'vr/-,: T^. Yk ). ** 1/ *< DUE WO WCEKC TROM LAST DATE DUE WQJ FEB 28TSB s» *>, &* v tir *- ^ «^x V NOTES ON THE SURGERY OP THE / WAR IN THE CRIMEA, WITH REMARKS ON THE TREATMENT OF GUNSHOT WOUNDS. BY GEORGE H. B. MACLEOD, M.D., F.R.C.S. Formerly Surgeon to the Civil Hospital at Smyrna, and to the General Hospital in Camp before Sebastopol: Lecturer on Military Surgery in Anderson's University, Glg,sg9w, &p. J. W. RANDOLPH, 121 Main Street, Richmond, Va. 1862. S*.uttpy Mil, 8oO IR6E - /. // Macfarlane & Fergusson, Printers, Richmond, Va. EDITOR'S PREFACE. i the republication of this work in its present somewhat undged form, the Editor has striven, while reducing its bulk within the narrowed resource ^f the times, to incorporate in it all of the more essential and pra. -al features of the original volume, and thus to present to the field surgeon^ in a convenient form, the highest recent authority to which reference could be had. The want of access to the standard European authors upon Mili- tary Surgery has been seriously felt by the Medical Corps of our army, and if this volume contributes anything towards the satisfac- tion of that want, the Editor will be more than compensated for the labor bestowed upon its reproduction. A. N. TALLEY, Surgeon P. A. C. S., President Army Medical Board at Richmond, Va. NOTES ON THE SURGERY OF THE CRIMEAN WAR. CHAPTER I. Distinction between Surgery as practised in the Army and in Civil Life—Soldiers as Patients, and the Character of the injuries to which they are liable—Some Peculiarities in the Wounds and Injuries seen during the late War. That military surgery does not differ from the surgery of civil life, is an assertion which is true in letter, but not in spirit. As a science, surgery, wherever practised, is one and indivisible; but as an art, it varies according to the peculiar nature of the injuries with which it has to deal, and with the circumstances in which it falls to be exercised. To the surgeon practising in the camp, many accidents are presented which seldom or never come within the observation of the civil practitioner; while not a few of the cases which are daily treated in domestic life, rarely come under the charge of the military surgeon. The two classes of prac- titioners may be said to be engaged in separate departments of the same profession, which, though uniting occasionally, aro yet tolerably distiuct from one another. The military surgeon during peace enters for a time into civil life; but during war he is called upon to exercise the very high- est functions of his profession, and has little to do with the more trivial accidents which constitute the sum of a private practi- tioner's daily routine. His observation is undoubtedly restricted to a smaller variety of cases. He sees less than the civilian of the modifications which are impressed upon disease by age and sex ; but in war he has a wider field for noticing the influence of external circumstances, of extremes of climate, of variations in food, work, and shelter on the same men, as well as the effects of mental causes, as seen in the exultation of victory and in the prostration and dejection of defeat. 6 SURGERY OF THE CRIMEAN WAR. But though there may exist Buch distinctions between the ppheres of the military and those of the civil surgeon, there is Burely nothing in the exercise of their different callings which should create an antagonism between them. They are both members of the same priesthood, whose office it is to minister to suffering man, and the experiences collected by each should be willingly laid as common offerings on the altar of science. To no class of professional men is a liberal education more im- portant than to the army surgeon. To command that respect which is necessary for the right exercise of his official duties, he must be superior in general knowledge to his comrades. The many countries-and varied climates to which he is sent, and the delicate positions in which his service often places him, demand the possession of an enlarged and well-stored mind ; while the deep responsibility attached to the charge of such a number of valuablo lives, and the necessity imposed by the absence of a "consultant" of deciding the most critical cases on his own un- aided judgment, demand the firm self-reliance founded on clear knowledge as essential to any measure of success. Even amid the falling ranks, where he is exposed to as great danger as any, he must completely forget self, and give his whole mind to the condition of the sufferers around him ; for often do his decisions, formed in a mere instant of time, settle for life or death the fate of the fellow-being before him. Then his powers of ob- servation must be so well trained that he can discriminate be- tween different diseases, whose types are mingled and masked by their union, as these are only seen in armies in the time of war. The hardships incident to a soldier's life fall equally on the surgeon as upon his comrades : and, besides tho dangers of bat- tle and exposure, he runs the risk of those epidemic diseases which devastate armies, and which are the product of exciting causes, to which he has been as liable as any of those actually seized, and to the infection of which, when developed, he is ever exposed. In civil practice, on the other hand, a surgeon is not subjected to those predisposing and exciting causes of disease— cold, want of food and clothing, &c.—which cause its appearance among the mass of the population, nor does be remain exposed to its infection longer than is necessary to prescribe for his pa- tient. The want of libraries for study and self-improvement are also drawbacks to the exercise of the profession in armios, of ■which the civilian has no exoerience. The strict discipline which prevails in military hospitals, gives the army surgeon some advantages over the civilian in the treat- ment of his cases. No interference from the ill-judged kindness of relatives, or from the headstrong wilfulness of the patient himself, can occur. His opinion is a law from which there is no appeal, and thus fewer obstacles stand in the way of his giving a fair trial to remedies, lie has, also, the advantages so often CIVIL AND MILITARY SURGERY. i denied tho civilian, of correcting or confirming his diagnosis and treatment by after-death examination—a point of the greatest moment, lie can, in general, exercise his judgment also to tho fullest without having his decision criticised by a host of igno- rant censors, and thus the moot points in surgery can often be determined by him in a manner not permissible in civil life. The greater uniformity in age, constitution, and external cir- cumstances that is to be found among patients in the public ser- vices, than among the mass of the population who enter civil hospitals, makes conclusions drawn from their treatment more reliable for future guidance in dealing with them, than any sta- tistics derived from civil practice can be for general purposes. But how different are the means of treating injury in the field and in civil life I The ample space, established routine, careful nursing, many comforts and appliances of a civil hospital, con- trast strongly with the temporary nature, hurried extemporised inventions, and incomplete arrangements of a military hospital in the field. The influx of patients from the works of a besieging force, or the shiftjng from place to place of an army during a campaign, makes the removal of the sick to the rear a necessity. Then, as this transference has often to be accomplished by means little adapted for the purpose, and at a period of the treatment the worst fitted for its execution, the evil done is often irreparable; so that injuries which might be completely cured in stationary hospitals have often to be relieved by amputation, while others whose treatment might, under more favourable circumstances, have afforded a fair prospect of success, are placed beyond recov- ery. From this it follows that the military surgeon cannot al- ways choose either his own time or circumstances in performing his operations. lie must be content to do the best he can in tho crisis, and thus his experience has sometimes to be sacrificed to expediency. His operations, too, often differ widely from the classic procedures of civil life. The adage, that " a good anato- mist may operate in any way," has often in him its illustration. The object being to save as much as possible, compels him to tax his ingenuity in order to take advantage of the eccentric manner in which tho ball has half accomplished the severance of the limb, and to seize hjs flaps here and there where they C;in bo got; and thus, though the immediate result may not appear so satisfactory, the final end is probably as effectively secured. • In the practice of field surgery, moreover, methods of operating will often succeed which are not adapted for civil practice. Thus, in the resection of joints which come to be performed in the field, a comparatively small and simnle incision will enable the opera- tor to remove the injured parts, while in those cases in which the operation is commonly performed in civil life, a much larger and more complex incision is generally required in order to per- mit of the extraction of the enlarged, adherent, unbroken bono 8 SURQERY uF THE CRIMEAN WAR. which has to be removed, ar d perhaps to allow of the excision of part of the articular cavity at the same time. As contrasted with the duties of the naval surgeon, those of the military surgeon are much more difficult. His patients arc widely scattei-ed, do not come so soon under his care when in- jured, are subjected to greater hardships both immediately after being wounded and during treatment, than are the patients of the naval surgeon. " The sailor fights at home," while the un- fortunate