cav., age 19. Allen, F. M., Corp'l, A, 29th Maine, age 23. Allen,P.,Pt,,C,5th Mich., age 40. Allen, T. B., Pt., E, 43d Missouri. Allen, J., Lieut., E, Sth Mich. Cav., age 25. Allgower, C. F., Pt., C, (ith New York. Amaun, C, Pt., C, 41st New York, age 18. Ambler, J., Pt., F, 170th New York, age 29. Anderson, J., Pt., B, 10th Illinois, age 29. Anderson, G., Pt., C, Sth Conn. Andrews, J., Pt., A, 40th Penn., age 30. Anderson, P., Pt., I, 90th Penn., age 48. Anderson, A., Pt., 1,100th Ohio. Annis, E. E., Serg't, G, 04th N. Y., age 31. Anthon. P., Pt., F, 7th Indiana CaA'alry, age 19. Armstrong, J., Pt., G, 140th Pennsylvania. Armstrong, W. A., Pt., G, 24th Mich., age 21. Arnold. J.. Pt.,C, 17th TJ. S. C. T., age 19. Auld, J. B., Pt., A, Sth Maine. Avery, Chas. E., Pt., A, 20th Maine. Aydt, J., Pt., A, C8th New York. Bad. L., Pt., K, 26th Penn.. age 23. Bagley, ('. R., Pt.,E,20th Connecticut. Bagaley.'l'.. Capt., K, G3d Pennsylvania. Bailey, H. C, Pt., G, Kane's Penn. Rifles. Baker, J., Pt., B, 08th Penn., age 38. July 30, 30, '64. Mav 12, 12,*'64. Mav 8, 9, '64. Julv 22. 22, ''64. July -, 1863. May 5, 6, "63. June 3, 4, '64. May 5, 5, *64. Sept. 14, 14, '63. Oct. 19, 21, '64. May 6, 6, '64. Oct. 15. 15, '64. Sept. 19, 19, '64. April 17 17, '63. July 2, 2, '63. May IS, 18, 'IM. May 27, 27, '64. Oct. 17, 18, '63. May 10, 10, '64. May 10, 10, '64. June 11. 12, '64. June 1, 1, '62. Dec. 2, 2, '64. May 3, 3, '63. July 1, 2, '63. Dec. 16 16, '64. Nov. 7. 8, '63. May 5, 6. '64. Mav 2, 4, *03. Mav 15, 15," '04. May 3, 3, '63. June 30, 30, '62. June 6, 6, '62. Nov. 27, 27, '03. Operations, Operator, RESULT. 35 Baker. II. L., Pt., E, 2d May (i, Vermont, nsre 24. ! 7, '64. Left; circular; by Surg. XV. C. Shurlock, 51st Penn. Disch'd Mar. 17, 1865; pensioned. Left; circular. Disch'd Oct. 17, 1864; pensioned. Left; circular; by Surgeon Wm. Thorndike, 39th Mass. Disch'd Jan. 20, 1865; pensioned. Left; by Surg. S. P. Bonner, 47th Ohio. Disch'd Jan. 25, 1865; pensioned. Paroled August 22, 1863. Left; flap; by Asst. Surg. L. C. French, 4th Mich. Disch'd Sept. 29, 1863; pensioned. Left; bilateral flap; by Surg. J. AV. AVishart, 140th Penn. To A'. P.. C. May 2,1865; pensioned. Right; lateral flap; by Surg. D. M. Goodwin, 3d VI. Disch'd August 17, 1865; pensioned. Right; circular; by Surg. W". B. Ilezlen, 3d Penn. Cav. Disch'd Noa-. 8, 1863; pensioned. Left; circular; by Asst. Surg. B. Fordyce, 160th N. Y. Disch'd Mar. 6, 1865; pensioned. Left; by Surg. II. F. Lyster, 5th Michigan ; pensioned. Right. Discharged June 6,1865; pensioned. Left; by Surg. A. K. St. Clair, 5th Mich. CaA'alry. Disch'd April 5, 1865; pensioned. Left, Discharged May 29, 1863; pensioned. Right; flap. Disch'd; pensioned. Right; flap; by Surgeon M. F. Reagan, J 64th N. Y. Disch'd June 5, 1865. Left; by Surg. Ii. R. Payne, 10th Illinois. Disch'd; pensioned. Right; flap; by A.Surg. J.E.Link, 2lst 111. Disch'd July 21, 1864. Left; antero-posterior flap. Dis- charged May 18,1865; pensioned. Left; antero-posterior flap; by Surg. J. II. Beach, 24th Mich. Disch'd April29,lS65; pensioned. Left; circular; by Surgeon G. A. Collamore, 100th Ohio. Disch'd Feb. 17, 1865 ; pensioned. Right; flap. Discharged July 29, 1862. Left; circular; by A. A. Surg. J. A.Edmunson. Disch'd May 10, 1805; pensioned. Flap; da>-Surgeon J. W. Wishart, 140th Penn. Disch'd Aug. 10, 1863; pensioned. Right. Disch'd Nov. 26, 1863. Right; flap; by A. A. Snrg. A.S. Giltner. Disch'd July 11, 1865; pensioned. Right; flap. Disch'd April 14, 1864; pensioned. Right; circular. Disch'd June 15, 1865: pensioned. Left: flap: bv*urg.L.Schultz,68th N.Y. Disc'd.Julyl7,1863; pens'd. Ricrht: circular. Disch'd June 2*5, 1865. Left, Disch'd August 11, 1865; pensioned. Right. Discharged Dec. 15,1862; pensioned. Left. Discharged and pensioned. By Surg. H. F. Lyster, Sth Mich. Discharged March 25,1865; pen- sioned. Loft: circular; by Surgeon W. J. Sawin, 2d A'ermont. Discharged j June 29, 1864 ; pensioned. Name, Age, and Military Description. B---, S., Pt., D, lllth Penn., age 31. Baker, J., Pt,, G, 7th N. Y. HeaA-y Artillery. Baker, IL, Pt., I, 12th Mass., age 30. Baker, G.W.,Pt.,G, 19th AVisconsin, age 31. Baldwin, W. M., Capt., D, 14th N.Y. S. M., age 32. Balde, F., Corp'l, D, 75th Pennsyh'ania. Balch, AV.L.,Pt.,G,19th Indiana, age 30. Ball, J. A., Corp'l, D, 23d New Y'ork. Bandell, H. C, Pt., A, 38th Mass. Banks, R., Serg't, D, 6th Virginia, age 27. Bane, J., Pt., 1,104th IU., ago 19. Barnes, T., Pt., Bowen's Battery, age 28. Barnes, G., Pt., A, 143d Penn., age 30. Barr.S.L., Serg't, B, 148th Penn., age 24. Barber, C. IL, Corp'l, G, 25th Conn. Barber, G., Pt,, D, 24th Indiana. Barnard, C, Pt., E, 6th Iowa. Barrickman, R.,Corp'l, B, 70th Ohio, age 21. Barnes, E., Serg't, F, 46th Penn., age 21. Barter, R., Pt., E, 3d In- fantry. Barnes, J., Pt., G, 76th New York. Basom, G. E., Pt., G, 49th Ohio, age 33. Bastain, M. D., Pt.. B, 184th Penn. Batchelor. J. M., Pt., G, 1st Me. H'y Art., age 47. Batty, IL, Pt., B, 26th Pennsyh'ania. Baugher, J. A., Pt., F, 207th Penn., age 18. Beany, J. IL, Pt., K, 5th TJ. S. Artillerv, age 26. Beakes, A. W*., Pt., E, 124th N. Y., age 19. Beasley, W. S., Pt., K, 41st Tenn., age 24. Bean. A. B., Pt., A, 58th Massachusetts, age 34. Beaver, A. J., Serg't, C, 53d Penn., age 32. Beardsley.D., Pt., F, 20th Michigan, age 21. Beason, J. J., Serg't. H, 1st Arkansas, age 29. Dates. July 20, 20, '64. May 30. 30, '64. Mav 6, 6, '64. Aug. 7, 7, ?64. May 10, 10, '64. July 1, 1, '63. June 25. 25, '64. Sept. 17, 17, '62. April 13, 13, '63. July 30, 30, '64. Sept. 19, 19, '63. Nov. 30, Dec. 1, 1864. Mav 6, 6, ;04. Oct. 14, 15, '63. June 14, 14, '63. April 14, 14, '64. May 27, 27, '64. Dec. 13, 14, '64. July 3, 3, '"63. Oct, 9, 10, '61. Dec. 11, 11, '62. May 27, 27, '64. June 22, 22, '64. June 18, 19, '64. Mav 3, 3, '63. April 2, 2, '65. July 3, 3, '63. May 3, 5, '63. Nov. 30, Dec. 1, 1864. July 30 30, '64. Oct. 14, 14, '63. Julv 30, 30, *'64. Nov. 30 30, '64. Beckman, C, Corp'l, K. Noa-. 27 13th Illinois. 27, '63. Beemer, L. O., Pt., F. 126th Ohio, age 22. Mav 12, 12,"'64. Operations, Operator, Result. Left; circular. Disch'd April 2, 1865. Left; flap; by Surg. G. L. Potter, 145th Penn. Disch'd Sept. 15, 1865 ; pensioned. Spec. 2951. Left; lateral flap; by Surg. P. E. Hubon, 28th Mass. Discharged July 19, 1864; pensioned. Right; flap; by Asst.Surg. E. F, Dodge, 19th AVis. Disch d Mar. 28, 1865; pensioned. Left; circular. Duty; pensioned. Left; circular. Disch'd May 11, 1864 ; pensioned. Left; semi-circular and posterior flap ; by Surg. J. Ebersole, 19th Ind. Disch'd Dec.2,1864; pens'd. Right; by Surgeon A\r. A. Madill, 23d N. Y. Disch'd Nov. 27,1802; pensioned. Left; circular; by Surgeon S. C. Hartwell, 38th 'Mass. Disch'd Aug. 4, 1863 ; pensioned. Right; circular. Furloughed Sept. 27, 1804. Right; flap; by Surg. R. F. Dver,' 104th 111. Disch'd May 1. 1864. Left; circular. Transferred to Provost Marshal April 6, 1865. Left; circular. Disch'd July 20, 1864; pensioned. Circular. Disch'd July 10, 1864. Left; circular; bv Surg.W.T.Pro- A'ost,159th N.Y." Duty Aug.7,'63. Flap; by Surg. A. W.Gray,24th Indiana. Disch'd June 27, 1864. Left; flap; by A. Surg. G. Morris, 56th HI. Diseh'd Sept. 26,1864. Left; flap; by Snrg. J. II. Hutch- inson, 15th Mich. Discharged March 21, 1865. Right; by Surg. W. II. Twiford, 27th Indiana. Disch'd June 23, 1865; pensioned. Right. Discharged Nov. 13,1861; pensioned. Right. Discharged Jan. 8, 1864; pensioned. Left; flap; by Surg. C.J. Walton, 21st Kentucky. Disch'd Sept. 2, 1864; pensioned. Right; flap; by a Confederate surgeon. Disch'd Mar. 22, 1865. Left; double flap. Disch'd Oct. 18, 1864 ; pensioned. Right. Discharged Aug. 4,1863; pensioned. Right; circular. Disch'd June 14,1865; pensioned. Left; flap method. Disch'd May 26, 1864; pensioned. Left: flap; by Surg. J. II.Thomp- son, 124th N. Y. Disch'd Oct. 12, 1863 ; pensioned. Left; antero-posterior flap. Pro- vost Marshal Feb. 8, 1865. Left; flap ; ln-Surg.A.A.Stocker, 58th Mass. Discharged Dec. 1. 1864; pensioned. Right; circular; by Surg. XV. X\r. Potter, 57th N. Y. V. R. C. Mar. 17, 1864; pensioned. Right; circular; bv Surg. A. F. Whelan, 1st Mich*S. S. Disch'd Dec. 10, 1864 ; pensioned. Left; circular; by Surg. Young, 1st Ark. Transferred to ProA'ost Marshal Jan. 3, 1865. Left; flap; by Surg. S. C. Plum- mer, 13th 111. Disch'd Mar. 10, 1864; pensioned. Left; antero-posterior flap: by Surgeon J. S. Ely, 120th Ohio. Disch'd Oct. 30,1864; pensioned. AMPUTATIONS IN TilK SHAFT OF TIIK IIUMERUS. 701 NAMK, AGE, AND MILITARY DESClUl'TlOX. Behrens, J., 1st Serg't, I, 1-th Missouri, ago 34. Beklen, AV. ('.. Serg't, B, 21th New York. 73 Bel, .Ala Pt., K, 1st . age Hi. Bennett. limerick. Corp'l, 11, l-12il N. Y., age 23. Bonder. It. l't., 1,, 17th l'enn. Cav.. age 20. Beuediot.M.A, 1st Lieut.. F,llth Michigan, ago 23. Bennett,AV. E.,Pt., B,5tli Maryland, age 18. Benson. S. T., Serg't, F, 3.'d Iowa, age 24. Benton. .1. !•'.. l't., E, 147th Xew York. Berger. C. Pt.. Oth AA'is- cousin Battery. Best. B.F., Lieut., E, 40th Illinois. Bigelow, P.. Pt., F, 2d Miehigan. age 28. Billington, S. II.. Pt., D, Sth Maine, age 34. Binnamon, H., PL, A, 2Gtli Indiana. Bingham, B. 1\, Serg't, II, 122d X. Y, age 21. Bird. S.. Pt., C, 43d U. S. C. T.. age 30. Bissell.G.N., PL,1st Conn. Light Battery, age 19. Blanchard, .AI., Serg't, C, Sth Ohio, age 21. Blanchard, Jos. B, PL. F 34th Illinois, age 27, Blue, W., Pt.. C. 12th Ohio Cavalry, age 18. Blunt, G. A., Pt., B, 2d N. \'. Heavy Artillery. Boardman. P.. Serg't, F, 121st X. Y\, age 35. Bochner, G., Pt., H, 32d Ohio. Bodine, AV. F., Pt., I, 4th Xew Jersey. Bolter, J. j., Pt., 4!)th A'irginia. age 23. Bolenius. A. AV., Capt.. G. 50th Penn. Bond, AV. A., Pt., E, Sth Maryland. Boob, L., Pt., A, 148th Pennsylvania, age 23. i Boosel, E., Pt., G, 149th J Pennsylvania, age 18. Borcliafd, E., I't.."lJ. 49th New Y'ork. age 20. Bostick, J. H., Corp'l, D, 47th Ohio. Bovee. J., Corp'l. G, 12th Infantry, ago 2ii. Bowers, *M., Pt.. E, 46th Pennsylvania, age 29. Boioen,'j. W., Pt., A, 3d A'irginia Cav., age 26. Bowd, M., Pt., F, 48th Xew York. Bowers, X. M., Pt., E, 5th Tennessee. Bowles, J., Pt., F, 27th Ohio, age 37. Bowers. F. A., Pt., C, 25th Massachusetts. Bowman, F., Corp'l, C, Cth Xew Jersey. July 23. 