soldier hns often much suffering to go through before he is admitted info hospital. The soldier as a patient differs from the civilian in f-everal well-marked points. In some respects he is a better patient, and in many respects he is a much worse one. Some of these points of distinction should always be borne in mind when tstimating the success of surgery as practised in the case of one or the other. Chosen when young from the mass of the population on ac- count cf his physical promise—selected with care during peace— with less discrimination during war—the soldier at starting is ad- vantageously contrasted with the majority^of the men of his own age. Chosen without anyreference to his moral character, he is not uncommonly depraved and profligate in his habits, and has perhaps enlisted in the recklessness which succeeds to debauch, or as a last resource to save him from penury. We have thus not unfrequently two conditions meeting in the young recruit, both of which bear their own fruit in his future history—a ten- dency to indulge in vices which lead to disease, but a state of health in which disease has not been as yet established. Taken from a domestic life in which he had possibly every lib- erty as to the disposal of his time, the formation of his habits, and the pursuit of his amusements, he is^sxt once placed under the rigours of a discipline which soon becomes irksome. He enjoys little leisure, but is harrassed by his accustomed, and, for a time at least, laborious duties. Nostalgia succeeds, and thus the period of acclimatization, as it may be termed, becomes an ordeal so trying as in many instances to implant the germs of disease. The prejudicial effects of this initiation will be the more sure, if the recruit be launced into the real business of a war camp before his constitution has had time to accommodate itself to the new condition of things in which it is for the future to exist. _ But it the young soldier get over this noviciate, then his physical condition, during a time of peace at least, is un- doubtedly favourable as contrasted with his fellow in civil life. His food, which is well adapted for his use, is provided for him regularly. He is systematically exercised. His hours of labour and repose are carefully arranged, and he is at all times liberally supplied with fresh air. The civilian, on the other hand, though not subjected to the rough change of existence which the soldier haTto undergo, is greatly less regular in his mode of life. He SOLDIERS AS PATIENTS. \ 9 lives frequently in close streets and airless dwellings. His food isirregular, varying with the profits of his labour. He indulges without restraint when he can afford it, and has to submit to pri- vation afterwards to compensate for the excess. In war, again, the soldier loses many of hts advantages over the civilian. The external circumstances which prodispose to, or generate disease, are more numerous and vastly more potent in his case than they ever are in civil life. The exposure, the bad and irregular food, the deficient shelter, the excessive fa- tigue, the unnatural excitement or depression of victory or de- feat, all tend to reduce him as much below as he was formerly above the civilian in the scale of health. He has, amidst "tho irregularities of war," opportunities for licentiousness of which he is not slow to take advantage, and his unquiet and exciting life is but too apt to occasion that " debility of excess" which conceals a constitution weak to resist injury, under an outward appearance of strength and vigour. Thus it is, that as in civil life different trades produce different diseases, so a soldier's life, both in peace and war, begets its own diseases, and secures ex- emption from others to which civilians are liable. Morally, as well as physically, the sick soldier differs from the inmate of a civil hospital. If wounded, he received his injury in the discharge of his duty ; if sick, in the fulfilment of praise- worthy service. His " honourable scars" recognize none of those causes referable to misconduct or stupid thoughtlessness, which so frequently make the civilian the inmate of an hospital. He has no fear like the civilian for the future, if incapacitated for further service, as he knows that his misfortune will entitle him to sustenance for the time to come, and that his country will re- gard him with gratitude. When struck down by sickness, the soldier is, however, thrown more upon himself than the civilian, and this isolation must in his case act prejudicially on his recovery. He has no visits from sympathizing friends, as he lies on a sick bed, far from home, amidst the selfish hardness of a camp. He is soon separated from his comrades, and placed among strangers gathered like himself frem the accidents of the field, and he finds himself in circum- stances where he has little to eheer, but much to depress him. In the injuries to which he is exposed in war, he is more hardly dealt with than the civilian. The accidents which befall him, equal in their severity the most terrible which occur in civil life. The effects produced by the massive round shot or ponderous shell, are very like the crushing and tearing of machinery im- pelled by the resistless steam ; so that, among the many assimi- lating effects of our railways and manufactories, one will evident- ly be, in course of time, the bringing of the surgery in civil hos- pitals more and more into conformity with that of war. But, besides all that I have said as to those matters in which 'military and civil surgery are similar, or disagree, and as to the 10 SURGERY OF THE CRIMEAN WAR. contrast which exists on some points between the patients falling to be treated in either case, there are yet some circumstances in the late war to which I must allude, as they arepeculiar in themselves, and have an especial bearing on its surgical annals. A siege differs cobsiderably from ordinary camppaign work, both in the description and mortality of the wounds to which it exposes the soldier. The close proximity of the opposed batteries, the steady and deadly aim which can be obtained by the riflemen, the range so soon ascertained for cannon and mortar, the guns so carefully and accurately worked from the absence of hurry, and from the daily practice of the gunners, all contribute to render the proportion of casualties higher and their severity greater in sieges, than the injuries which attend a campaign in the field. Wounds of the upper half of the body may be expected to be more common in a siege, from the lower parts being protected by the works, and shell wounds must also be of more frequent oc- currence, from the larger employment of mortars in attacking or defending a city. The sudden sorties from the beleaguered gar- rison, the long and constant exposure to the enemy's fire while forming and guarding the trenches, all conduce to swell the number of those injured. The health of the troops, moreover, does not maintain so high a standard when they are stationary, and want the wholesome animation which results from the change and stirring incidents of a moving campaign ; whence it follows, that on becoming in- mates of the hospital, they are not so fit to stand active treat- ment, nor are they so " lively at recovery." However, there is one advantage which a siege has over a cam- paign in the field, and it is a considerable one. The hospitals being more stationary can be better arranged, and placed so near tho scene of conflict, that the injured may be more quickly succoured. During the late war, our army had not only to go through tho ordeal of great battles, but the prosecution of a siege unequalled for its difficulties in the history of war—a siege in which every obstacle and every trial was enhanced by the stubborn resolution of a brave enemy, and#the frailty of our own military prepara- tion. Tho sorties were on a scale so gigantic, and pushed so resolutely, as to occasion effects little inferior to those of a pitched battle; and the extraordinary length and active pros- ecution of the siege caused results resembling those of a con- stant battle, several months in duration. A few general en- gagements, and the casualties of outpost service, make up the accidents of an ordinary campaign ; but with us, day after day, and night after night, kept up a constant strain, which was more exhausting to the strength of the army than any other sort of warfare could have been. The majority of the recruits who joined the army early in 1855, and who supplied many of the wounded of that year, were far from being well chosen. They were selected under a pressure, RECRUITS. 11 and were the contributions of a country where the drag-net of the conscription is not used to inclose tho good as well as the bad, and where a soldier's life is not in any honour or favour with the. generality of the people. Many of them were raw boys, ill-conditioned, below the standard age, undeveloped in body, unconfirmed in constitution, and hence without stamina or powers of endurance. Often selected on account of their preco- cious growth, at once launched into the turmoil, unwonted la- bour, and hardship of a siege, in which the strength of full-grown men soon failed, they were very quickly " used up." Cholera or fever speedily seized them, overtaxed as they were in work, and unaccustomed to either the food or the exposure which fell to them. The hospitals became filled with such unpromising pa- tients, whose " wizened" look of premature age was remarked by the most casual observer. If these unfortunate boys were se- verely wounded they almost invariably died, as their weakly constitutions and overstrained powers could not withstand " the ordeal of recovery." To them Hunter's saying applied with pe- culiar force, that, "their condition of health did not bear dis- ease." If they survived the first effects of their injury, their convalescence was painfully prolonged, and the least imprudence produced a relapse. Their ailments were seldom acute—their life-power was unequal to its production—their nervous systems were shattered, and that undefined but most fatal disease, known as the " mal des tranches," was soon setup. Depletory mea- sures had soon to be abandoned, and a more rational treatment, founded on special symptoms.and the observed effects of remedies, substituted for the conventional medication. Again, several of the regiments which suffered most in many of the assaults, and which consequently contributed the greater number of the operative cases, were, either wholly or in part, composed of men who had just returned from prolonged service in India. Men so circumstanced were but ill calculated to un- dergo the rigours of a Crimean winter, or the hard work of the trenches, or yet the great trial of a capital operation. There was yet another element which demands attention, when estimating the surgical records of the war. I refer to the use of tho new rifle, with its conical ball. The rifle used by the Rus- sians was little inferior in range or force to our Minie, while its conical, deep-cupped ball was much heavier. The greater preci- sion in aim, the immensely increased range, the peculiar shape, great force, and unwonted motion imparted by the new rifles to their conical balls, have introduced into the prognosis of gun-shot wounds an element of the utmost importance. I am not pre- pared to say whether the great destruction of the soft and hard tissues which these balls occasion, results from their wedgelike shape, immense force and velocity, or the-revolving motion, or from si combination of all these causes combined ; but of one thing I am convinced, that their use has changed the bearing of 12 SURGERY OF THE CRIMEAN WAR. many points which fall to be considered by tho surgeon in the field. The severity of the primary action on the part struck, and especially the aggravated evils which follow their wounds, com- bined to exercise a most prejudicial influence on the surgery of the war, to which due weight has never been given. Immense comminution of bone has been their most prominent effect. The amount of laceration of the soft parts seems to depend on the distance at which the missile is fired. The wide-spread destruction of the bone often fenders consol- idation impossible, so that amputation has more frequently to be had recourse to, and the distance from the trunk at which that operation has to be performed being diminished by the same causes, the resulting mortality has been greatly increased. All who compared the dead of this with former wars, especially of Indian battles, were painfully struck with the greater disfigure- ment of the corpse caused by the conical, than by any other spe- cies of ball. But besides the more destructive nature of the small-arms em- ployed, cannons and mortars were used on both sides, of a cali- bre and range never before tried in any war. When Pare thought the cannon of his day so enormous and destructive, what can we say of those huge sea-service mortars and immense cannon used to defend and attack Sebastopol, compared with which those of the last century are as toys !* The fragments of our modern shells must be as weighty as the whole projectile known to our forefathers, and the grape which was so freely used in the East were half as large as the round shot fired from the field guns in the Peninsula. With us, every refinement in the art of destruc- tion was liberally practised, so that " l'art de tuer les hommes avec methode, et gloire," was, unhappily, never carried nearer perfection, though we may comfort ourselves with the reflection of Percy, that this very perfection, " nous a donne la meme tache et la meme recompense dans l'art de les conserver." " Lea circonstances," says Briot, " qui contribuent le plus a la destruc- tion des hommes sont aussi celles qui font decouvrir et develop- pent plus de moyens propres a leur conservation." Finally, if in war the surgeon sees much which is terrible, much which taxes his feelings of humanity, and his regret at the feebleness of his art, he has also the comforting conviction that * "Truly," says Pare, '-when I speak of the machines which the ancients used for assaulting men in combats and encounters, it ap- pears to me as if I spoke of infants' toys in comparison with these, which, to speak literally, surpass in figure and cruelty the things svhich they thought the most cruel/' THE NEW FIRE-ARMS. 13 nowhere is his beneficent mission so felt, nowhere is the saving power of his profession so fully exercised; so true is it, that " Chirurgery triumphs in armies and in sieges. 'Tis there that its empire is owned, 'tis there that its effects, and not words, express its eulogium." * • Dionis, quoted by Sir George Ballingall. CHAPTER II. The '• peculiarities" of Gun-shot Wounds, and their general Treat- ment. In saying that " there is a peculiarity, but no mystery, in gun- shot wounds," John Bell has expressed the change of opinion which late times have brought about'with regard to the nature of these injuries. It was the mysterious character ascribed by the old surgeons to wounds from so " devilish an engine" as a gun, which so long surrounded them with dread, and made incanta- tions and charms the favourite resource in their treatment. The new philosophy has dispelled the mystery, but left us still to study the eccentricities which so often mark these injuries. The contused appearance and unavoidable sloughing of the walls of the ball's track, the little-suspected, but serious destruction of deep parts, and the grave consequences which may ensue from such a wound, appear to have been the circumstances that sug- gested the envenomed nature of gunpowder, and the cautery-like action of its projected ball, as well as the idea which prevailed, that in order to get quit of the injurious influences thus exerted on the wound, it was necessary to pour into it burning oil, or curious tinctures concocted from the most opposite and absurd ingredients, or to smear the part with natiseous grease and "charmed salves." The description of the sensation caused by a gun-shot wound in a fleshy part, usually given by the sufferer, is, that it resem- bles the effect of a smart blow from a supple cane. Some, how- ever, feel as if a red-hot wire were passed through the part. The fracturing or splintering of a bone is always more painful than a flesh wound, and if a joint or larger cavity be penetrated, the pain is still more acute, and the shock still greater—in most cases proportioned to the vitality of the part injured. It is a very remarkable, though universally known fact, that when the mind is greatly engrossed by external objects—excited " 'mid the current of the heady fight," severe wounds may bo received without any consciousness on the part of the receiver. Whether the sensation may be so very slight as to be immedi- ately obliterated by the tide of strong passions rushing through the mind of the combatant, or whether a reflex act of the mind be necessary for receiving a sensation—in common words, for perceiving the state of its companion, the body—I shall not attempt to'discuss. But all military airgeons will confirm the statement of Hennen, when he says-that "some men will have a limb carried off, or shattered to pieces by a cannon-ball, without GUN-SHOT WOUNDS AND THEIR TREATMENT. 15 exhibiting the slightest signs of mental or corporeal agitation— nay, without being conscious of it." I myself have known an officer who had both legs carried away, ard who said that it was only when he attempted to rise, he became aware of the injury he had received ; and very many who had suffered slighter wounds, have said that the trickling of blood along the skin was what first called their attention to their state. The " collapse" and the mental trepidation which frequently follow the infliction of a mortal wound in the trunk, are, in many cases, most appalling. But although the presence or absence of this severe constitutional effect is useful as a diagnos- tic indication of the gravity of the injury, it is not entirely to be depended on, for the terror and amount of "shock" frequently depend as much on the "nerve" and frame of the sufferer, as on the severity of the wound. The different effects produced on different persons by wounds in every respect alike, are obvious to every one who has seen war, and call for the exercise of a most discriminating judgment on the part of the surgeon.' Then, the period of "collapse/' which will, to some degree, occur in every case of a severe wound, varies greatly, which mu>st determine whether immediate amputation bo necessary, or whether it would be safe to delay it. The only other remark we make on this subject is, that the "commotion" succeeding gun- shot wounds is greater when the lower extremities are injured, than when the arms suffer; and this is more especially seen, if the person be in an ere.it position when the injury is inflicted ; which observation is consistent with the remark made by Cheva- lier, that the shock is always greater when the ball strikes a muscle in action, than when it impinges against one which is 'relaxed. The destruction inflicted by a ball depends on the distance at which it is fired, .the direction of its flight, its shape and velocity, as well as on the nature of the part struck. If fragments of metal are fired, as sometimes happened during the sieges of the Peninsula, as well as in tho civil emeutes of Paris, and of which we had some experience in the Crimea also, a very lacerated, irregular, and dangerous wound may be caused. A ball passing at great speed over the surface of a limb, may occasion a wound similar to that made by a knife. But this action of a ball is rare. Tlie^reat velocity, peculiar shape, and motion of the conical ball, give to its wounds a character considerably different from those which is present in wounds caused by a round musket ball. If fired at short range, and if it strike a fleshy part, the conical ball produces, I think, less laceration of the soft parts than the old ball; but if the range be great, and the part struck bony, with little covering of flesh, as in the case of tho hand or foot, then the tearing, especially at the place of exit, is greatly more marked. 