23, "'01. Sept. 14. 14, '02, Aug. 16, 10, '04. Oct. 22, 23, VI. Mav 30 30,*'G4. July 4, 4, 'til. (let. 27, 28, '64. April 9, 9, '64. Jnlvl, 3, '63. May 19, 19, '63. April 6, 0, '02. Mav 0. 6, '64. July 2, 2, '01. Dec. 7, 9, '02. Operations, Operator, RESULT. Mar 05' Julj 30, 30. 64. Mm 14," Xov 14. 04. Mar 10. Jim 10. 04. June 3, 3, '04. Atav 10, 10, "'04. Sept. 15. 15, '0 2. J une 27. 28, '(.2. Sept. 17. 17. '02. Aug. 27, Sept. 17, 18. '02. 26,""'04. May 23, 24, '04. May 0. 0, '04. Mav 22, 22, "03. June 18, 18, '64. May 15, 16, "'04. May 11, 11. '04. July 18 20,*'03. 8cpt. 14, 15, '62. June 18, 18. '04. July 14, Julv 3, 3, "63. Left; flap; by Surg. M. AV. Bob- bins, 4th Iowa. Diseh'd .Alar. 22, 1805: pensioned. Left; circular; by Asst. Surg. IL A. DuBois, V. *S. A. Diseh'd Jan. 5. 1803. Left; circular. Transferred to A'. R.C.Jan. 17, 1805; pensioned. Left: lateral Map; by a Confed. surgeon. Disch'd Jan. 27,1805. Left; circular. Disch'd Dee. 10, 1864 ; pensioned. Right; circular; by Asst. Surg. N.I. Packard, llth Mich. Duty July 20, 1804 ; pensioned. Left:' circular; by Surg. <). AV. Harrison. C.S. A. Disch'd Aug. 17, 1S05; pensioned. Left. Discharged Oct. 8, 1864. Left; by Surg. A. S. Coo, 117th X. Y. Disch'd Dec. 3d, 1803; pensioned. Left. Disch'd Aug. 28, 1863; pensioned. Left; by Asst. Surg. AV. E. Tur- ner. 40th 111. Resig'd Sept.0.180.'. Left; antero-posterior flap ; by Surg. U.J.Bnnius. 2d Michigan. Disch'd Aug. 27.1804: pensioned. Right; flap. "Discharged Nov. 24, 1804; pensioned. Bight; flap; by Surgeon T. AV. Flora, 26th Ind. Disch'd Mar. 7, 1803; pensioned. Lett; Hap; by Surg. E. A.Knapp, 122d X. Y. Disch'd June 23, 1805; pensioned. Left; (lap; by Surg. J. P. Prince, 36th Mass. Transferred to the insane asvlum Dec. 20,1865. Left: flap." Disch'd Oct. 20,1864; pensioned. Right: double flap. Disch'd April 12. 1864 : pensioned. Right; antero-posterior flap. Dis- charged July 12,1805; pensioned. Left; circular: by Asst. Surg. AV. E. Sc.iby. 45th Ky. Disch'd Sept 15. 1804; pensioned. Left: circular ; by Surgeon J. C. Howe. 2d X. \'. Heavy Artillerv. Disch'd Nov. 18,1864:* pensioned. Left; flap; by Surg. J. O.Slocum, 121st X. Y. Disch'd Dee. 10, 1804 ; pensioned. Bight; flap. Disch'd October 25, 1802. Left. Disch'd Oct. 13, 1832, and pensioned. Left; flap; doing well. Right: by Surgeon D. AV. Bliss, U. S.V.'Resigned A prill 8,1803. Left. Discharged Marcli 4, 1803; pensioned. Left; circular; by Surgeon John Houston, 81st Penn. Disch'd December 24, 1801. Left; flap. Diseh'd July 18,1865. Left; flap. Disch'd April 6,1865; pensioned. Right; by Surgeon S. P. Bonner, 47th Ohio. Discharged July 31, 1803; pensioned. Left. Discharged and pensioned. Left; circular Disch'd Feb. 3, 1805; pensioned. Right; circular. June 16, 1864, stump healed. Right; circular; by Surgeon II. AVirtz, U. S. A. "Disch'd Xov. 29, 1803: pensioned. Left; by Surg. (I. XV. McMillan, 5th Tennessee. Discharged; pen- sioned. Left; anteroposterior flap. Duty Nov. 14, 1804: pensioned. Right; flap; by Asst. Surg. S. I'lagg. 25th Mass. Disch'd Oct. 13. 1803; pensioned. Right; flap; by Surg. John AA'il- sey, 6th Xew Jersey. Disch'd Sept. 3, 1863; pensioned. Name, Age, and Military Description. Operaii; by Dr. Edmondson. Diseh'd Jan."9,1805: pensioned. Left: flap: by Asst. Surg. J. T. Duffield, 7th Indiana. Disch'd Sept. 24, 1864: pensioned. Left: flap; by Asst. Surg. (!. R. B. Bobinson, 71st Penn. Diseh'd Oct. 21, 1605; pensioned. Right; circular; by Surg. J. S. Ross, llth N. Hamp. Disch'd June 10, 1805. Right; circular; by Surg. Geo. A. Otis, 27th Mass. Disch'd Nov. 10, 1862; pensioned. Left; circular: by Asst. Snrg. J. T. Dntlield. 7th Ind. Diseh'd May 17, 1865; pensioned. Lett: circular: by Asst. Sing. F.B. Kimball. '.IdN.'lIamp. Mustered out Dee. 2.'. 1S0-1; pensioned. Left; circular; by Surg. P. O'AL Fdson. 17th A'c'rnionL Disch'd Allg. 22. 180-1; pensioned. Left; circular; bv Surg. M. H. Raymond, 26th Mich. Disch'd July 26, 1865: pensioned. Right. Disch'd March 27, 1863. Right: bvSurg. A. A. AA'hitc. 8'tli Md. Dis'dFcb.25. 1805; pens'd. Left: circular. Furloughed June 14,1804. Right; lateral (lap; by Sui-gcn George T. Stevens, 77ih N. Y. Disch'd Oct. 18,1804; pensioned. Left; by Surg. S. P. Thornhill,8th AA'is. Disch'd June 10,'62; pens'd. 7<»2 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. Name. Aue, and Military description. 147 i Buhr, P., Pt., C, 37th Julv 7, Ohio, age 19. 7. '63. 148 Billiard, G. XV., Pt., C, ■ Mar. 28 9th Minn., age 37. ■ 28, 'Go. Operations, Operator, Result. 149 Bunker. E. A., Pt., E, 10th lowa. 150 Burklew, B. P., Pt., D, 51st Ohio, age 16. 151 Burbank,D.N..Corp'l, K, 111th N. Y., age 19. Burbank, J. M., PL, E, 5th AA'isconsin, age 18. Burke, J., Serg't, M, 1st Cavalry, ago 32. Bun-ill, A., Pt., K, 88th Indiana, age 25. 15 Burt, A. S., PL, C, 12th Massachusetts, age 28. 156 Burtz, A., PL, E, 5th New Jersey, age 33. 157 Burns, AV., PL, G, 40th New York. 158 Butler, Z., PL, E, Sth Colored CaA'alry. 159 Byerline, J. G., PL, G, 1st Missouri Cavalry. 10 Byrum, J. R., PL, C, 12th North Carolina, age 19. il Byram, C. E., Pt., D, 7th Illinois CaA'alry, age 20. 162 Byrne, IL, PL, E, 9th New York. Cable. E. AV., Corp'l, G, 99th Indiana. CaflYey. T., Pt., G, 155th Xew York, age 33. 15 Callahan, J., PL, G, 17th Infantry, age 40. 166 Callahan, P., PL, C, llth Ohio. !7 Calvin, A. P., PL.G. 111th New Y'ork, age 18. !8 Canon. W.S.. Artificer, K. 1st Xew York Engineers. 9 Cupps.J.M.. PL, B, 28th Alabama, age 25. 170 Carney, T., Pt., C, 32d C. T*., age 32. Carroll, T., Pt., C, 58th Massachusetts, age 26. Carter, J. B., Pt., II, 13th Ohio Cav , age 30. Carter. J. L„ 1st Lieut., 118th New York, age 24. Carver, AY., l't., E, 14th Maine, age 19. C'ary, M., Pt., K, 23d 111., age 50. 176 Carpenter, L. J., Pt., K, 149th Penn., age 21. 177 Carpenter, 8., PL, A, 124th Ohio, age 18. Carr, B. L., Serg't, M, 1st N. 11. Cav.. age 24. 179 Casey. J.. Serg't, K, 42d New York. Cassidy. P.. PL, G, 67th New A'ork. age 19. Casford. D., Pt., A, 30th Ohio, age 33. 182 Cassels, A., Pt., G, 56th Mass.. age 21. 183 Caulk. J., l't., H, Purnell I Legion, age 19. 184 j Gavins. J., PL. H, Sth Cavalry, age 30. 185 Chase, A. S.", Pt.. A, 19th Mass. May 16, 17, '63. Dec. 16, 16, '64. July 3, 5, '63. Aprils, 2, '65. Sept. 28, 30, '64. July 29, 29, '64. May 5, 6, '04. July 2, 2, '63. June 1, 1, '62. June 15, 15, '64. Jan. 1, 3, '63. Sept. 19, 19, '64. Dec. 15, 15, '04. April 9, 9, '62. July 28, 30, '64. Mav 18, 18,''64. Mav 6, 8, "(14. Aug. 23, 23, '01. June 22, 22, '64. Aug. 19, 19, '63. Dee. 15. 16, '61. Dec. 7, 7, '64. May 12, 12." '64. Sept. 30. 30, '04. Mav 16. 17,''64. Oct, 19, 31, '64. Sept. 19. 19, '64. July 2, 2, '03. May 27, 28, '64. April 8, 8, '65. July 3, 3, '63. May 6, 6. '64. June 27, 28, '64. May 24. 24, '64. Aug. 18, 18, '64. Oct. 9, 9, '64. Dee. 13, 15. '62. Left: by Surg. S. P. Bonner, 47th Ohio. Dis'd J une 8,1864; pens'd. Left; by Asst. Surg. P. H. Milli- gan, 9th Mint). Disch'd Mav 17, 1865. Right; flap. Discharged Sept. 3, 1863; pensioned. Left; circular. Disch'd May 3, 1865; pensioned. Eight; circular; bA' Surg. A. Ball, 5th Ohio. Disch'd Dee. 30,1863; pensioned. Right; flap; by Surgeon Geo. D. AVilber, 5th Wis. Diseh'd July 26, 1865; pensioned. Right; antero-posterior flap ; hy Surg. Ferguson, C. S. A. Dis- charged ; pensioned. Right; flap ; by Surg. J. S.Gregg, 8.8th Ind. Disch'dMay 24,1865; pensioned. Right: antero-posterior flap. Dis- charged J une 20. l,-:i•!; pensioned. Left: "flap; by Surg. H. P. Yan- derveer, 5th'X.J. X', R. Corps Dec. 11, 1803; pensioned. Left. Disch'd Oct. 3, 1862, and pensioned. Left. Disch'd Nov. 8, 1864. Left; double flap; by Surgeon Joseph E. Lynch, 1st Mo. CaA'. Disch'd Aug. 2, 1864 ; pensioned. Circular; by Surg. R. J. Hicks, 23d-N. C. Discharged. Right; flap. Disch'd June 22, 1805; pensioned. Right; flap; by Surgeon G. H. Humphreys, 9th N. Y. Disch'd Sept. 30, 1862; pensioned. Left: bv Surg. D. Halderman, 46th Ohio." Diseh'd Nov. 17, 1864; pensioned. Right; circular; bv Smg. J. A\". Wishart, llnth Penn. "Disch'd June 1, 1805; pensioned. Antcro-postor'mr flap. Discharged August 0, 18*04. Left: Asst, Surg. H. Z. Gill, llth Ohio. Disch'd April 25, 1862. Left: by Surg. J. W. AVishart, 140tli i.'a. Disch'd Jan. 19, 1865. Left; flap ; by Asst. Surgeon C. Mudge, 1st N. Y. Eng. Diseh'd April 5. 1864 ; pensioned. Right; lateral flap. Transfer'd to ProA'ost Marshal Jan. 17, 1865. Right: circular; by Surg. C. M. White. 32d C. Troops. Disch'd March 15. 1865. Left; circular; by Surgeon J. S. Ross, llth X. H.' Disch'd Jan. 1, 1865: pensioned. Spec. 1541. Right; circular; by Surg. \Ar. B. Fox.8thMieh. Disc'dFeb.2 i.'Go. Right; flap; bvDr. Baxter, C.S. A. Resigned October 11, 1864. Left; circular;. by Asst. Surg. B. Fordyee, 160th *N. Y. Disch'd July 8, 1805; pensioned. Left; circular ; by Asst. Surg. J. E. Barret, 23d Ohio. Disch'd Feb. 24, 1805; pensioned. Left; circular. Disch'd Oct, 23, 1863; pensioned. Right; antero-post. flap ; by Surg. D. C. Patterson, 124th* Ohio. Disch'd Aug. 29, 1864: pens'd. Right; antero-posterior flap. Dis- charged June 24, '65; pensioned. Right; by Surg. H. Haywood, 20thMass. Disch'd; pensioned. Left; flap. Disch'd Oct. 18,1864 : pensioned. Left; flap; by Asst. Surg. Chas. B. Richards. 