10 SURGERY OF THE CRIMEA*? WAR. I have not been able to satisfy myself in all cases, so clearly as the description of authors would lead me to suppose I could, as to the characteristics which distinguish the wound of entrance from that of exit. That the former is more regular and less dis- coloured than the latter, is true in many cases, but that the lips of one wound are inverted, while those of the other are everted, has seldom been clearly marked to my observation. If the speed of the ball be great, and no bone have been struck, then there is little difference in either the size or discoloration of the wounds ; but if the flight of the projectile be so far spent as to be retarded by contact with the body, especially if it have encountered a bone or a strong aponeurosis, so that its speed is considerably diminished before it passes out of tho body, then the wound of exit will considerably exceed in size that of entrance. This is especially true of conical balls. If, on the contrary, the ball be fired close at hand, so that its speed is not sensibly diminished by its passage through a limb, then the difference of size will be very small, and may even be in favour of the wound of entrance, as I had twice an opportunity of observing. The usual action of a ball in proportioning the size of the two orifices is easily understood, when we consider that the part of entrance is supported by the whole thickness of the limb, while that of escape is quite unsustained, and therefore the more liable to be torn. Huguier has shown that the loss of substance which occurs at the place of entrance, and the flap-like tearing which takes place at the orifice of exit, form the best marks of recog- nition we possess, and that these characters can always be made out by examination of the clothes or accoutrements traversed in cases in which the supervention of inflammation has effaced them from the wound itself. The introduction, but non-escape of a foreign body, as a piece of the breastplate, belt, buckle, or part of the musket, &c, along with the ball, which alone passes out; or the flattening of the ball against a bone within, and its diameter being thus increased before it escapes, will all contribute to vary the relative characters of the orifices of the wound.* To the military surgeon, it is often of consequence to be able to conclude whether the two apertures in his patient's limb have been occasioned by one ball, which is thus seen to have passed *In Arnel's experiments given in the Journal Univer. de Med. for 1830, it is shown that a ball, fired against a number of planks firmly bound together, causes a series of holes progressively increasing in size, so that a cone is formed by their union, whose base is repre- sented by the last exit hole. M. Devergie's experiments on the same point, given in his communication to the Academy, go to prove this also. Velpeau -and others have objected, but without good grounds, to the deductions drawn from the experiments being applied to the question. GUN-SHOT WOUNDS AND THEIR TREATMENT. 17 out, or by two balls still imbedded in the limb, and'to the medico- legal jurist, the knowledge of the marks which characterize the two wounds, is of much moment.* The action of a ball on the different tissues of the body may be, in a great-measure, inferred from a consideration of the shape of the projectile, and the nature of the part struck. It carries away, as I before remarked, a piece of the skin at the place of entrance, and rends it where it escapes. The small plug of integument which is carried into the wound, Huguier tells us can often be discovered there.f The contusion which a ball causes in traversing muscle gives rise to one marked characteristic of gun-shot wounds—their heal- ing only by suppuration and granulation. Occasionally an exception occurs to this rule. Thus, I have seen a case in which a superficial wound of the gastronemius was said to have healed without suppuration by the fifth day, and in the records of a Sepoy regiment in India, I find mention of even a deeper gun- shot wound of the deltoid healing in the same way by first inten- tion. Dr. Stewart, staff assistant surgeon, reportsf a case of a similar union, as having been observed by him during the Caffre war. A Fingo received a pretty severe gun-shot wound ofthe muscles of the back, and union without suppuration took place. Two things are necessary to produce such a happy result: 1st, a mest .healthy and temperate patient; and 2nd, the rapid flight of the ball. It is curious to notice how large a body may enter through a muscle, and hide itself without producing any great wound. Thus, I saw a case at Scutari, in which a piece of shell, weigh- ing nearly three pounds, was extracted from the hip of a man * * Between the opposite views held by Blendin and Dupuytren, the opinions of military surgeons and medical jurists have oscillated, evidently from the fact that no constant relations exist between the entrance and exit wounds. Velpeau, holding a middle view, con- cludes with truth, "Dupuytren is wrong, and his antagonist is not right/' The distance at which the gun is fired has most to do in determining their character, according to Devergie, who has him- self, however, recorded a case which proves that the wound of entrance may be the larger, even when the gun is fired at a distance. Begin has given us the following valuable observation, with regard to the resulting cicatrics. That of entrance, he says, is generally white, depressed, and often adherent to the underlying parts, while that of exit is only a sort of irregular spot which does not adhere to the parts below, and is sometimes so indistinct as to be concealed in the folds of the skin. This difference he explains by the loss of substance sustained at the point of entrance. | John Hunter speaks also of this piece of detached integument. J Unpublished records of medical department. 18 SURGERY OF THE CRIMEAN WAR. wounded at the Almn, which had been overlooked for a couple of months, and to which but a small opening led. Larrey gives a case in which a ball, weighing five pounds, was extracted by him from tho thigh of a soldier. The presence of so largo a body had not been detected by the surgeon in charge, and the patient Buffered no inconvenience from it beyond a feeling of weight in the limb. Paillard mentions, having heard M. Begin recount a case in which a ball of nine pounds so buried itself for a time. Ilennen, too, mentions a case as having occurred at Seiingapa-. tarn, in which a spent twelve pound shot, buried itself in the thigh of an .officer, and "so little appearance was there of a body of such bulk, that he was brought to the camp, where he soon expired, without any suspicion of the presence of the ball till it was discovered on examination." It is more easy to understand how a large fragment of shell should so conceal itself than a round shot, as if its long diameter corresponded with the run of the fibres of the superficial muscles, and especially if the muscle was relaxed at tho time of contact, then a large piece might enter a muscular limb without causing an amount of injury pro- portioned to the size of the body introduced. Such an instance occurred in the Crimea to a French soldier, of whose case Bau- dens has given an acceunt. A fragment of shell, weighing 2 kilog. 150 grammes, so completely buried itself in the thigh as almost to be invisible. The elasticity of the soft parts doubtless assist in closing the opening by which such a mass entered. Baudens has made an observation which I am not aware has been confirmed by any other, viz.: that when the ball is cut out from among the muscles, however early it may be accomplished, it has a cellular envelope round it, which he calls "kyste prima- tif," as contrasted with the "kyste definitif," which forms its sac when it has been long inclosed in the tissues. Muscles which have been severely injured by ball are very apt to become contracted during cure, if precautions are not taken to prevent it. Of this most disagreeable result I have seen a good many cases in the East. On tendons a ball may cause little or no injury, especially if they be relaxed at the moment they arc struck. Their tough- ness, elasticity, form, and mobility, all help in protecting them from being cut across, or pierced. A round ball is often deflected by a strong aponeurosis like the " fascia lata," particularly if it Btrike at an angle to the surface, and at a period of its flight when the force is soinowhat expended. A conical ball, how- ever, is seldom so turned. It is on bone that the destructive effects of a ball become most evident. (1.) When its line of flight is very oblique, and it is a flat bone against which it strikes, then it may be thrown off, causing no other damage than depriving the bone of its perios- teum. When this occurs in the case of bones of the head, much danger may subsequently ensue, as will afterwards be shown. (1UN-SH0T WOUNDS AND THEIR TREATMENT. 19 C/ntused wounds of the long bones, though seemingly of little moment at first, are sometimes very serious in their results, not only from the separation of the periosteum, and subsequent dis- ease of the bone arising from that source, but also from inflam- mation being set up in the medullaiy canal. (2.) A round ball may be flattened against the shaft of a long bone, without caus- ing any subsequent harm. This was often seen in India, where the matchlock is used.-. (3.) It may turn round a bone without breaking it. Thus, Chevalier records a case in which a ball, entering at the lower part of the thigh, passed spirally round the bone to the top of tho limb, "comprehending nearly the whole length of the bone in one circumvolution." (4.) A round ball, as is well known, may notch or partly perforate a long bone with- out causing fracture, arrd pass off, or remain in the medul- lary cavity, having passed through the outer wall. This is, as can be easily understood, a most dangerous accident. (5.) If the force of propulsion be a little greater, then the bone may be split longitudinally, without being fractured across, as in a case related by Leveiile, and quoted by Malgaigne, in which an Austrian soldier at Marengo was struek by a ball in the lower third of the leg. He walked several miles to the rear, where he was seen, and the wound thought to be very slight. A super- ficial exfoliation of the bone was alone expected; however, his symptoms became so serious that the leg had to be removed, when it was found that, from the place where " the impression of the ball" existed, there proceeded several longitudinal and ob- lique clefts, which extended from the lower third of the tibia up to near the head of the bone. (G.) Into the spongy heads of bones, and, more rarely, into their shafts, a ball may be driven as into a plank of wood, without almost any splintering, and be- come encysted there. (7.) It may pass through, causing a clean hole, of several of which occurrences I will afterwards relate cases; but the conical ball never acts in any of these ways, so far as I have seen. It is seldom split itself, but invariably splin- ters the bone against which it strikes to a greater or less degree, according to circumstances, and that in the direction of the bone's axis. This tendency to splitting in the bone shows itself much more in a downward than in an upward direction, so that tho destruction which such a ball will occasion will be greater when it strikes the upper than the lower end of a shaft. All kinds of balls generally fracture and split the shaft of a bone if they strike it about its middle, but while a fracture with but little comminution results from the round ball, the conical ball—especially that which has a broad deep cup in its base— Bplits and rends the bone so extensively, that narrow fragments, many inches in length, are detached, and lesser portions are thrown in all directions, crosswise at the seat of fracture, and driven into the neighbouring soft parts. It is tho pressure of these-fragments, as will be shown further on, which renders tho 20 SURGERY OF THE CRIMEAN WAR. fractnre of long bones .by the new ball so hopeless.* I had many most interesting opportunities of seeing the extraordinary man- ner in which the conical ball destroys bone in tho way I refer to. I have never met with an instance in which such a ball, fired at whatever range, and striking at all perpendicularlyon a long bone, has failed to traverse it and comminute it extensively. From the comparatively little employment of the round ball during the late war, there were fewer illustrations of the split- ting of balls on the edge of bone, as, for instance, on the edge of the tibia, or on the bridge of the nose, or on the humerus, than usually occur in a campaign. I do not believe that the conical ball, with its immense force of propulsion, could be so ■split. There is a case borrowed from Mr. Wall of the 38th, given later under wounds of tho head, in which "a round rifle (?) ball" was thus split on the parietal bone, one-half entering and the other half going off externally, in a soldier of the 38th, wounded on the 8th September. Another somewhat similar case Occurred in the 19th regiment. It is by no means uncommon that a ball should be thus split on the head. Many examples of it occur in-works on military surgery. No case clearly made out as one >, of splitting came under my own notice; but in one instance, a ball so changed in shape as to appear the section of one, was ■extracted from within the iliac fossa. Instances are on record in which balls have been split into three parts by the bones of the face, and the trochanter major. Although it cannot be for a moment doubted that balls may remain for a lifetime imbedded in bone, and cause little, if any annoyance, yet it is equally certain that the most grievous re- sults much more frequently arise from their presence in such sit- uations. Of this, innumerable examples readily occur to any one who has seen many " veterans ;" or who has read much on *As instances of how great a difference it makes in the prog- nosis of cases whether a round or a conical ball has been the wounding agent, 1 may relate two cases from a host of others. In the first instance, the ball entered on the external side of the ankle, near the tendo-achillis, and passing forwards and inwards, lodged, as if in a piece of wood, in the lower end of the tibia, close over the ankle joint. When the ball was removed, the bone was found not to have been sjilit in any direction. A conical ball would have, to a certainty, opened the joint, and, in all probability, so split the tibia as to have necessitated amputation in the upper part of tho leg. In another case, a round ball made a clean hole through one of the condyles of the femur, and did not split the bone; while, if a conical ball had struck the same part, it would have so cleft the bone that amputation in the middle of the femur would have been called for ; whereas, the removal of the limb at the knee joint—a much less serious operation—sufficed in the case referred to. GUN-SHOT WOUNDS AND THEIR TREATMENT. 21 the subject to which I refer. When speaking of wounds of the shoulder joint, I will detail some cases which illustrate the per- nicious action of balls left impacted in bone. Guthrie is very emphatic in his directions to remove balls so placed, and predicts the most disastrous consequences from the neglect of this mea- sure. ^ Malgaigne, after relating several cases in which balls have remained without causing harm, concludes thus: "It is neces- sary to mention these fortunate cases as evidence of the resources of nature, but they hardly serve to weaken the force of the prog- nosis when a ball cannot be extracted, or the essential indication of this sort of lesion—the extraction of the foreign.body. This indication is, then, that of the first importance." The nerves most commonly escape injury from a ball. If the missile has been rendered irregular in shape by previous contact with some hard substance, then it may do much damage to even the larger nerve trunks. Numbness, succeeded by pain in the extremity of a limb traversed by a ball is not uncommon, and probably arises from the contusion or laceration of some chief nerve—the swelling and the pressure it occasions assisting to give rise to the subsequent uneasiness. The paralysis which succeeds the injury of a nerve may come on at once, or after an interval, and may, or may not, be accompanied with pain in the jp&rb itself, or in other regions connected with it by nervous com- munication. I have seen the hand several times waste when some of its nerves had been injured by a ball. In one case in particular, in which the ball had coursed up under the muscles on the external surface of the upper arm, this symptom was very marked. Even though making all due allowance for the elasticity, strong coat, mobility, and form of the arteries, it is yet difficult to under- stand how they escape injury in gun-shot wounds as they do. The rarity of primary hcemorrhage on the field of battle has been long remarked, and yet how often do we meet with ball wounds apparently through the course of a great vessel! The veins are more easily cut than the arteries, and primary hcemorrhage, when it docs occur, proceeds more commonly from them. Some vessels are more liable to injury from balls than others. Thus, those firmly tied down, or lying on bone, are more subject to damage than those loosely reposing on the soft tissues. This remark applies especially to two vessels, the femoral as it passes over the brim of the pelvis, and the popliteal, where it lies on the head of the tibia. The lower parts of the ulnar, the ra- dial, and the facial, where it turns over the jaw, are subject to injury from the same* reason. An artery has not rarely been opened by a spiculum of bone detached by a ball which had itself spared the artery. The eccentric course often pursued by balls has been a frequent subject of remark, and though we had many most striking in- stances of this, still I suspect wo have had less of it than oc- 22 SURGERY OF THE CRIMEAN WAR. curred in the experience of former wars. The conical ball sel* dom fails to take the shortest cut through a cavity or limb, and it has at times been seen (as at the Alma) to pass through the bodies of two men and lodge in that of the third. But of the wanderings of the old round ball there were many illustrations. 1 have known it enter above the elbow, and be removed from the opposite axilla ; and in another case it entered* the right hip, and was found in the left popliteal space.