30th Ohio. Disch'd June 9. 1865. Right; duty Dec. 27, 1864. Right; flap; bv Surgeon A. A. AVhite, Sth Md. Disch'd April 29, 1865; pensioned. Right; duty Jan. 19, 1865. Left: flap; bv A.Surg.Y.R. Stone, 19th Mass. Disch'd Feb. 28,1863. Name, Aoe. ami Military Description. Chase. J. P.. PL, 5th Maine Battery, age 20. Chadwick,G.,Pt,,F,28th Mass., age 19. !8 Chadwick, C, Serg't, H, 1st Vermont Heavy Ar- tillerA', age 40. 189 Chalice, II. IL. Serg't, E, 4th Vermont, age 24. 10 Church, L. E., Pt., I, 9th Ohio CaA'alry, age 18. >1 Claiborne, D.. Serg't, D, 29th Missouri. 192 Clapper, C. A., PL, K, 128th New York. 193 Clark, IL. Corp'l, G, 1st Maryland. 194 Clark, J. T., PL, 24th Georgia, age 27. 195 Clark, AV. R., PL, K, 59th Ohio. 196 Clark. N. M., Capt., E, 125th Illinois, age 38. Clark, E. L., PL, A, 60th New York, age 20. 18 Cleveland. J. H., Sergt., B, 85th Illinois, age 28. 199 Clifton, AY. B., PL, K, 8th Indiana Cav., age 20. 200 Close, F., PL, A, 55th Ohio, age 20. 11 Cloyd, S. J., Lieut., 12th Penn. Reserves. 202 Cobb, E., l't., D, 5th Maine, age 20. Cockran, M.,PL, C, 115th New York, age 35. 234 Cochrum, B , PL. E, 7th Kentucky, age 19. )5 Coe, R. AY., Pt., A, 2d Conn. Art., age 33. 16 Coffin, J. D., Pt., D, 2d N. Y. Heavy Artillery, age 19. 17 Cole, J., PL, A. 14th New Jersey, age 21. 18 Coles, T., PL, E, 21th New York. 209 Coleman, G. W., PL, B, 142d Penn., age 28. .0 Coleman, W. M.. Corp'l, D, 17th Mich., age 20. .1 Coltron. C. Pt.. D, 24th N. Y. Cavalry, age 19. .2 Collins, AY., PL, E, 187th Penn., age 21. .3 Collins. P., PL, E, 57th New York. .4 Conner, D., Pt., F, 28th Mass. 5 Connor. AY. M. Corp'l, C, 6th Michigan. 216, Connor, E., PL. A, 12th 1 Infantry, age 44. 217 Cotilev, 'l!.. PL, B, 21st Mass., age 30. .8 Condo, S.. PL, C, 98th Ohio, age 27. .9 Conrad. L. D.,PL,C, 6th Iowa Cavalry. •0 Conger. J. H., PL, A, 2d New Jersev. age 25. >1 Conant, S. <*;.. PL, A, 2d Vermont, age 25. July 3, 5, '63. June 3, 4, '64. June 1, 1, '64. Oct. 19, 19, '64. June 1, 1, '64. Dec. 29. 29. '62. Alav 27. 27,"'63. Aug. 18, 19, '64. Sept. 17, 17, '62. Dee. 31, 31, '62. June 27, 27, '64. Dec. 20, 20, '64. July 19, 19, '64. Ausr.20. 20, "'64. A lay 15, 15." "64. Sept. 17, 17, '02. May 10, 10, '64. June 7, 7, '64. Sept. 26, 26, '64. June 1, 2, '64. Dee. 9, 9, '64. June 1, 2, '64. Aug. 30, 30, '62. June 2, 3, '64. Alav 6, 7, '64. Aug. 3, 3, '64. June 18, 19, '01. 8ePt. 17. June 3, 3, '64. Mav 27, 27,"'63. Mav 5, 7, '64. Mar. 14, 14, '62. Mar. 19 19, '65. April 14 14, '65. May 5. 5.''64. Mav 5, 6, "64. ol'kkations, opeuatou, Result. Right; flap: bvSurg. G. XV. Xew, 7th Ind. Disch'd Nov. 25, 1803; pensioned. Left; flap; by Surg. G. L. Potter, 145th Penn. Disch'd Nov. 15, 1865; pensioned. Left; flap: by Surg. G. L. Potter, 145th Penn. Disch'd June 22, 1805; pensioned. Right; circular; by Surg. ('. B. Park, jr., llth Vermont. Disch'd July 31, 1865; pensioned. Left. Discharged: pensioned. Right. Disch'd Feb. 22, 1863. Left. Returned to duty Aug. 13, 1863; pensioned. Right. Discharged Feb. 8,1865; pensioned. Left: antero-posterior flap; doing well. Left; flap. Discharged Feb. 19, 1863; pensioned. Right; flap; by Surgeon E. G. Donee, C. S. A. Disch'd Jan. 15, 1865; pensioned. Right; antero-posterior flap ; by Surg. J. V. Kendall, 149th X. Y. Disch'd July 19, 1865; pens'd. Right; circular. Diseh'd May 5, 1865; pensioned. Left; circular: by a Confederate surgeon. Diseh'd Mar. 30.1805. Left; oval flap. Disch'd Oct. 15, 1864; pensioned. Right, Resigned Jan. 7, 1863; pensioned. Left; circular: by Surg. Francis G. Warren, 5th Maine. Disch'd July 27, 1864 ; pensioned. Right; flap; by Surg. J. M. Pal- mer, 3d N. Y.; amp. at shoulder joint Mar. 25, 1865. Disch'd July 17, 1865; pensioned. Left; antero-posterior flap. Trans- ferred to Piwost Marshal Mar. 7, 1865. Left; circular; by Surg. Henry Plumb. 2d Conn. Art. Disch'd April 25, 1865; pensioned. Left; antero-posterior flap; by Surg. Wm. Lyon, 191st Penn. Diseh'd Mar. 30,1865; pensioned. Right; circular: by Asst. Surg. T. A. Helvig, S7tli Pa. Diseh'd July 20, 1865; pensioned. Right: bv Surg. J. B. Murdock, 24th N. Y. Disch'd Dec. 2.1862; pensioned. Right; by Asst. Surg.C. E. Hum- phrey. 142d Pa. Disch'd Nov. 29, 1864. Left; bilateral flap; by Surg. J. D. Bevier, 17th Mich. Disch'd October 2, 1864 ; pensioned. Right: by Surg. W. C. Shurlock, 51st Penn. Discharged Feb. 12, 1865; pensioned. Right; flap; by Sung. IL B. King, 21st Penn. Cav. Diseh'd July 21, 1865; pensioned. Left; by Surg. G. P.. Coggswell, 39th Mass. Disch'd.Ian 14,1863; pensioned. Left: bv Surg. P. E. Hubon.28th Mass.' Diseh'd Mar. 17, 1865; pensioned. Flap. Diseh'd Dec. 22, 1863. Left; antero-posterior flap. Duty Jan. 19, 1865; pensioned. Left: circular; by Surg. Calvin Cutler. 21st Mass. Disch'd Sept. 25, 1862; pensioned. Left; flap; by Surg. E. Batwell. 14th Mich. Disch'd June 13, .1865; pensioned. Flap; by Surg. Jacob II. Cam- burn, 6th Iowa Cav. Diseh'd July 28, 1865; pensioned. Left;" antero-posterior flap. Re- turned to duty Aug. 2, 1864. Left; lateral Hap: by Surg. W. J. Sawin, 2d Vermont. Dischd D*c. 29, 1864; pensioned. AMPUTATIONS IN THE SHAFT OF THE HUMERUS. '03 230 231 232 233 234 235 236 237 238 247 248 249 250 251 252 253 254 255 256 NAMK, A(iK, AM) MILITARY DESC ItlPTION. Conger, AV., PL, A, 50th Illinois, age 22. Cook. AV. D., PL, A, 7th Connecticut. Cook. 'I'., PL, P. IstMd., Cook, J. F., PL, E, 52d North Carolina, age 25. Peni A., PL, G. 56th sylvania, age 20. Cook, S., Pt., B, 54th Ohio. Cooney, (>., PL. II, 12th Infantry, age 28. Covey. AV., PL, 0th Ohio Battery. Cornish. T., PL, E, 30th C. 0., age 39. Cornish, (i. (i., 1st Lieut., II, Olth X. Y.. age30. Cerdeus. IL, PL. G, ISth Infantry, age 27. Cornier, L.D..PL, H.llth X. Hampshire, age 19. Covert.A.M.. Pt..F.,148th Xew York, age 20. Coyle, J., PL, C. If8th Pennsylvania, age 20. C-----, H.. Corp I. C, 3d Xew York, age -9. Crane, P., Pt.. F, 83d Pennsylvania, age 19. Cranfiei'd, B., Pt., F, 21st Michigan. Craven, M.. Serg't, D, 105th Penn., age 21. Creasy, AV. A.. PL, G, 7th Wisconsin, age 2l. Crill. J.. Pt., D, 50th Xew A'ork. Croft, G.. PL. F, 30th Missouri. ' Croft, S., PL.G, 2d Penn. Heavy Art., age 27. C-----, AV. E., PL, A, 72d Penn., age 30. Cromwell, J., Pt., I, 86th Illinois, age 19. Crosby, J. AV., Major, 61st Penn., age 29. Crosby, J. Q.. Serg't, G, 13th .Mass.. age 02. Crcssett, M. S., Pt., D, 51th Xew Yrork. Crothers. J., l't., G, 6th Maryland, age 28. Crown, J., Serg't, C, 12th Infantry. Cunliff, J. G., PL, E, 51st New Y'ork, age 20. Curran, J., Pt., A, 57th Illinois. Curtis, O. B., PL, F, 5th New Hampshire. Curry, A.. PL, G, 60th New York. Cushman, J. E., PL, D, 27th Mass. Dahl, J., PL, I, 6th Ky. Dailey, AV., Pt., H, 125th Ohio, age 17. Dailey, A.. Pt.. B, 162d New Y'ork. age 21. Dailey, J. 1'., Pt., I, 73d New A'ork, age 31. Oct. 5, 0, '04. July 11, 12,''03. Sept. 8, 8, '64. July 20, 22,''64. June 18, 18, '64. April 7, 7, '02. May 6, 0, '64. Uec.ni, 31, '02. July 30, 31,''04. Dec. 20, 20, '64. Sept. 1, 2, '04. Sept. 30 30, '64. June 2, 2, 04. Mar. 29, 22. '65. July 8, 8. '64. .Alav 5, 3. 04. Mar. Ii), 19, '05. Alav 5, 6, '04. Sept. 14. 1(>. '02. May 31, June 2. Dee. 29, 2J, '02. June 17, 17, '64. July 2, 3, '63. 27, '04. Julv 12, 12, ''64. May 8, 9, '64. Dec. 12 13, '62. May 5, 5, '64. June 27 29, '62. Sept. 30, Oct. 1, 1864. Feb. 13 13, '62. June 1, 2, '62. Sept. 17, 18, '62. Mar. 14 14, '62. Sept. 20 20, '03. June 27 27, '64. May 13, 13,"'64. Operations, Operator,, Re.-.ult. Light; flap; by Surg. AV. L. Leonard, 7th 111. V. R. C. May 14, 1805. Left. Diseh'd Juno 6,1864 ; pen- stoned. Left; flap ; by Surg. A. A. AVhite, 8th Md. Disch'd July 29, 1805; pensioned. Right; anteroposterior flap; by Surg. Miller, C. S. A. Sent to Provost Marshal Nov. 1, 1801. Lett; Hap; by Surg .!. C Lyons. 50th Penn. ' Disch'd March 24, ISO. Bight, Disch; il; pensioned. Left; circular. Discharged .May 12, 1865. liight; by Suig. AV. (!. Bogue, 19th 111. Disch'd Mar. 18,1803; pensioned. liight; Hap Discharged June 22, flap; by Surg. .1. L.Dunn.109th Penn. * Discii'd April 29, IMiO; pensioned. Circular; by A. A. Surg. J. G. Bingham. Duty Dec 26,1864; pensioned. Right; circular; by Surg. J. E. Beatty, 2d Md. Disch'd May 13, 18*65. Left. Discharged; pensioned. Left; flap. Disch'd Aug. 2, 1865. Left; flap. Discharged June 26, 1805; pensioned. Spec. 2978. Left; flap. Discharged July 18, 1805; pensioned. Right; by Surg. J. Avery, 21st Mich. Disch d June 12, 1865; pensioned. Right; circular; by Surg. G. T. Stevens, 77th X. Y. Disch'd June 16, 1865; pensioned. Left; antero-posterior flap. Dis- charged.Xov. 5, 1802; pensioned Bight. Disch'd July 18, 1802; pensioned Left. Disch'd March 19, 1803; pensioned. Right. Discharged Feb. 5,1866; pensioned. Right; by Surg. M. Rizer, 72dPa.; amp. at shoulder joint Jan. 8, '04. Disch'd May 3, 1804; pensioned. Spec. 2006. Left; flap; by Surg. M. M. Hoo- ton, 80th Illinois. Disch'd Xov. 11, 1865; pensioned. By Surg. G. T. Stevens, 77th X. York; afterward killed in action. Bight; circular; by Surg. A. AV. AVhitney, 13th Mass. Disch'd Aug. 1, 1864; pensioned. Right; flap: by Asst. Surg. II. C. Dean. 51th New Ycrk. Disch'd Jan. 19, 1803; pensioned. Right; anteroposterior flap. Dis- charged Jan. H7,1865; pension'd. Left; by Surg. Lee, 3d Alabama, C. S. A. Disch'd: pensioned. Right; antero-pest. (lap. Disch'd July 8, 1865. Spec. 4070. Left; flap. Disch'd August 22, 1802; pensioned. Right. Disch'd Sept. 18, 