* This " bizarrerie " in a ball's course is accounted for by the deflecting action of tendons, aponeuroses, or processes of bone, or by the angle at which the ball strikes, qjid the way in which, during certain positions of the body, distant parts are placed in a line, as in the well-known case recorded by Ilennen, in which a ball entering the upper arm of a man ascending a scaling ladder, was found half way down the thigh of the.opposite side. The fact of this wandering, however, is a peculiarity in gun-shot wounds which often ren- ders the discovery of the wounding agent difficult. Foreign bodies, as pieces of cloth or part of the soldier's accou- trements, are often far more troublesome when introduced into a wound than the ball which occasioned their presence there. In- numerable and must heterogeneous have been the foreign bodies thus forced into wounds ; but those which are capable of acting chemically as well as mechanically, are the worst of all, Of these, lime, pieces of copper, &c, are the "most frequently mot with. Round lead balls are, perhaps, from their nature and shape, the least noxious of any, and arc most likely to become encysted in the tissues. r Few questions connected with gun-shofc wounds have given rise to so much discussion and diversity of opinion as that with reference to the extraction of balls. For my own part, I have seen enough to make me subscribe, with all sincerity, to Begin's precept, when he says in his communication to the Academy: " Selon moi l'indication de leur extraction est toujours presente, toujours le chirugeon doit chercher a la remplir; mais il doit lo faire avec la prudence et la measure que la raison conseille. S'il recussit, il aura beaucoup fait en faveur du blesse. S'il s'arrete de- vant l'impossibilito absolue ou devant la crainte de produire les * The surgeon of the 24th, when serving in India, mentions n case in one of his reports, in which a ball entered below the anulo of tho lower jaw, on the left side and made its exit above the spina of the right scapula, without injuring any important part; and M. Meniere, in his account of the Hotel Dieu during the " three days."' tells us of a ball which entered at the inner angle of the left eye, passed downwards, backwards, and to thr> right side, under the base of the cranium, and was removed above the right shoulder. The rapid recovery, without a bad symptom, was no less wonderful in this case than the direction taken by the missile was curious. GUN-SHOT WOUNDS AND THEIR TREATMENT. 23 lesions additionelles trop graves il aura encore satisfait aux prin- cipes de l'art; et quels que soient les resultats de la blessure il n'aura pas a se reprocher de les avoir laisse devenir funestes par son inertie." If we examine into the opinions of surgeons on this point, we find that nearly all those who look upon the extraction of the ball as a matter of secondary importance are civilians, while military • Burgeons place great weight upon its accomplishment. The true way of putting the questioa is, not whether balls may remain in the body without causing annoyance, but whether they do so in so large a number of cases as to warrant non-interference. We must always remember that "science is not made up of excep- tions," but is established by a collection of positive facts. Those who have studied gun-shot wounds in the field, know full well how enormous is the irritability caused by the presence in a wound of a ball or other foreign body—how restless and irritable the patient is till it is removed—how prolonged the period of treatment is in the cases in which it is left—and how frequently the results are so distressing as to demand future interference, or condemn the unfortunate sufferer to a life of discomfort. As it is the surgeon's duty to treat his patients with reference to their future ease as well as to their present cure, so he should not try to bring about a healing of the wound which can be only tem- porary and fallacious, to the sacrifice of the efficiency of a limb and the future health of the body. In this country we have not many opportunities of obtaining extensive information on the point as connected with the subse- quent history of men with balls remaining unextracted, but such information is supplied from the Hotel des Invalides of France, by M. Hutin, the chief surgeon to that magnificent establishment. He tells us, that while 4,000 cases had been examined by him in five years, only twelve men presented themselves who suffered no inconvenience from unextracted balls, and the wounds of 200 continued to open and close continually till the foreign body had been removed. This epitome is of much value in estimating the question I am considering. In leaving the ball unextracted, we never know what evils may follow. The keeping open of the wound exposes the patients in the first place to all the dangers of a life in hospital, and the very elimination of the foreign body by suppuration, if it take place at all, necessitates a vast amount of annoyance. If it be a piece of shell or such like which is present, then its size will prevent its unaided extrusion, and the blocking up of the track which it is so apt to occasion, may cause burrowing abscesses of a most destructive character. Before a ball becomes encysted, it may set up grave inflamma- tion, which will mat together and embarrass parts; pr"ess upon bone, and perhaps cause exfoliation ; ulcerate blood vessels, and so irritate nerves as to occasion affccvijn:i as severe and fatal in their results as tetanus. It is .somewhat remarkable, that in the 24 SURGERY OF THE CRIMEAN WAR. wounded who came under my own care, two died of tetanus, in the very small number of instances—four or five at most—in which I could not find the ball. If this was a mere coincidence, it is the more curious. Gravitation and muscular action may so change the position of a ball, that from a harmless site it maybe removed to one of much danger. It may thus work its way into a cavity, and cause fatal results. But suppose the ball to become encysted in the first instance, what security have we that some very trivial circumstance (it may be a blow or even a deterioration in the health of the pa- tient,) may not set up irritation, inflammation and suppuration in the cyst, and so come to set the ball free again to work harm in the economy ? In any case, its continued pressure gives rise to much uneasiness. The constant weight and weakness felt in the limb, the wandering pains, ascribed to rheumatism from their aggravation by cold and damp, which attack even distant parts of the extremity, and the ever-present dread felt by tho pa- tient, if the ball he in close neighborhood to any vital organ, all unite to give much annoyance and discomfort. The aversion which patients who have long carried unextracted balls express to have them removed, is not, as some would try to show, any proof of the slight annoyance they occasion, but simply indicates that they choose to suffer the discomfort rather than undergo what appears to them an uncertain and dangerous pro- ceeding to free themselves of a bearable inconvenience. It seems, then, the teaching of experience, as it is of common sense, that whether the question be viewed as one bearing im- mediately or remotely on the result—on the cure of the patient, in the proper acceptation of the term—then we should, as soon as practicable, ascertain the position of the ball, remove it along with any other foreign body which may have been introduced with it, always supposing that by such a proceeding we do not cause more serious mischief than experience shows the presence and after effects of the ball can produce. To extract a ball is, in general, not difficult. It is of much consequence to proceed to its accomplishment before inflamma- tion and swelling have come on, so as to close the wound* The great point to attend to undoubtedly is the fulfilment of the rule, which is as old as Hippocrates, to place the patient as nearly as possible in the same position as that he occupied at the mo- ment of injury—to put the same muscles into action, and the angle which the parts form to one another in the same relation ; also, to place ourselves relatively to him in a position to corres- 1 * Percy adds another reason to encourage us in the early removal of balls, when he says that men submit the more readily soon after the receipt of the wound to the necessary incisions, before their courage has been broken by pain and suppuration. GUN-SHOT WOUNDS AND THEIR TREATMENT. 25 pond as nearly as possible with the direction from which the ball came. By considering the effect which bones or strong tendinous expansions may have had in deflecting the ball, or by paying at- tention to what Guthrie calls the general " anatomy of the whole circle of injury," and consulting the patient'c own ideas, which often convey to us most useful hints, we shall in general succeed without much difficulty in discovering the ball. An examination of the patient's clothes will show us whether any part of them has been carried into and left in the wound—whether the two holes seen in the limb have been caused by the same ball which has thus passed out, or by two balls which are still in ; as well as whether the ball may not have carried in a cul de-sac of the dothes, and been withdrawn with it. If this be not attended to, very awkward mistakes may be made, as the mere correspondence in the direction of the two apertures, any more than their seem- ing want of relationship, cannot be taken as decisive in settling the "matter. This point is well illustrated in the following in- . stance, related by an Indian surgeon: A wound was found be- low, and another above, the patella of a wounded man. The former had all the signs of the wound of entrance, and the latter those usually found at the place of exit of a ball. The opening of an abscess, which formed in the thigh a fortnight after, gave exit to a grapcshot, and it was found that the external condyle had been injured, and that each opening had been caused by a different ball. In another instance, which occurred in the case of a soldier of the 40th regiment in Cabul,-* the ball appeared to have passed through the elbow joint, and to have fractured the radius. There were two openings, having all the appearance of being those of en- trance and exit; yet the ball was found and removed from the limb three weeks after. Such a mistake is most apt to arise when two balls have been fired together from the same gun, which happens not uncommonly in civil commotions, or when such fire-arms are used as the "espignole" of the Danes, from which a number of balls are fired in rapid succession, or when a cartridge, similar to that used during the Schleswic-Holstein war, is employed, in which two balls and a piece of lead are bound up together. One ball, too, it should be remembered, may make several openings. Thus, I have seen two in the leg and two in the hip, and also two in either thigh, occasioned in each case by one ball. Dupuytren relates a case in which, from its splitting, one ball made five holes ; and the younger Larry saw at Antwerp six orifices caused in the same way. Sir Stephen Hammick mentions a case in which an aperture was found on either side of the chest of an officer shot in a duel. These cor- , responded both in position and character to those which would *> * Unpublished Report. 