1862; pensioned. Left; by Surg. J. S. Gale, 60th N. Y. Disch'd Nov. 24, 1862; pensioned. Left; circular; by Surg. G. A. Otis, 27th Mass. Disch'd July 29, 1862; pensioned. Left; re-amp. at shoulder joint, Mar. 9, 1864. Disch'd March 8, 1865; pensioned. Right; circular; by Surg. Z. P. Hanson, 42d 111. V. R. C. Feb. 3, 1865; pensioned. Left; flap. Disch'd Aug. 5,1863. Right; circular. Disch'd July 8, 1865. Namk, Age, and Military Description'. Daiver, ('., PL, II, 10th Missouri, age -.'5, Dnii/'iird, IP. II, PL, I), 200 \ irginin. Darling, ,L. PL, G, 20th Michigan, ago 4 5. Davis. I). O., Corp'l, F, Mi X. IL, ago 34. Davis, g., Pt., C, Sth Maine, age J2. Davis, F. IL, Capt., and Asst. lnsp'rl leu.,age :;;_>. Davis, \Y., Pt., [■', Mh N. Y. Cavalry, age 29. Danidson, J. P., PL, K, 45th N. ('., age 29. Davwalt, T. A.. PL, A, 91st Ohio, age 34. Dean, (!., Pt., E, 83d Pennsylvania. Dean, O.K., l't., G, 109th New York, age 20. Dean, D. L., Serg't Maj., 207th Penn., age 25. Dean, J. L., Pt., D, 19th Indiana. De Castro, AVm. E., PL, D, 1st Mass , age 29. Decker, M., Pt., E, 3d Missouri. Decker, L,Corp'l, F, 67th Ohio, age 23. De Diemer, L. N., Pt., E, 1st AA'isconsin. De Hass, C, PL, D, 49th Pennsylvania, age 43. Delame'ter,J., Pt., C,26th Michigan, age 28. Dcmmons, W. H.,Pt.,H, 31st Maine. Denmark, C, Corp'l, D, 132d Pennsylvania. Depue. H. J.JPL, F, 105th Illinois, age 18. Derby, I. XV., Corp'l, A, 2d New Hampshire. Derndinger, A.,Corp'l, K, 54th Xew Y'ork. Dibble, J. T., PL, II, 3d Michigan. Dickie, J. A., Serg't, E, 13th N. Carolina, ago 21. Dickhart, J., Pt., 1, 72d Penn. Dingwcll, J. II., Serg't, G,"8lh New Jersey. D----, G. S., Corp'l, A, 1st Col'd Troops, age 18. Dodge, C. B., PL, A, 5th Penn. Beserves. Dolan, J., PL, G, Sth N. Hampshire. Donnelly, J., Serg't, K, 191st Penn., age 23. Donnelly, C, PL, E, 2d Louisiana. Donohee, F. P., PL, I, 90th Penn. Dooling, T., Pt., I-I, 155th New York, age 32. Dorter, J., Pt., C, 143d Penn., age 29. Oct 13, 15, '64. July 3, :s, '09. June 0, 3, '04. May 25, 26, '05. July 8, 8, Til. Mar. 25, 26, '65. Aug. 1, 1, '03. June 2, 2. '64. July 20, 20, '64. June 27, 28, '62. Oct. 27, 27, '64. April 2, 2, '65. Aug. 28, 29, '62. May 12, 12, '64. Jan. 11, 12, '63. April 2, 2, '65. Oct. 8, 9, '62. April 6, 7, '65. May 5, 6, '64. May 12, 12, "'64. Dec. 13, IJ, '62. May 25, 25, '04. July 21, 21, ''61. 29, '02. Feb. 3, 4, '62. July 1, 2. '63. -cpt. 17. 18, '62. May 3, 3, '03. June 15, 15, '64. Dec. 13, 13, '62. June 1, 2, '62. June 19 19, '64. May 27 Aug. 20, 20, '02. June 15, 16, ;64. June 18, 18, '64. Operation's, Operator, Result. Light; flap. Returned to duty Jan. 29, 1865. Paroled August. 23, 1863. Right; flap; by Surg. F. M. Lin- coln, 35th Mass. Disch'd March 2, 1805; pensioned. Left; flap; by Surg.AV.A'osburg, 111th N. Y. Disch'd July 21, 1805; pensioned. Right; flap; by Surg. C. Gray, llth N. Y'. Disch'd August 15, 1801; pensioned. Right. Recovered. Left; by Surg. N. D. Ferguson. 8th N.Y. Cav. Diseh'd October 14, 1803; pensioned. Clap. Furloughed July 22,1804. Left; flap; bv Surg. J. B. AVar- wick. '91st Ohio. Disch'd Dec. 15. 1804; pensioned. Light; Hap. Discharged Oct. 20, 18ci2. Bight; flap; by Surgeon AV. E. Johnson, 109th N. Y. Disch'd Jan. 20, 1805; pensioned. Left; flap: by Surg. AVashington Burg, 2u1th Penn. Disch'd June 23, 1865; pensioned. Right; by Surg. J. A. AVard, 2d AVis. Diseh'd Nov. J8, IbOJ; pensioned. Bight; flap; by Surgeon E. A. AVhiston, 1st Mass. Discharged May 24, 1864 ; pensioned. Left; flap. Disch'd April 8,1863; pensioned. Left; circular; by Surg. James AVestfall, 67th Ohio. Disch'd Julv 8, 1865; pensioned. Right; flap; by Asst. Sure. D. P.. Davendorf, 1st AVis. Disch'd Nov. 1, 1862; pensioned. Left; circular. Disch'd June 22, 1865; pensioned. Right; circular; by Surg. J. XV. AVishart, 140th Penn. Disch'd Aug. 19, 1864; pensioned. Left; flap; by Surg. T. F. Oakes, 50th Mass. Discharged Nov. 2, 1804; pensioned. Left. Discharged. Left; flap; by Surg. A. W.Reagan, 70th Indiana. Disch'd Sept. 12, 1864; pensioned. Lett; by Surg. G. H. Hubbard, 2d X. II. Discharged Sept. 17, 1801; pensioned. Right: by Surg. C. AA". Hagen, 54th New A'ork. Disch'd Noa'. 1, 1862; pensioned. Left; flap; by Surg. D. W. Bliss, U. S. V. Disch'd Mar. 5, 1802; pensioned. Furloughed Nov. 9, 1863. Right; by Surg. G. S. Palmer, C. S. V. Disch'd Dec. 15, 1862; pensioned. Left. Disch'd May 30, 1864; pen- sioned. Left; flap; by Surg. J. R. Weist, 1st C. T. Disch d Feb. 10, '65; pensioned. Died July 15, 1870. Spec. 96. Left; flap; by Surg. C. Bower, 6th Pa, R. C. Disch'd Mar. 17,1863; pensioned. Right; flap; by Surg.L.M.Knight, Sth N. H. Disch'd July 25, '62. Left; lateral flaps. Disch'd Dec. 23, 1804 ; pensioned. Right; flap. Disch'd March 8. 1864; pensioned. Left; flap; by Surg. A. Ii. Cox, U. S. V. Disch'd Sept. 23,1802; pensioned. Left; flap; by Surg. T. Wylic, 155th New York. Diseh'd Feb. 18, 1805; pensioned. Left; flap; by Surg. F.C. Reamer; 143d Penn. Disch'd Dec. 9, 1804; pensioned. I INJURIES OF THE UPPER EXTREMITIES. [(HAP. IX. Name, Aok. and Mil.11 ARY DESCRIPTION. Dow 'is, C. L., Lieut., E, 2d Maine. Dow. K. P., Pt., D, Sth Ohio, age 21. Dow. AW, PL, II, 7th Cold Troops. Dow, AV. I,., PL. B. 13th Cold Troops, age 21. Drake. S. R., Corp 1, E, 47th Illinois. Drain. V., Corp'l, I, 14th Col'd Troops, age 21. Drew. AV.. Corp'l, G, 96th Illinois, age 34. Ducy, M., Pt., K, 97th I'enn., age 21. Duffy, 'lO't.,0, 2d New Jersey. Duffy, E., PL, C, 95th Penn., age 22. Dunbar, E. M., Corp'l, H, 10th Vermont, age 22. Dunlap, L, Serg't, E, 6th Penn. CaA'., age 20. Dunkel, J., Pt., F, 86th Ohio. Dunham, AV. H., PL, E, 14th New Jersey. Dunton, A. B., Corp'l, G. 56th Mass. Duncan. R R., 1st Lieut., U, (ith Viiginia, age 32. Duncan, L. P., 2d Lieut., E, 33d Indiana, age 21. Dunton, A. J., PL, B, Sth Maine. Dunn, C, Corp'l, II, 5th Maine. Dunn, G. XV., PL, K, 4th Iowa. Durstine, II. C, Pt., E, 4.ith Penn. Durrah, F. II, PL, F, 31st Penn., age 30. Durfee. E. O., Serg't, C, 21th iiichigan, age 21. Di/l.c.i, E. 11., Pt,,'E, 8th Florida. Dyer, J., PL, F, 2d West Virginia Cav., age 21. Earley, J., Pt., B, 10th New Hampshire. Easterbrooks, A. J., Mu- sician, I, (ith Penn. Re- serves. Eastman. G. Pt., K, 4th U. S. Artillery, age 21. Eastman, P. M., Corp'l, H, 102d Penn., age 21. Eaton, AV., Pt., 19th Ind. Battery, age 21. Ebb, A.. PL, A. 30th U. S. Col'd Troops, age 19. Ebert, C, Pt., K, 1st X. York. Eckstein, J., Pt., F, 183d Penn., age 28. Edelberle,R..Pt..H,12th Penn. Reset yes. Edgell. S. AV.. Corp'l, B, 15th Mass., age 33. Edgewcrth, R.. PL, D, 25th New Y'ork. Edmundson, G. V., Pt., B, 13th Georgia, age 20. Edmonds, C. A., Capt., II. 17th Michigan. Edwards. J. XV., Pt., F, 83d Cold Troops. Dec. 13. 'i May Aug 17. Dec 17, Mav 22 Dec 17, June 20, 20, '64. Jan. 15, 16, '65. Dec. 28, 28, '64. May 12. 12, 64. Sept. 19, 19, '64. Aug. 29, 29, '64. Aug. 10, 10, '62. June 2, 2, '64. May 5, 6, '64. Oct. 9, 10, '64. Julv 20, 20,''64. Sept. 2, 3. '62. July 21, 22,''01. Dec. 29, 29, '62. July 29, 22, '64. May 31, June 1, 1802. Julv 1, 2, r63. Feb. 5, 5, '65. Sept. 5, 6, '64. June 3, ' 3, '64. Aug. 30. 31, '62. April 6, 7, '65. Oct. 19, 19, '64. Mav 15. 15, "'64. July 30, 30, '64. Aug. 29. 29, '62. May 12 12, '64. Sept. 17, 17, '62. June 3, 4, '64. May 27, 29,' '62. July 9, 9, '64. Sept. 14, 14. '62. Jan. 17, 19, '65. OPERATION'S, Ol'KRATOlt, Result. Name, Ace, and Military Description. Left; by Surg. C. S. Wood. 66th N. Y. Disci June 9. (>3; pens'd. Left; flap. Disch'd Aug. 18, 1864. Left; flap. Disch'd Feb. 10, 1865; pensioned. Right; flap. Disch'd Aug. 8, 1865; pensioned. Circular; by Asst. Surg. T. Babb, 47thlll. Disc'dOct.9,'63: pens'd. Right; antero-posterior Hap: by Act. Asst, Surg. A. S. Giltner. Disch'd Aug. 8,1865; pensioned. Left; flap; by Surg. S. II. Ker- sey, 36th Illinois. Disch'd Oct. 27. 1864; pensioned. Right; circular. Disch'd Oct. 21, 1865; pensioned. Right; flap. Discharged June 5, 1865; pensioned. Right; antero-posterior flap; by Surg. E. B. P. Kelly, 95th Pa. Disch'd Oct. 3, 1864; pensioned. Left; circular; by Surg. W. A. Barry, 98th Penn. Disch'd Aug. 15, 1865; pensioned. Left; circular. Disch'd Dec. 18, 1864; pensioned. Spec. 3177. Right, Disch'd Sept. 25, 1802; pensioned. Right; flap; by Asst. Surg. T. A. Helwig, 87th Penn. Disch'd Sept. 20, 1884; pensioned. Left; flap; by Surg. Hunt, C. S.A. Disch'd April 1,1865; pensioned. Left; flap: by Confederate Surg. Ferguson. Transferred, for ex- change, January 10, 1865. Left; flap; Surg. T. Hatchard, 22d AVisconsin. Resigned Dec. 17, 1864; pensioned. Left; flap. Disch'd Nov. 1,1862; pensioned. Left; flap; by Surg. B. F. Bux- ton, Sth Maine. Disch'd Noa". 12. 1861; pensioned. Left. Disch'd Jan. 22, 1863. Left, Discharged Nov. 30, 1864; pensioned. Right; circular. Disch'd Aug. 21, 1862; peusioned. Right; antero-posterior flap. Dis- charged Dec. 23, 1803; pens'd. Right; flap. Released June 28, 1855. Left; flap; by Surg. T. Morton, 3d AVest Va. Cavalry. Disch'd March 4, 1865; pensioned. Left; by Surg. II. N. Small, ICth N.IL Disch dDec.2,'64; pens'd. Left; flap; by Surg. S. D Free- man, 1st Penn. Rifles. Disch'd Sept. 9, 1862; pensioned. Circular : by Surg. J. II. Kimball, 31st Maine. Transferred to reg- imental headquarters Julyl,'65. Left; flap; by Surg. E. ll. Um- berger, 93d Penn. Disch'd June 25, 1865; pensioned. Right; flap. Disch'd April 25, 1865; pensioned. Left; circular. Disch'd Dec. 29, 1864; pensioned. Left; flap; by Asst. Surg. John Howe, 1st New York. Disch'd Sept. 26, 1862; pensioned. Left; anteroposterior flap; by Surg. J. AV. AVishart, 140th Pa. Disch'd Julv 10,1865; pension'd. Right. Disch'd Nov. 15, 1862. Right: flap; bv Surgeon S. H. Plumb, 8~'d N. Y. Disch'd Dec. 2. 1364; pensioned. Right; flap. Disch'd Aug. 29, 1802: pensioned. Right; circular; by Surg. Green, 13th Georgia. Transferred Sept. 9, 1864, for exchange. Right. Disch'd Jan. 31, 1863; pensioned. Left; by Surg. J. S. Rcdfield, 6th Kansas Cavalry. Disch'd June 1, 1805; pensioned. Edwards, A. AA'., Corp'l, E, 37th Illinois. Eggleston, R. J., Pt., D, 3d A'irginia, age 23. Ellison, A. P., P, 16th Georgia. Elliston, J., PL, D, 5th Kv. Mt'd Inf., age 19. Ellis, O. A., PL, A, 61st l'enn., age 23. Ellis, H. E., Pt., K, 1st Maine Hy Art., age 21. Ellis, A., PL, A, 74th Illinois, age 22. Elliott, G. AY., PL, G, 5th Michigan, age 28. Elston, J., PL, A, 57th Ohio, age 22. Ely, D. IL, PL, F, 22d Iowa. EnterJine, E., Pt.,B, 116th Illinois. Erdley, S.. PL. D, 15Cth Penn.. age 2 i. Eskbridge. W. H, PL. E, 12th N. C, age 24. Estell, E., Pt., B, 207th PennsA'lvania. Euschef, A., Pt., E, 49th N. Y., age 28. Evans, D., PL, D., 51st Ohio, age 24. Evans, L. C, PL, I, 2d U. S. Infantry, age 20. Everman, J.. Pt., D, 5th U. S. Cold CaA'alry. Ewing, W., Tt., E, 119th Penu., age 40. Fahey, J., Pt., A, 111th New Y'ork. Falk, P., PL, D, 7th N. York. Fallon, T., Pt., II, 93d Illinois, age Ai. Parr, H. F., Pt., K, 16th Maine, age 27. Farringcr, J., Pt., C, 82d Penn., age 22. Fearcy. J., PL, K, 2d New Jersey. Dates. Jan. 8, 8, '63. July 13, 14. '64. Sept. —, 1802. Prim'ry. July 19, IP,''63. Mav 5, 6, '64. June 18, 20, '64. Julv 4, 4, '64. Oct. 27, 28, '64. July 22, 22, '64. Sept. 19, 20, '04. Dec. 30, 30, '62. Oct. 27, 28. '64. Sept. 23, 23, '64. April 2, 2, '65. Sept. 19, 19, '64. Tune 23, Aug. 21 21, '64. Dec. 23. 20, '64. Mav 10, 11, "'04. Sept. 14, 15. '62. Dee. 13, 13. '02. Nov. 25, 25, '03. May 8, 9, '"64. June 1, 1, '64. Sept. 14, 15, '62. Feen, J., Corp'l, M., 5th May 18, N. Y. Cav., age 30. i 19, "'04. Feirick. I. 11., Pt., I, 49th June 2, Penn.. age 28. 2, '64. Fenn, A. II.. Capt., K, Oct. 19, 2d Conn. H'vy Art. 19, '64. Fenton, P. S., Corp'l, C. June 3, 116th Illinois, age 21. 3, '64. Ferus, M.. PL, K, 74th May 5, New York. 7, '02. Fetterman, G., Pt., E, 5th Oct. 13, Pa. Cav., age 30. 13, '64. Field, E., Corp'l, I, 27th June 21 Ohio, age 23. 21, '64. Findlev, J. D., PL, K, June26 112th'X. Y., age 28. 26,'64. Finneal, E., PL, B, 5th Nov. 28. Michigan. 28, '(3. Finnell, S., PL, I, 69th June 10, N. Y., age 20. i 17, '64. Fipps. W. P., PL, K, 30th \ Aug. 12, Illinois, age 19. 14, 04. Fisher, C, PL, II. 17th Mar. 8, Wisconsin, age 27. 8, '65. Operations, Operator, Result. Right: flap. Diseh'd March 27, 1863; pensioned. Left; flap. Furloughed August 19, 1864. Bv Asst. Surg. II. A. DuBois. U. S. A. Paroled Oct. 15. 1862. Left; circular. Released August 14, 1863. Right; circular; by Surg. Wm. Buck, 6th Maine. Disch'd Feb. 7. 1865; pensioned. Left; lateral flap. Disch'd May 5,1865. Left: flap ; by Surg. W. E. Hasse, 24th AVis. Disch'd Mar. 4. 1805; pensioned. Left; flap; by Surg. II. F. Lyster, 5th Mich. Disch'd March 17, 1865; pensioned. Spec. 4118. Right; by Surgeon S. P. Bonner, 47th Ohio. Discharged April 17, 1865; pensioned. Right: flap; by Surgeon J. C. Strader, 22d Iowa. Discharged May 2, 1865 ; pensioned. Left; flap; by Surg G. S. Wal- ker, 6:h Missouri. Disch'd Mar. 16, 1863; pensioned. Right; flap. Disch'd June 28, 1865; pensioned. Right; circular; by Surgeon A. Atkinson, C. S. A. Transferred to Fort Mcllenry Dec. 9, 1864. Left: flap. Discharged July 12, 1865; pensioned. Right; flap; by Surg. G. T. Ste- A-cns, 77th N. Y. Disch'd July 15, 1865. Left; flap; by Surg. J. N. Beach, 40th Ohio. Disch'd Oct. 28,1804; pensioned. Left: by skin flaps and circular section of muscles. Disch'd Oct, 23, 1864 ; pensioned. S/hc. 416, plaster cast. A. B. b. 55. Left; flap: by Surg. James G. Hatchitt, U.S. V. Disch'd Mar, 29. 1865; pensioned. Left: flap; by Surg. P. Leidy, 119th Penn. Disch'd April 6, 1865; pensioned. Right. Disch'd Aug. 18, 1863; pensioned. Right; flap. Disch'd Feb. 27, 1863. Right: flap; by Ass't Surg. J. O. Skinner, 10th Iowa. Disch'd July 20, 1865; pensioned. Left; antero-posterior flap. Dis- charged Dec. 15, 1864; pens'd. Right; flap. Disch'd June 11, 1865. Left; circular; bv Surg. L. AA'. Oakley, 2d N. j'. Disch'd Dec. 23. 1802; pensioned. Left; (lap. Diseh'd Aug. 2, 1865; pensioned. Right; double flap. Disch'd June 16, 1865; pensioned. Left; flap; by Surg. II. Plumb, 2d Conn. Il'vy Art, Mustered out Aug., 1865; pensioned. Right; flap; by Surgeon Ira N. Barnes, 116th Illinois. Disch'd June 7. 1865; pensioned. Left, Disch'd; pensioned. Left. Disch'd April 23, 1865; pensioned. Left; antero-posterior flap; by Surg. D. S. Y'oung. 2!st Ohio. Disch'd Xov. 29, 1864 ; pens'd. Left; flap; by Surg. C. E. AYash- burne. 112th N. York. Disch'd Sept. 11, 1865; pensioned. Right; bv Snrg. H. F. Lyster, Sth Mich. Disch'd July 15, '64. Left: circular: by Surg. X. Hay ward. 20th Mass. Disch'd Nov. 7, 1865: pensioned. Right; flap: by Surg. H. Me- Kcnnan, 17th AA'isconsin. Dis- charged Dec. 27, 1864: pens'd. Right; circular: bya Confederate surg. Disch'd May 31,'65; pen.s'd. SECT. FY AMPUTATIONS IN THE SHAFT OF THE HUMERUS. 705 Name, Aoe, and military description. 372 373 374 375 376 37 378 319 380 381 382 380 384 385 392 393 394 395 396 397 398 399 400 401 402 Fisher, J. IL, PL, F, 7th Indiana, age 25. Fitzpatrick, M., Private, AVicken's Hat y, C.S. A., age 48. l'lynn, M., Pt., E, 4th Delaware, age 48. Fogle, A., Pt.,K, 1st Pa. Rifles, ago 19. Foley, D., Pt., C, 63d X. York. Foley, J., PL, H, 61st Pa., age 28. Forbes, G., Pt., H, 13th Iowa. Ford, T., Landsman, U. S. Navy. Fortinberry. W. G„ PL, H, 19th Ala., age 23. /"osier, A. J., l't., G, 7th Tennessee, age 27. Foster, J. P., Corp'l, F, 35th Mass. Foster. AY. E., Lieut., E, 30th Illinois, age 25. Fox, T. B., Pt., H, 55th Ohio, age 19. Frain, J. F., PL, D, 1st Pa. Cav., age 19. France, H., PL, C, 5th Pa. Res. Corps. Francey, F.. PL, B, 6th Wisconsin, age 44. Frey, A., Corp'l, I, 97fb Pa., age 36. Fromwiler, L., Pt., B, 116th New York. Fry, G.. Pt., B, 107th Pennsylvania, age 23. Fry,S.,Pt.,L148th Penn., age 30. Fuller, E., Corp'l, B. 6th X. Y. H'y Art., age 29. Fuller, J., Pt., F, 2d A't. Fuller, AV., Pt., C, 68th Ohio, age 24. Fult. M., Pt., E, 66th New Y'ork. Furlong, P.,Serg't, A, 7th Michigan. Gall, G., Serg't, E, 29th New York. Gallagher, E., Pt., K, 42d New York, age 33. Gallagher, L., PL, A, 69th Ohio, age 18. Galvin, J., PL, A. 136th New York, age 17. Gans, P., Serg't, C, 15th Infantry, age 27. Gardiner, AV. H., Pt., C, 91st N. Y., age 18. Gardner, N. B., Pt., K, 2d Michigan, age 23. Gardner, I. B., Capt., I, 14th Maine, age 21. Gardner, E. B., PL, H, 35th Mass., age 31. Gaudy, A..Corp'l, K, 46th Indiana. Gault, J. M.. PL, H, 13th Ohio, age 36. Geiger, J. C, Serg't, E, 105th Pa., age 25. Gelray, J. W., Lieut., G, 2d Mass. Dates. Alav 6, 7, '04. Aug. 31, Sept. 2, 1804. June 19, 19, '64. May 30, 30, '64. Dec. 13, 13, '62. Aug. 21, 21, '64. July 23 1804, I In Held April 21 17, '04. July 3, 4, 'Oil. Dec. 13, 13, '62. .Aug. 28 28, '64. June 19 19, '64. June 3, 3, '64. Sept. 14 1802, 10 hours after. April 1, 1, '05. Jan. 15, 15, '65. June 14, 14, '63. June 3, 3, '64. Julv 2, 4, '63. Junel, 1. '64. May 4, 5, "63. Julv 22, 23," '64. Dec. 13. 13, '62. Dec. 13, 14, '62. Aug. 29, 29, '62. Oct. 21, 22, '61. Sept. 1. 2, '64. Mar. 16, 16, '65. Sept. 1, 1, '04. Alar. 30, 31, '65. June 17, 19, '64. Sept 19, 20, '64. Sept. 17, 19, '62. May 1, 18*63. Aug. 8, 8, '64. July 2, 3, '63. July 3, 3, '63. Operations, Operator, Result. Left; by Surg. G. AV. New, 7th Indiana. Duty Sept. 25, 1864; pensioned. Right; anteroposterior flap; by A. A. Surg. IL L. MeClure. To Provost .Marshal Jan. 31, 1805. liight; antero-posterior flap; by A. Surg. C. B. Haynes, U.S. V. A'. B. ('. April 29, 1805. Right. Disch'd July 31, 1864; pensioned. liight; (lap: by Surg. L. Rey- nolds, OOd N. Y. Disch'd May 13, 1803; pensioned. Right; circular; bv Surg. G. T. Stevens, 77th N. Y. Duty, Nov. 18,1864, for muster out; pens'd. Right; flap. Discharged Oct. 27, 1864. Left; by Dr. Lyons, U. S. Navy. Disch'd; pensioned. Left; lateral flap; by A. A. Surg. A. Rolls. Pro. Mur. Feb. 28, '65. Right; paroled Aug. 22, 1863. Right; flap: by Surg. J. P. Ho- sack, 51st Pa. Dis'd Mar. 12, '63. Left: circular; by Surg. J. H. Boucher. U. S. V. Mustered out Feb. 2, 1805: pensioned. Circular: by Surg. I. N. Hines, 73d Ohio. Disch'd May 30,1865; pensioned Right; flap: by Ass't Surg. L. E. Atkinson, 1st Pa. Cav. Head and remaining shaft removed in fragments on Oot. 21,1864. Dis- charged April 1,1865; pens'd. Right; flap. Disch'd Nov. 12, 1802; pensioned. Left: circular. Disch'd July 10, 1865. Left; circular; by Surg. G. C. Jarvis, 7th Conn. Disch'd May 2, 1865; pensioned. Left. Duty Aug. 21, 1863; pen- sioned. Circular ; by Surg. J. F. Hutch- inson, 107th Penn. Disch'dMay 20. 