26 SURGERY OF THE CRIMEAN WAR. be occasioned by a ball that had traversed the chest; yet, after death, two balls were found in the body. As showing tho necessity of an early and careful search, as well as that wo should never rely too much on the patient's state- ment, I may mention the following case : A soldier, wounded on the 18th June, came under my care in the general hospital. His right arm, which had been fractured compoundly, was greatly swollen at the time of- admission. I was told, and accepted the story, that the accident had been caused by a piece of shell, to which species of injury the wound bcre every resemblance, and that it had been removed by a surgeon in one of the trenches. -At the earnest solicitation of the patient, 1 contented myself with applying the apparatus necessary to save the limb without mi- nutely examining the wound. The injury turned out to be much masked, and to be greatly more severe than it at first appeared, the shaft of the humerus having been split into the joint. When removing the limb at the shoulder, some days after, to my gfeat astonishment a large grape shot dropped from among the mus- cles.* I before alluded to another case in which a piece of shell, weighing nearly three pounds, had remained concealed for two months without suspicion, from a like neglect of a pBOper exami- nation. ^ It is well to remember, also, in searching for balls, 4hat they may have dropped out by the same aperture by which they en- tered, before we come to examine the case. Stromeyer has put us upon our guard against very curious errors, which he says he ( lias seen made in cutting on the head of the fibula, alia* on a me- tatarsal bone for balls. Sir Charles Bell has shown how the nerves may indicate to us the position of the ball. In one case he found it by pressing on the radial nerve, and so discovered that the ball lay behind it. " So when a ball has taken its course through the pelvis or Across the shoulder, the defect of feeling in the extremity, being studied anatomically, will inform you of its course—that it has cut or is pressing on a certain trunk of nerve." » From all this, then, it is at thb least very evident that we should not be too hasty in concluding that no ball remains in the limb, even although all the signs usually indicative of its having es- caped arc present; and also, that immediately before proceeding to take any steps for the removal of a ball, wo should make cer- tain of its position, remembering the rule laid down by Dupuy- tran—never to act upon information regarding the site of a b|ll obtained the day before, from the rapid manner in which they often shift from one spot to another. >l^iayJ however, remark that this splitting upwards of the head < frorntthe shaft is very rare. In general, the splitting ceases at the epiphysis. GUN-SHOT WOUNDS AND THEIR TREATMENT. 27 The common dressing forceps, if long enough and fine enough in the handle, will, I believe, be found the most useful bullet ex- tractor. That invented by Mr. Tuffnel, of Dublin, acted well in the few cases in which I tried it. Larrey employed polypus for- ceps in preference to anything else, but the inventions which have been made to accomplish this simple end are innumerable. To support the limb with the disengaged hand on the side oppo- site to that at which we introduce the forceps, is of much im- portance. If the course of the ball has been from above down- wards, and if it has approached at all near the surface, it should always be cut upon the dependent part, by which two objects are secured—the removal is facilitated, and an opening for the pus is insured. If the wound be large, as it generally is from the con- ical ball, tho finger forms the best prob6, both to discover tho ball, and also to examine the state of the adjoining parts ; other- wise, a large gum elastic boughie is our best resource. Causing the patient to move his limb, sometimes makes the site of the ball be felt by him, if not by us. Its position under a fascia, or in contact with a bone, would make us risk much in order to re- move it. Tho contentment of mind which results from tho extraction assists recovery amazingly. Tho long continuance of the' dis- charge, its gleety character, and the persistence of pain in the trathe vessels and nerves in the axilla, and escaped behind. His cure was rapid and un- interrupted. Another Frenchman was struck in the trenches by a ball, a little below the middle of the right clavicle. The ball escaped behind, breaking off the upper third of the posterior border of the 6capula, and yet he recovered perfectly, without any bleeding taking place. Endless numbers of similar cases are presented to us in military hospitals. A considerable artery may be fairly cut across, and give no further trouble, beyond the first gush of blood which takes place at the moment of injury. In such cases, the vessel contracts and closes itself. If only half divided, as it is apt to be by shell, or by the quick passage of a ball, then the haemorrhage will be, in all probability, fatal. The best example, perhaps, on record of the former result, is that mentioned by Larrey. A soldier, struck on the lower third of the thigh by a ball, suffered one severe hcemorrhage, which was never repeated. The limb became cold, the popliteal ceased to beat, and the ends of the divided femoral could be fel.t retracted when the finger was placed in the wound. This man recovered perfectly. The younger Larrey records a very curious case from the wounded at the siege of Antwerp. A shell passed between a man's thighs, and, destroying the soft parts, divided both femorals; yet there was no haemorrhage, al- though tho pulsation continued in the upper ends of the vessels to within a few lines of their extremities. The speed of the ball at the moment when it comes in contact with an artery has a good deal to do with the injury it inflicts. If it be in full flight it may so cut open the vessel as to allow of instantaneous haemorrhage; whereas, if its speed be much di- minished, the contusion it occasions opposes immediate, but favours secondary bleeding. Primary haemorrhage may take place either instantaneously on the receipt of a wound, or after a little time, when the faint- ness resulting from the accident has gone off. I have already referred to some instances in which the former is liable to occur. In wounds of the face, too, this instantaneous bleeding is very usual. Some cases occurred iu the Crimea of the well kuown fact, 36 SURGERY OF THE CRIMEAN WAR. that limbs may be carried away, and their arteries hang loosely from the shattered stump without bleeding. Two came under my own notice, in which legs were carried away by round shot, and no haemorrhage took place, though both men died subse- quently from other causes. This spontaneous cessation of haemorrhage is perhaps most commonly seen in the upper arm. The returns fail to inform us of the number of cases either ab- solutely or proportionately to the whole number of wounds, in which secondary haemorrhage took place during the war. Al- though I have no figures to which I can refer as corroborating the statement, yet I am inclined to think that the proportion of cases in which serious bleeding did take place, is higher than that set down by Mr. Guthrie. The distinction drawn by Dr. John Thomson between secondary haemorrhage pi'oceeding from sloughing, ulceration, and excited arterial action as it occurs at different stages of treatment, is a good one. That which takes place after twenty-four hours and up to the tenth day being usually due to sloughing, resulting directly from the injury, should always have the term "intermediary" applied to it; and the bleeding which proceeds from morbid action, such as ulcera- tion attacking the part, and which takes place at a later period, would be more appropriately called •' par excellence" secondary. Haemorrhage should thus be distinguished into three periods: " primary," occurring within twenty-four hours ; " intermedia- ry." between that and the tenth day ; and " secondary," that which takes place at a later date. More precision would be given to our language on this important subject, by such a distinction being always recognized. The period at which consecutive bleeding is most apt to take place has been variously estimated. Guthrie >sets it down as oc- curring from the eighth to the twentieth day, Dupuytren from the tenth to the twentieth, Ilenman from the fifth to eleventh, and Roux from the sixth to the twentieth. In the cases I have myself observed, it has taken place between the fifth and twen- ty-fifth days, and by a curious coincidence, it has appeared in the majority on the fifteenth after the receipt of the wound. In one case, a wound without fracture of the thigh, it was said to have taken place as late as the seventh week, and that when no gan- grene or apparent ulceration was present. Consecutive haemorrhage may occur from very insignificant vessels, and be arrested by simple means; but "when it takes place from a large arterial trunk, it is an accident of tho-most se- rious importance* With us, in particular, such effusions were HEMORRHAGE FROM GUN-SHOT WOUNDS. 