1865; pensioned. Right; antero-posterior skin flap; byConfed. Surg. Knox. Disch'd Nov. 21, 1803; pensioned. Right; circular. Disch'd Oct. 22, 1864, and pensioned. Right; by Surg. AV. J. Sawin, 2d A't. Disch'd J une 15,'63; pens'd. Right; circular. Disch'd June 27, 1865; pensioned. Left; flap. Disch'd Mar. 6,1863; pensioned. Right. Disch'd June 10, 1863; pensioned. Left; flap; by Surg.C.Newhaus, 29th X. Y. Disch'd Nov. 14,'62. Right: flap; by Snrg.J.D.Osborne, 42dX. Y. Disch'd Dec. 14,1861; pensioned. Left: circular; bySurg.L.Slusser, 69th O. Dis d Mar.2,'66; pens'd. Left; flap. Disch'd July 31,1865: pensioned. Left. Duty October 27, 1864. Right; flap; by Surg. A. S. Coe, 147th N. Y. Disch'd October 3, 1865; pensioned. Left; flap; bySurg.E.J.Bonine, 2dMich. Disch'd Xov. 28,1864; pensioned. Right. Duty Oct. 18, 1864 ; pen- sioned. Right. Disch'd March 4, 1863; pensioned. Right; double flap. Disch'd Aug. 8, 1863; pensioned. Left; circular; by Act. Staff Surg. C. B. Richards, U. S. A. Disch'd June 27, 1865; pensioned. Left; circular. Diseh'd Oct. 7,'63. Right; by Surg. W. H. Heath, 2d Mass. M. O.; pensioned. Name, Age. and Military 1 ncscitirnoN. Gerhauser, J. L., Pt , 1), 20th AVisconsin. Gibson, L., cabin boy, Gunboat Xo. 10, nge 25. Gibson, W. M., l't., C, 30th Illinois. Gilford, A. A., Serg't, K, 119th Pa., age 40. Gilbert, G. P., Corp'l, D, 4th Vermont, age 21. Gill, J. C, Corp'l, D, 5th Kentucky. Gilman, .LE., Pt., E,12th Mass. Gissingcr, G. B., Corp'l, G, 02d Pa., ago 21. Dates. S., PL, L, 5th Glenn, \V., PL, F, 187th Pennsylvania. (Hidden*, AV. H., PL, A, 13th X. H., age 19. Godfrey, A., PL, D, 58th Pa., age 48. Godfrey,AV., PL, E, 169th N. Y., age 20. Goldworthy, T. M., PL, C, 12th Wis., age 22. Goller, H., Pt., D, 65th N. Y., age 36. Goodwin, L., PL, F, 8th Maine, age 18. Goodwin, A. K., PL, I, 4th N. H., age 23. Goodman, Win. R., PL, A, IstMd.Lt. Artillery, age 19. Gordon, J. M., Pt., G, 147th X. Y., age 24. Gordon, D., Pt., H, 4th Va. Cav., age 21. Gordon. Ira, PL, F, 124th New York. Grabach, R., Pt., K, 2d New Jersey. Grace, E., PL, D, 27th Indiana. Grady, J. R., Pt., A, 23d North Carolina, age 33. Graham, J., Pt., C, 107th Pennsylvania. Graham, J., PL, F, 29th Pa., age 21. Granger, E. O., Serg't, F, 7th Ohio, age 30. Grant, G., PL, G, 60th N. Y., age 22. Graves, AV., Pt., 1st N. Y. Independ't Bat., age 44. Gray, G. W., PL, D, 37th Mass. Greely, AV. AV., PL, C, 3d Vermont, age 19. Greene, II. P., PL, F, 7th June 17 July 1, 1, '63. Jan. 12, 12, '05. Mar. 7, 7, '02. May 5, 5, '04. April 2, 2, '05. April 7, 7, '62. July 1, 1, '03. May 5, 5, '04. July 18 20, '64. June 18 18, '64. June 15, 15, '64 June 3, 3, '64. June 30. 30, '64. July 21 21,*'64. Oct. 19, 19, '64. July 30, 30, '64. May 16, 16, '64. Dec. 13, 13, '62. June 3, 3, '64. April 6, 6, '65. July 2, 3, '63. Sept. 14, '62, 18 b's after. Sept. 17. 18, '62. Julv 3, 3, '63. Dec. 13. 13, '02. June 15, 16, '64. May 25, 26. '04. Julv 2, 2, '63. Oct. 19, 19, '64. May 6, 6, '64. May 4, 5, *63. AA'isconsin, age 16. Greenfield, C. IL. Pt., F, 9th N. Y. Heavy Art., age 29. Grcenwault, A., PL, F, 03d Pennsylvania. Gregg, A., Pt., E, 4th Pa. Cav., age 24. Gregg, D., PL, F, 10th N. Y., age 34. Griffith, J. M., Corp'l, G, 191st Penn., age 27. Grover. J..Serg't, F, 14th New Jersey, age 18. Gromley, M., PL, I, 3d R. I. Artillery, age 20. Gudknecht.C. H., PL, D, 187th Penn., age 36. Guilder, C. B., PL, E, 10th A'ermont, age 25. Operations, Operator, Besult. 18, '64. April 2, 3, '65. June 1, 1, '62. Aug. 16, 16, '04. Sept. 28. 28, '64. Feb. 6, 6, '65. April 2, 3, '65. Aug. 28 28, '63. June 18 18, '64. April 2, 2, '65. Bight Disch'd May 13, 1864; pensioned. Left; Hap; by A. A.Su.rg.Gco.Har- vey. Disch'd Mar. 7,'65; pens'd. liight. Disch'd April 14, 1862; pension...!. Lett; bv Surg. P. Leidy, 119th Pa. Disch'd Mar. 27, '65; pens'd. Left; (lap. Disch'd July 25,'65; pensioned. Left. Disch'd Sept. 9, 1862; pen- sioned. Right; circular. Disch'd Sept. 28, 1863; pensioned. Left; anteroposterior flap; by Surg. A. S. Coe, 147th N. York. Duty July 11, 1864; pensioned, Left; flap; by Surg. Jones, C.S.A. Disch'd July 7,1865; pensioned. Right; circular. Diseh'd Nov. 10, 1864; pensioned. Right. Disch'd; pensioned. Right; bilateral flap. Disch'd Nov. 11, 1864; pensioned. Left: flap. Disch'd Sept. 19,1865; pensioned. Spec. 3044. Right; circular. Disch'd June 28, 1865; pensioned. Left; flap. Disch'd Nov. 7,1865; pensioned. Left; flap. Disch'd June 24,1865; pensioned. Right. Disch'd Sept. 23, 1864; pensioned. Left; circular: by Surg. E. Ship- pen, U. S. V. Mustered out Aug. 8, 1866: pensioned. Left; circular: by Surg. A. S. Coe, 147th X. Y. Disch'd Oct. 24, 1864; pensioned. Left; circular; by Surg. T. H. Squier, 89th X. Y. Released June 14, 1865. Left; flap. Disch'd Oct. 19,1863; pensioned. Left: circular: by Surg. L. W. Oakley, 2d X. J. Disch'd Dec. 23, 1802; pensioned. Left: circular. Disch'd Dec. 6, 1802. Left. Retired Jan. 20, 1865. Left. Disch'd Aug. 3, 1863. Right; antero-posterior flap; by Surg. H. E. Goodman, U. S. V. Disch'd Junel, 1805; pensioned. Right; bv Snrg. A. K. Fifield, 20th Ohio. Diseh'd Jan. 9,1865. Left. Disch'd Dec. 9, 1863; pen- sioned. Right; circular. Disch'd July 4, 1865; pensioned. . Left; flap. Disch'd Oct. 16, 1864; pensioned. Right; flap; by Surgeon D. M. Goodwin, 3d A't. Disch'd Aug. 4, 1863; pensioned. Left; flap; by Ass't Surg. J. T. Duffield, 7thlnd. Disch'd Dec. 6, 1864; pensioned. Spic. 1388. Left; antero-post. flaps : by Surg. D. S. Chamberlin, 9th X.*Y. H'y Art. Disch'd July 7,'65; pens'd. Right; by A. Surg. N. R.Gunn.lst Mass. Disc'd Aug. 8,'62; pens'd. Left; flap. V. R. C. Jan. 14,1865; pensioned. Right; by antero-posterior flap; by Surg. G. Chaddock, 7th Mich. Disch'd July 12, 1865; pens'd. Right; ant.-post. flap; bv Surg. J. AV.AVishart,140th Penn". Disch'd May 5, 1865. Left: circular; by Surgeon J. S. Martin, 14th N. J. Discharged Sept. 12, 1865; pensioned. Left; circular ; by Surg. Gen. W. A. Hammond, U. S. A. Disch'd June 17, 1864; pensioned. Left; flap. Disch'd Dec. 9, 1864; pensioned. Right; flap; by Surgeon AV. A. Child, 10th Vt. Disch'd July 21, 1865; pensioned. 89 706 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. 451 452 453 454 455 456 457 458 459 460 461 462 463 464 466 467 408 470 471 472 474 475 476 477 478 479 482 433 484 485 486 487 488 499 48(1 491 492 X \MF. Ai;l\ AND Military Description. Gumbert, J. II.. PL, G, 81st Penn. Gunning, A. J., Pt., H, 35th Mass. Haag, S. 0.. Ci.rp'l, G, 51st Ohio, age 23. Hains, AV'.. PL, H, 97th Ohio, age 21. Halt W. K., Ft., I, 4th Georgia, age 35. Hall, H. S., Lieut.-Col., 43d C. T. Hall, B., PL, D, 40th New York. Hall. H., Pt., H, 108th New York, age 21. Hall. N., Corp'l, D, 2d U. S. Sharpshooters. Hamilton, Z. C, Serg't, D. 1st California Cav. Ilankinson, T. D., Corp'l, B, 3d X. Y., age 31. Hannah. J., PL, C. 45th New York. Ilarkins. A., Capt., B, 2d Minnesota. Harlan, (4., PL, D, 106th Pennsylvania, age 38. Harlow, G.R., Corp'l, E, 39th Mass., age 26. Harn, C. E., 1st Lieut., I, 13th Mass.; asre 25. Harrelt, IP., PL, A, ICtb Kentucky Cav., age 22. Harrington, D. M..Serg't, G, 73d N. Y., age 37. Harrington, J. H., PL, G, 107th N. Y., age 22. Harris, J., 1st Lieut., D, 2d Ky. Cav., age 25. Harris, H. L., Pt., F. 2d Vermont. Harshaw, II.B., 2d Lieut., E, 2d AVis., age 21. Hartnett, T., Pt., F, 30th Massachusetts. Hartmau. J. P., Pt., I, 7th Illinois Cavalry. Harwood.L C, Serg't, C, 34th A'irginia, age 32. Hastings. R. H., Pt., D, 38th Virginia. Hatcher, L , PL, C, 57th Pennsylvania, age 40. HaA'erly, J. P., PL, C, 2d .Massachusetts. Hiw'.iiis. M. V., Serg't, E, 1st Tenn., age 22. Hawkins, G., PL, F, 2d Michigan. Hayes, P. T.. PL, A, Sth N. IL, age 20. Haynes, J., Pt.. F, 122d Illinois, age 20. Oavward, A. B., Serg't, A", 2d N. H., age 26. Hay. J.. Serg't, I, 57th Pennsylvania, age 24. Healey, J , PL, 1, 65th New York. Heaney, G. S.. PL, D,lst New Jersey. Heathe. J., Pt.. K, 7th TJ. S. C. T., age 30. Henderson, A. P.. Pt., K, llth N. II , age 19. HendersoD, J., PL, H,57th Indiana, age 30. Hendrick, T. C, Pt.. A. Sth Vermont, age 27. Henifer, T., Corp'l, D, 2d Delaware. Henry. W., Pt.. H, 68th C. T.. age 20. Opkuatioxs, Operator, Rp.sri.T. Name, Age, and Military Description. Sept. 17, 17. '62. Dec. 13, 14. '62. lept. 2, 3, '64. June 18, 18, '64. April 2, 2, '65. July 30, 30, '64. July 2, 4, '63. Sept. 17, 17, '62. May 4, 4, '63. July 13, 15, '65. Julv 12, 12, *'64. Mav 3, 3, *63. sept. 23. 22, '63. June 3, 3, '64. Aug. 18. 18, '64. May 8, 9, r64. June 12, 12, '64. June 1, 1, '64. May 25, 27, "'64. June 12. 12, '64. June 29. 30, '02. May 8, 9, '64. Oct. 19, 21, '64. Mar. 1, 2, '62. Oct. 27, :.'7. '04. Mav 10. 10,"'04. Mav 5, 6, *'64. Aug. 9, 10, '62. May 5, 5, '64. Xov. 24, 24. '63. Aug. 27 27, '64. Julv 14 14, "'64. June 3, 3, 'G4. Xov. 27, 27, '63. July 2, 2, '62. Sept. 14, 14, '62 Sept. 29, Oct,l,'64 July 30, 30, '64. Alav 27. 27." '64. May 12. 12.''64. Julv 2, 4, "63. April 2. 2, '65. Right; flap. Discharged May 21, 1863; pensioned. Left. Discharged Feb. 20, 1863; pensioned. Left; flap; bv Surg. M. G. Sher- man, 9th Ind. Disch'd Mar. 21, 1865; pensioned. Left; flap; bv Surg. E. B. Glick, 40thlnd. Disch'd Dec. 22,1864. Left: circular. Released June 14, 1865. Right; cir.; by Surg. D. MacKav, 29th C. T. Discli'd Oct. 25, 05. Right; flap; by Surg. Wm. Wat- son, 105th Penn. Diseh'd Oct. 19, 1863; pensioned. Right; ant.-post. flap. Disch'd Oct. 11, 1862; pensioned. Bv Surg. J. S. Jamison, 86th X. Y. Disch'd Aug. 14, '63; pens'd. Right; circular; by Surg. J. E. Kunkler. 1st Cal. Cav.; pens'd. Right; circular. Disch'd Oct, 26, 1864: pensioned. Left; circular. Disch'd August 13, 1863. Left; flap ; by A. Surg. O. Aver, 2d Minn. Duty June 20. 1864. Right; circular: by Surgeon M. Rizer, 72d Peun. Disch'd July 18, 1865; pensioned. Right; circular ; by Surg. Wm. Thorndike, 39th Mass. Disch'd March 17, 1865; pensioned. Right; flap; by a Confed. surg. Disch'd Sept. 9,1864; pensioned. Left; circular; by Surg. Miller. C. S.A. To Milit y Pris. Aug.16,'64. Left; ant.-post, flap; by Surgeon Fowler Prentice, 73d New York. Disch'd Mar.22,1865: pensioned. Left; flap; by Asst. Surg. L. AV. Kennedy, 123d N. Y. Disch'd April 14, 1865; pensioned. Right; flap: by Surg. Miller. C. S.A. To Milit'v Pris. Aug.16,'64. Right: by Surg". W. J. Sawin, 2d Vt. Disch'd Aug. 27,'64; pens'd. Left; circular: by Surg. A.J. Ward, 2d AVis. Disch'd June 28,1864; pensioned. Right; circular; bv Asst. Surg. S. H. Davis, 3Jth ioass. Disch'd April 1, 1865. Right. Discharged July, 1862 ; pensioned. Right; circular; by Surg. W. L. Baylor.C.S.A. FuiTdDec.13,'64. Left; circular; by Surg. Swallow, 38th Ya. Disch'd Mar. 17,1865. Left; circular. Disch'd June 1, 1865: pensioned. Left; circular; by a Confed. surg. Disch'd Dec. 26,1862; pensioned. Right; flap. Furloughed June 21, 1864. Right, Discharged Mar. 26,1864; pensioned. Right; flap; by A. A.Surg. A.H. Robinson. Discharged Dec. 1, 1864; pensioned. Right; flap. Discharged July 22, 1865; pensioned. Right; circular; by Surg. J. M. Merron, 2d N. II. Disch'd June 21, 1864; pensioned. Left; flap; by Sur. II.F.Lvster,5th Mich. Disc'dFeb.19,'64"; pens'd. Right; flap; by a Confed. surg. Discharged April 9, 1863. Left: circular; by Surg. W. B. Little, 32d N. Y. Disch'd Mar. 6, 1863; pensioned. Right; flap; by a Confed. surg Discharged August 16, 1865. Left: flap. Disch'd October 26, 1864; pensioned. Left; by Surg. E. B. Glick, 40th Ind. Disch'd Dee 10.'64: pens'd. Right; oval flap: by Surg. A. H. Chcssmore. Sth A't. Discharged Sept. 15, 1864; pensioned. Left. Discharged Oct. 9, 1863; pensioned. Left: circular. Disch'd June 10, 1865. Henry. A. B.. PL, K, 2d ' Mav 19, AA'est A'irginia Cav. Henry, P., If., II, 12th Iowa. Herron, W., Pt.. D, 9th Louisiana, age 32. Herman, II. IL, Pt., C, 37th Ohio, age 20. Hesson, J., PL, C, 81st Pennsylvania, age 44. Hubbard, O. N., PL, I, 16th New York, age 21. Hudson. R. W., Serg't.G, 4th Ind. Cav., age 26. Huddleson, AV., PL, B, 125th Illinois, age 18. Huff, R. D., Pt., K, 1st Michigan. Hughes. S.T.,PL, K, Sth Tennessee. Humphrey, A. J., Q. M. Serg't, E, 2d New Y'ork Mounted Rifles, age 22. Hunter. F.J..PL.II, M8th PennsylA'ania, age 23. Hunter, N.. PL. C, 2d X. Y. Heavy Artillery. Hunter, J. IL, PL, G, 6th A'ermont, age 27. Hunt. D., Corp'l, B, 7th AA'. Ya., age 42. Hurst, P., PL, C, 16th Ohio, age 24. Hutchins, L. W., PL, C, 1st Georgia, age 26. Hicks, G. V., Pt., B, :fcl Kentucky CaA\, age 19. Iliekey, M., PL, E, 63d New York, age 38. Higgs, J., Corp'l, H, 1st Mich. Light Art., age24. Higson. AV. IL, Pt., H, 12th N. I-I., age 20. Hill, I. L., Corp'l, I, 30th Maine. Hilton, AV. G.. Pt., C, 52d Ohio, age 35. Hillyer. I. C, PL, D, 28th Illinois. Hines, J., PL, E, 52d New Y'ork, age 23. Hine, C. E., Pt., G, 8tb Wisconsin. Hipp.C, Major, 37th Ohio. Hodgdon, J. F.,Pt., 1,1st Mass. Heavy Artillery. Hoel, C, Pt., D, 105tb Pennsylvania, age 25. Hogarty, W. P., Pt., B, 4th II. S. Artillerv. Holsehuh.W., Pt,,F, 28th Ohio, age 22. Honecker, J., PL, D, 1st AV. Ya. Light Artillery. Homan, P., Pt., F, 75th Illinois. Hood, J. D., Sfirg't, H, Kith S. C, age 34. Hoover, M., PL, C, 64th Ohio, age 43. Hook, L. T., PL, G, 73d Pennsylvania. Hoobler, J.. PL, F, 61st Penns\'lvania. Hopkins, 11., PL, M, 100th Pennsyh'ania. Horner, H., Serg't, H, 70th New York. 19, '63. Julv 13, 14, *'G4 July 9, 11, ''64. Mav 22, 22,"'63. Mar. 25, 25, '65. Mav 3, 4, !63. May 26. 26, '64. June 27, 27, '64. Mav 3, 3, '(',3. Mav 14. 14,''64. Julv I, I, '64. Mav 3, 3, \>.i. June 16, 17, '64. Mav 6, 6, '64. Mar. 30, 30, '65. Dec. 29, 29, '62. Nov. 30, Dec. 1. Sept. 2, 2, '64. June 16, 18, '64. July 5, 5, '64. Aug. 17, 18, *64. April 23, 23, '64. Mar. 16, 16, '65. Oct. 5, 5. '62. Mav 19, 19, "'64. Oct. 3, 3, '62. July _S. -8, ML June 14, 14, '63 Mav 10, 10,' '64. Dec. 13. 13, '62. Sept, 17, 19, '62. June 6, 6, '64. Oct. 8, 8, '02. Xov. 30. Dec. 1. Xov. 29. 29, '64. Xoa\ 25, 25, '63. June 1, 1, '62. Aug. 29 30, '62. June 1, 1, '62. Operations. Operator, Blsclt. Left; circular. Disch'd Sept. 20, 1863; pensioned. Right; by Surg. J. IL Niglas. Cth III. Cav. Disch'd: pensioned. Right; circular: bv Surg. ('. II Todd.C.S.A. Duty Sopt.19,'04. Left: flap: bv.A.Surg. E.Ringlcr, 37th O. Dis'd Sept. 14, 63; pon'd. Left; double flap; by Surg. M. II. Raymond. 20th Mich. Disch'd June 20, 1865; pensioned. Right; flap: bv a Confed. surg. Discli'd July 7,1863; pensioned. Left; circular: by Surgeon J. F. Taggart, 4th Ind. CaA-. Diseh'd June 29, 1865: pensioned. Right; flap. Discharged Oct, 29, 1804; pensioned. Left; circular: by Surgeon C. ?L AA'ood. 66th N. Y. Diseh'd Get. 17, 1863; pensioned. Left: by Surg. L. D. Griswold, 103d Ohio. Disch'd Sept, 11, 1804; pensioned. Left; circular: by Surgeon R. T. Payne, 2d N. Y.*M. R. Diseh'd October 3, 1865: pensioned. Right; by Surg. G. L. Potter, 145th Penn. Disch'd July 20, 1863: pensioned. Left; (lap; by Surg.J.AV. AVishart. 140th Penn. Disch'd Oct. 11, J 804; pensioned. Right; by Surg. X.Hayward,20th Mass. Dise'dMar.10,'05; pens'd. Right; ant.-post. flap: by Surg. A. Satterthwaite, ICtli X. Jersey. Discli'd June 15, 1865. Right; by A. Surg. B. S. Chase, 16th Ohio. Discharged Mar. 7, 1863. Antero-posteriorflaps. ToProA'OSt Marshal March 7, 1865. Right; flap: by Surg.R. M. Fair- leigh, 3d Kentucky Cav. Disch'd May 16, 1865: pensioned. Left; flap; by Surg. P. E.IIubon, 28th Mass. Disch'd Jan. 31,1865; pensioned. Circular. Disch'd March 13,1865; pensi' ned. Left; flap. Discli'd Jan. 17,1865. Right; flap : by Surg. J. Al. Bates, 13th Me. Discli'd J une 23,1864; pensioned. Left; circular. Disch'd Jul}' 4, 1965; pensioned. Right: bv Surg.AV. F. West, 28th 111. Disch'dNov.10,1862: pens'd. Left: circular: by Snrg. A. \"an Devere. 60th N.'York. Discli'd October 19, 1804: pensioned. Right. Discharged Dec. 1, 1802 ; pensioned. Left; flap; by Surg. A. C. Messen- ger. 57th Ohio. Duty Oct. 15,'04. Right; circular; by A. Surg. M. F. Bowes, 12th Penn. Cav.: and left; circular: by A. Surg. T.C. Smith, 116th Ohio. Dis. barged Aug. 5, 1863; pensioned. Right; circular: by Surg. II. P. Lyster, Sth Mich.' Disch'd Sept. 8. 1864 : pensioned. Left; flap. Disch'd Feb. 1, 1863; pensioned. Left; by A. Surg. A. Schonbein, 28thO. Disc'd.Iune9,'63; pens'd. Right; flap, bv Surg. David Bag- ley, 1st \V. Va. Disch'd June 14, 1865; pensioned. Right, Disch'd Jan. 12, 1863; pensioned. Left; circular. To ProA'ost Mar- shal March 28, 1865. Right: circular. Disch'd Feb. 21, 1865. Discharged June 7, 1864. Right. Discharged Aug. 4,1862; pensioned. Right; flap. Disch'd October IP. 1862: pensioned. Right; flap. Disch'd July 18, 1862. AMPUTATIONS IN THE SHAFT OF THE HUMERUS. 707 550 551 552 553 555 556 557 558 559 SCO 561 562 563 564 Nami", Ac Military Di:; , AMI 'Rll'TION. Borle, J.. Pt., G, 3d New- York Artillerv. Hosier.S. 11.,1't'., D, 112th New York, age 20. Hosier, \Y. X., PL, 1,143d Pennsylvania, age 21. Hose, I'., PL, 11, 13th Ohio. Hover, S„ PL, D, 5th U. S. C. T., age 42. Howard. J. AV., Pt., II, 14th New York Heavy Artillery, age 19. Howard, 1'., l't., E, llth Mass.. age 23. Howard, J.R., Pt.,B,7tli Iowa. Ilgenfrety,AV..Pt.,E,87th Pennsylvania, age 21. Ingraham, J. J., PL, F 33d Mo., age 33. Ingram, M. L., PL, F, 2d S. Carolina, age 24. Ingram. AV. A., PL, G, Liist Illinois. Ives, H.. PL, A, 1st Penu, Artillery. Jackson, C. C, Pt., F, 183d Penn., age 19. Jackson, F. R., Serg't, F, 7th Conn. Jagger, S.G.. PL, C,20th Conn., age 23. Jaines. S. F.. Serg't, D, 33d N. C, age 21. Jeffrey, J., Pt., B, 5th Me., age 22. Jenkins, H., Pt., G, 123d Illinois. Jenney, G, Pt., F, 5tli A'ermont. age 45. Johnson, A., Pt., E, 67th New York. Johnson, P., Corp'l, B, 142dN. Y'., age 22. Johuson, G. IL, Serg't, B, 50th Pennsylvania. Johnson, J., Pt., F, 4th Maine, age 30. Johnson, J., Pt., E, 6th Georgia, age 24. Johnson, N., Pt.. A, Par- nell Legion, Md. Vols. Johnson. T. H., Pt., E, 3Jth Illinois, age 19. Johnson. AV. L., Pt., G, 12th N. H., age 34. Jones. A.. PL, G, 28th Illinois. Jones. L. F., Pt., A, 12th N. 11.. age 23. Jones, Michael, Pt., F, 103d New York. Jones. 11., Pt., I, 132d Pennsylvania. Jones, \V. D., Corp'l. C 3d N.Y. Heavy Artil'v, age 23. Jones, AV. J., Pt., C, 16th AVisconsin. Jordan, R. H., Serg't, B, 33d Indiana, age 26. Judkins, M. AV., Pt., G, 15th Iowa, age 21. Jukes, H., Serg't, L, 18th Pennsylvania, age 28. Kappenberg, F., PL, E, 14th Connecticut. Kaufman, F., PL, C, 2d New Jersey, age 32. Keene, G., Pt., E, 1st Penn. Reserves. Operations, Operator, Result. Dee. 16, 16, '04. July 2. 3, '63. May 10, 20, 04. July 3, 3, '63. Mav 9, 10, "'61. Oct. 8, 8, '62. April 2, 2. '65. May 12, 12, '04. Julv 4, 4, 04. April 30, May 1, 1863. May 2, 2, '63. Aug. 19. 20, '64. May 31. 31, '62. May 16, 16, '64. July2, 3, '63. Oct. 5, fi, '02. July 2, 3, '03. Dec. 13, 13, '62. Sept. 17, 19, '62. Jan. 9, 9, '05. Oct. 3, 4, '62. June 22, 22, '64. April 6, 6, '62. June 30. July 1, 1863. Dec. 13, 13, '62. May 3, 4, '03. June 26, 26, '62. Right. Discharged; pensioned. Right; flap. Discharged July 8, IShO; pensioned. light; (lap. Dischd July 20, ISO.',; pensioned. .eft. Discli'd March 19, 1803; pensioned. .eft; antero-posteriorflaps. Dis charged Dec. 15, 1804. ,cl't; tlap; by Surg. I. V. Mullen, 14th N. Y. 1*1. A. Disch'd Alav 31. 1805; pensioned. ,elt; lateral flaps. Discharged November 28, 1803. Iv Dr. liateinan. Diseh'd June, *803. tight; flap ; by Surg. T. A. Ilel- wig. 87th Penn. Disch'd July 21, 1805 ; pensioned. Left; circular: by Surg. A. T. Bartlett, 33d Mo. Disch'd May 29, 1805; pensioned. Right, Exchanged Nov. 12,1863. Right; by Surg. D. T. AYhitnell, 31st 111.* Disch'd Aug. 13, 1803; pensioned. Right. Dischargedand pensioned. Right; circular; by Surg. AA'. C. Byington, 183d Penn. Disch'd Jan. 15, 1805; pensioned. Left; flap; by Surg. M. Bellinger, C. S. A. Diseh'd Oct. 19, 1802; pensioned. Left; flap; by Asst. Surg. J. AV. Perry, 20th Conn. Disch'd Feb. 4, 1865; pensioned. Right; flap. Paroled Sept. 1,1863. Right; ant.-post. flap; by Surg. F. G. AVarren, 5th Me. Disch'd July 27, 1804 ; pensioned. Left. Discharged Nov. 21, 1862; pensioned. Right; flap. Discharged Sept. 11, 1865: pensioned. Left; flap. Duty Sept. 24, 1864; pensioned. Left; flap; by Surg. D. McFalls, 142d N. Y. Disch'd May 4,1865; pensioned. Right; flap: bySurg.G.AV.New, 7th Ind. Disch'd July 20,1803; pensioned. Spec. 1147. Left; by A. Surg. G. H. Martin,4th Me. Disch'd Oct. 6,1803: pens'd. Left; flap. To prison Nov. 23, 1804. Left; flap; by Surg. II. F. Bowen, Purnell Legion. Disch'd July 17, 18C2; pensioned. Right. Dischargedand pensioned. Right; flap; by Surg. IL B. Fow- ler, 12th N. H. Disch'd Aug. 9, 1864; pensioned. Right: by Surg. J. G. Keenon, IT. S.A'. Discharged; pensioned. Left. Disch d Dec. 9, 1803; pen- Left: . 1803. Discli'd May 23, Left. Diseh'd Dec. 4, 1802. Left; circular; by Surgeon C. A. Cowgill, P. S. V. Disch'd Oct. 5. 1865; pens'd. A. M. M..Sp. c.o'.r.j. Right; circular; by A. Surg. I. A. Torrey, 10th Wis. Disch'd Nov. 4, 1862: pensioned. Flap; by Surg. J. liennet-t, 19th Mich. Discli'd .Mar. 14, ISO.".. Left; by Surg. S. B. Davis, 16th Iowa. Disc .1 Aug. 15,'62; pen'd. Left; flap; by Asst. Surg. Perin Gardner, 1st Va. (lav. Diseh'd Jan. 8. 1864; pensioned. Right: (lap; by Surg. P. G. Rock- well. 14th Conn. Discli'd June 25, 1803; pensioned. Left; flap; by Dr. Tavlor.C.S.A. Disch'd Oct.20, 1803;" pensioned. Right; by Surg. L. AV. Read, 1st Pa.Res. Dis'dDec.6,'62; pens'd. Name, Age, and Military Description. k'celer, S., Pt., G, 10th Connecticut. Kcel'cr, A., Pt.. F, 87th Pennsylvania, ago 21. Kellogg, E. S., PL, A, 80th New York, ago 25. Keller, I., Pt., I, 23d U. S. C. T. Kelly, L., Serg't, B, 2d B. L, age 2d. Kelley, A..I., PL, D, 87th Pennsylvania, ago 18. Kelch, YV., PL, II, 9th Mich. Cav., age 20. Kelly, J., PL, C, 8th New Jersey, ago 30. Kellerinan,E.,PL, F,49th Pennsylvania, ago 41. Kelley, 'P., PL, F, 69th New York. Kcnncy, C. T., PL, D, 130th N. Y., age 20. Kenoyer, J., Pt., B, 31st Indiana. Kern, J. D., PL, H, 89th Illinois, age 32. Kerfoot, W. F., Pt., B, 8th Virginia, age 19. Keynan, J., Pt., G, 49th Indiana. Kibley, G. B., PL, B, 3d Michigan, age 27. Kille, T., Corp'l, B, 53d Ohio, age 21. Killian, AV.. Pt., A, 2d U. S. Artillery, age 25. Kimball. C. M., PL, 5th Maine Battery. King, J., PL," K, 100th Pennsylvania, age 19. Kinney, D., Pt., E, 123d Indiana, age 19. Kingly, F., Pt., B, 12th New Hampshire. Kinder,I.,Pt,,F, 82dOhio, age 26. Kirchner, C, PL, II, 15th U. S. Infantry. Kitzmiller, J. A., PL. 15. 138th Penn., age 21. Kitrell, J. H., PL, D, 3d Tennessee. Klechner, J., Pt., I, 53d Pennsylvania. Kline, D.AV., PL, B, 148th Pennsylvania, age 28. Knapp. E., Serg't, H, 1st AVis. Cav., age 27. Knapp, C. T., PL, H, 45th Pennsylvania. Kniqht, !P.jtf.,Pt.,G,13th Alabama, age 28. Kooglcr, J., Pt., F, 110th Ohio. Kornberger, B., Corp'l, C, 4th Missouri Cavalry. Koster. J. S., Serg't, H, 21st Alass., age 22. Krahl, H. I,.. PL, H, 13th Infantry. Kreig, P., Pt., (', 46th New York, age 28. Kretzer, J. H., PL, I, 73d Ohio, age 16. Kinder, J., Pt., F, 82d Ohio, age 26. Kuhns, P., Pt., D, 6th Iowa, age 22. Operations, Operator, Result. Aug. 7, 7, F62. Juno 3, 3, '64. rune IP, 18, '64. July 30, 31, '04. Alav 5, 5, '04. May 16. 18, '04. Oct. 1, 2, '64. May 5, 0, "64. April 6, 7, '05. Sept. 17, 19, '62. Mar. 10, 16, '65. Dec. 31, 31, '62. May 27, 28, "'64. July 2, 4, '"63. June 1, 1, '63. May 31, 31, '62. July 22, 22, '64. April 3, 3, '03. May 3, 3, '63. Mar. 25, 25, '65. Aug. 24. 25,'64. Dec. 23, 23, "63. July 19. 20, '64. Aug. 7, 7, 04. Mav 12 12,' '04. July 12 12, "'63. July 2, 2, '"63. June 22, 22, '64. April 14, 15, '65. Sept, 17. 17, '02. Mav 3. 1803. July 27, 22, "'64. July 10, 10, '03. June 2, 3, '64. Jan. 11, 11, '03. Aug. 21. 21, '64. May 25. 27, '64. July 19, 20, '64. April 6. 6, '62. Right; flap ; by Surg. M. T. New- ton, 10th Conn. Disch'd Dee. 10, 1862; pensioned. Right: circular; by Surg. D. F. McKinney, 87th Penn. Disch'd Aug. 21, 1864; pensioned. Left; flap; by Surg. T.H. Squire, Kith N. York. Disch'd April 0, IS05; pensioned. Left; flap; by Surg. F. M. Weld, 27th C. T. Disch'd June 23, '65. Right; flap; bySurg.d.AV.Curr, 2d R.I. Dis'd".Iune7,'64; pens'd. Right: flap; by a Confed. surg. Disch'd .May 19,1805; pensioned. Left: circular; by A. Snrg. It. A. Stebbins, 14th Ky. Discharged June 17, 1805: Left; circular. Discli'd Aug. 22, 1805. Right; flap. Disch'd July 26, 1865; pensioned. Left. Discharged Dec. 13, 1802 ; pensioned. Left; circul'r; by Surg.E.Amsden, 130th N.Y. Disch'dSept. 7,1805; pensioned. Right. Disch'd Mar. 25, 1863; pensioned. Left; circular; by Surgeon H. B. Tuttle, 89th 111. Disch'd Mar. 27, 1805; pensioned. Right; by Surg. C. J. Bellows, 7th Ohio. Transfer'.! Sept. 14,'63. Right; by Surg. B.P.Stevenson, 22d Ky. Discli'd Aug. 16,1863; pensioned. Left; flap. Disch'd Nov. 20,1862; pensioned. Left; flap; by Surg. S. P. Bon- ner, 47th Ohio. Disch'd May 27, 1805; pensioned. Right; circular. Disch'd Aug. 7, 1804; died April 20, 1871. Right; flap. V. R. C. Nov. 21, 1803. Left; circular; by Surg. W. C. Shurlock, 51st Penn. Diseh'd June 15, 1865; pensioned. Left; circular; by Surg. John H. Bodgers, 104th Ohio. Disch'd August 25, 1865; pensioned. Right; circ: by A. A. Surg. AV. L. AA'ard, Disch'd April 1, 1864. Left; by a Confed. surg. Disch'd May 12, 1865 ; pensioned. Right. Duty October 21, 1864; pensioned. Left; flap; by Surg. C. E. Cady, 138th Penn. Disch'd Sept. 20, 1864; pensioned. Right; flap; bySurg.P.F.AA'right, P. A. C. S. Furl'd Sept, 1, '63. Left; double flap: by Surg. J. Y. Cantwell, 82d Ohio, and A. A. Surgeon A. D. Kibbee. Disch'd Dec. 14, 1863; pensioned. Left; ant.-post, flap ; by Surg. J. AV. AVishart, 140th Pa. Disch'd Oct. 35, 1864 ; pensioned. Right: Hap: by Surg. G. 10. Ran- ney. 2d Mich. Cavalry. Diseh'd Nov. 15. 1865: pensioned. Left. Discharged Dec. 27, 1862; pensioned. Transferred May 23, 1863. Left; circular; by Surgeon R. B. McCandliss, 110th Ohio. Diseh'd February 7, 1865. Left; flap. Discharged March 28, 1864. Right, Disch'd August 30,1864; pensioned. Right; flap. Disch'd April 6, '63; pensioned. Left; circular; by Surgeon W. B. Fox, 8th Mich. Disch'd April 27, 1805; pensioned. Left; flap; bv Surg. J. M. Hines, 73d Ohio. Discharged Sept. 30, 1804; pensioned. Left; ant.-post. flaps; by A.Sur. G. G.Boy.C.S. A. Dis'd Mavll,'65. Right. Disch'd Sept. 27, 1802; pensioned. 708 INJURIES OF THE UPPER EXTREMITIES. [CHAP. IX. 611 612 613 614 615 616 017 618 619 620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 048 649 Name. Ale, and Military Description. Kutzleb, A., Pt., B, 9th Ohio. Lacy, J. L., PL, C, 2d Delaware, age 23. Ladd, J. O., Pt., I, 15th Massachusetts. Lambert, W., Corp'l, K, 13th New Jersey. Landon, J. H.,*PL, F, 142d N. Y., age 31. La Pine, A., Pt., I, 37th Mass., age 20. Larkin, J. M., Pt., C, 39th Illinois, age 21. Law, J., PL, I, 104th New York. Law, R., Pt., E, 6th AVis. LeaA'ens, G. G.,» PL, I, 16th Maine. Leech, E. A., Serg't, I, 109th Pennsylvania. Leech, W. H., Corp'l, E, 49th Ohio, age 23. Leighow, J., PL, A, 132d Pennsylvania. Lendall, S., PL, A, 12th Massachusetts. Lennox, R., 1st Lieut., 2d U. S. Cavalry, age 29. Leonard, E. M., Corp'l, A, 5th Michigan. Leonard, T., PL, K, 15th Kentucky. Lewis, H., Serg't, B,145th Pennsylvania. Lewis, J., PL, H, 19th Colored Troops, age 29. Lieber, IL, Lieut., B, 9th Illinois. Lindlev, D. AV., Corp'l, H, 38tb Wis., age 20. Lindsay. J.. Serg't, C, 9th Colored Troops. Lindsey, W. H., Capt., I, 26th Alabama, age 24. Livermore, A\'. B., PL, F, 89th New York. Livingstone, E., PL, B, 3d South Carolina. Lochbiler, C., Capt., I, 1st Missouri Engineers. Loechner, C, PL, A, 183d Penn., age 21. Lombard, D. C, Pt., K, 19th Maine, age 23. Loomis, E. W., PL, F, 2d Y'ermont. Loreh, H., Corp'l, K, 26th Wisconsin, age 19. Lounsbury, J. M., Pt., A, 143d New York. Lovell, A., PL, H, 40th Mass., age 37. Lowell, D. K., Pt.,E, llth Maine, age 24. Lucas, S., PL, M, 2d N. Y'. Heavy Art., age 17. Lukens. J. L., Pt., G, 116th Illinois, age 25. Lundy, J., PL, 1,9th Ind., age 22. Lupient, G., Pt., G, 2d \A isccnsin, age 24. Lyde, M., Pt., D, 97th Illinois. Lyon. N. A., Pt.. F, 6th Alabama, age 26. Dates. Noa-. 25, 25, '63. June 5, 5, '64. Sept. 17, 19, '62. May 3, 3, '63. Oct. 27, 27, '64. May 12, 12, '64. Oct. 13, 13, '64. Aug. 19. 19, '64. April 29, 29, '63. Dec. 13, 14, '62. Oct. 28, 29, '63. May 26, 28, '64. Sept. 17, 17, '62. May 12, 12, '64. Aug. 10, 10, '64. July 2, 3, "63. Oct. 8, 9, '62. July 3, 4, '63. July 30, 30, '64. Feb. 15, 15, '62. April 2, 2, '65. Oct. 27, 27, '64. Nov. 30, 30, '64. Sept. 17, 18, '62. July 2, 3, '63. Sept, —, —, '63. Aug. 16. 16, '64. July 2, 3, '63. June 29, 30, '62. July 20, 22, '64. July 11. 11, '04. July L 1, '64. May 18, 18, '64. June 18, 18, '64. June 27. 27, '64. Dec. 15, 15, '64. Mav 0, 6. "64. May 23, 23, '63. Julv 1, 1, '63. Operations, Operator, Result. Left; by Surg. C. Soellheim, 9th Ohio. Discharged; pensioned. Right; circular; by Surgeon A. Van DeA-ere, 66th N. Y. Duty July 18, 1864 ; pensioned. Flap; by Asst. Surg. C. H. Rich- mond, 104th N. Y. Discharged Dec. 27, 1862; pensioned. Left; flap. Disch'd Sept. 3,1863; pensioned. Right; fla.p; by Surg.G.C.Jarvis, 7th Conn. Disch'd Feb. 18,1865; pensioned. Left; flap. Disch'd Jan. 4,1865; pensioned. Left; circular. Disch'd June 19, 18G5. Transferred to Soldiers' Home; healed. Right; by Surg. E. Shippen, U. S. V. Disch'd June 22, 1863; pensioned. Right. Disch'd Feb. 20, 1863; pensioned. Right; flap; by Surg. J. L.Dunn, 109th Penn. Disch'd March 17, 1864 ; pensioned. Right; flap. Diseh'd October 26, 1864; pensioned. Left; by A. Surg. G. K. Thomp- son and G. AV. Hoover, 132d Pa. Disch'd Oct. 28,1862; pensioned. Left, Discharged Nov. 28, 18C4; pensioned. Left; ant.-post. flap; by A. Surg. J. W. Williams, U. S. A. Duty Jan. 11, 1865; pensioned. Left; by Surg. II