37 causes of extreme anxiety, as the deteriorated state of the health of our patients made such an accident peculiarly disastrous. Their strength could not withstand such a diain, and the pcurvy made their blood so thin and effusible that they were liable to great loss of blood, not by vigorous haemorrhages, but by slow, though not less destructive, discharges. From this it can be un- derstood that in the Crimea many of the time-honoured remedies for haemorrhage, such as venesection, starving, &c, were entirely discarded, and replaced most generally by their opposites. Tonics, as quinine and iron, were the remedies most wanted; and as to styptics given internally, they always appeared to mo to be mere farces, except in so far as they acted as general tonics. The more useful prophylactics to such consecutive haemor- rhages, such as quiet of mind, and perfect rest of the wounded part, are not always attainable in field practice, especially when the necessity of removing patients occurs so frequently. It is of course impossible altogether to avoid such movements during war, but it is most unfortunate that they fall so often to be exe- cuted at the very period when they become most dangerous. No man, at all severely wounded by gun-shot, can be considered safe from haemorrhago till his wound is closed, but yet, after twenty- five days, the danger may be said to be in a great measure over- come. In reference to this point a siege has an advantage over an open campaign, from the greater fixedness of the hospitals, and the less frequent moving. Haemorrhage occurring early was universally treated by the rule laid down by Bell and Guthrie, of tying both ends of the bleeding vessel. When, however, the bleeding appears at a lato date, when the limb is much swollen, its tissues infiltrated, mfttted together, and disorganized, it is by no means an ea*sy thing to follow this practice. The difficulty is perhaps greatest in wounds of the calf of the leg, where the muscles are much de- veloped, when the posterior tibial has repeatedly bled, the wound large and irregular, the contusion severe, and the blood welling out from among the disorganized tissues in no collected 6tream. The rules and precepts laid down in b >oks about tho struck by a ball at Moolfan, about a line anterior to the left carotid artery, below where it divides into tin external and internal, and passing through the oesophagus, escaped at a point corresponding to its entrance. No unfavourable symptom appeared for nine days, when a fit of coughing came on, and blood issued from both the mouth and the wounds, and the patient instantly expired. The right carotid had been grazed at its bifurcation, and a piece of it about the size of a small pea, and including all its coasts, had sphacelated, and, giving way, caused death before assistance could be got.'' 38 SURGERY OF THE CRIMEAN WAR. appearance of the vessel and the orifice, about the mode of pass- ing a probe towards it from the surface, and tho best way'of cut- ting so as to fall upon the vessel, are all worse than useless; as they lead us to expect guides where there arc none, but thoso which watchful eyes and careful incisions afford. From the results of several cases which fell under my observa- tion in the East, I have reason to believe in the soundness of the views lately put forth by Nclaton.in opposition to the long- credited opinion of Dupuytren, as to the unsound state of the ar- . tery in suppurating wounds. I feel pretty sure that the vessel will, in most cases, bear a ligature for a sufficient time to fulfil the end we have in view in its application. It will be necessary to attach it with caution, to emply no more force than is abso- lutely necessary, and we may expect it to separate, as Nelaton shows, before the usual time, yet it will continue attached suffi- ciently long to close tho vessel, if we do not keep pulling at it po as to tear it away prematurely. It requires but a small force to oppose the blood-impulse, and that the vessel will commonly stand, if carefully handled. The French, although generally applying the ligature at th"to-discovw the INJURIES OF THE HEAD. 69 pression, to warrant us in undertaking, at an early period at any rate, an operation of so serious a description, as all recorded ex- perience has shown trephining to be, without more reliable and more clearly-defined evidence of its presence than is commonly thought to denote it. Symptoms which, by the dicta of books, were unquestionably those of compression, have passed off, in the experience of every one, under a treatment of which non- interference was the most important item ; while in other cases such large quantities of fluid—blood and pus—have been found, post mortem, on the brain, as all recorded experience tells us should have caused a compression which yet never appeared. We find cases on record in which it is evident that traumatic en- cephalitis was mistaken for compression, and the skull trephined; and in some such instances good effects have followed, evidently from the local bleeding, which, in several of these cases, was con- siderable ; or, perhaps, from the preliminary incising of the peri- cranium, which we know has, in some cases, succeeded of itself in removing symptoms analagous to those caused by compres- sion. Blood rapidly effused may cause early compression, which we know often passes off as the effusion is absorbed ; or mere con- gestion, the result of injury, may give rise to the same symp- toms, and be allayed by depletion ; yet, if we trephine early, we may have only such conditions to contend with. If the bone be very deeply depressed on the brain, and the pa- tient be comatose, with stertorous breathing, slow pulse, and dilated pupil, then it may be admissible practice to use the ele- vator cautiously, with or without the assistance of Heys' saw ; but in'all cases in which the bone is not very deeply depressed, and in which these symptoms are not very decidedly marked, nor have continued for a considerable time, I do not believe any interference should be attempted. It is too much the custom, I think, to deny or overlook the danger which arises from the operation itself. This is no place to inquire what is the source of this danger, whether it.be the ad- mission of atmospheric air to the membranes, as supposed by particular part of the cranium which is injured, the patient in the meantime being afflicted with the most urgent and dangerous symp- toms. In these cases it will be necessary to trepan first on the right side, then on the left side of the head, afterwards upon the forehead, and lastly upon the occiput, and so all round until you meet with the seat of the disorder." Even in recent times the same practice has been recommended by Benjamin Bell, who says we must -'form the first perforation in the most inferior part,of the cranium in which it can with any propriety be made, and proceed to perforate every accessible part of the skull till the cause of the compression is discovered." 70 SURGERY OF TnE CRIMEAN WAR. Larrey and Stromeyer, or the renewed irritation and injury of the brain coverings, or, as others say, from pus poisoning; but the fact recurs that the most serious, and at times fatal symp- tims, have followed the operation itself, in cases in which, con- trary to expectation, the parts below the bone were found sound.* Injury of the skull, followed at a late date by compression, is perhaps the most hopeless of all the circumstances in which the trephine can be used, yet it seems that in which it is most pTO- perly and incontestably employed. Rigors followed by vomiting, a rapid pulse, stupor, delirium and palsy, usher in a condition of things which, except in rare oases, is fatal. The longer the time which intervenes before the appearance of such symptoms, the more deadly does their indication appear to be.f It is well known *The mortality which attends the operation of trephining needs little proof, as it is one of the best recognized surgical facts. Take such a statement as that of Stromeyer, who tells us that during the three years he attended the hospitals of Vienna, London and Paris, he had not met with a sinsjie successful case, while many severe injuries recovered which were left alone. In the New York hospital only one-fourth of their cases recovered, i. e., eleven cases out of forty-five. In ten of these the operation was prophylactic, and in thirty-two therapeutic ; three of the former and eight of the latter recovered. In India 1 find a record of four cases of trephining for .symptoms setting in late, and all ended fatally. In the Glasgow hospital register I find no record of a recovery after trephining. In University College hospital Mr. Erichson speaks of four cases of recovery in thirteen operated on, and in the Paris hospitals Nelaton tells that in fifteen years all their operations of this kind for trau- matic effusion have ended fatally. Mr. Guthrie thinks the danger greater when the operation is performed late. He thinks the sooner it is undertaken, if it is to be had recourse to at all, the better, "be- lieving the violence to be greater when done on parts already in a state of inflammation than when they are sound." Larrey expresses himself in almost the same words : " We say, then, that the trepan should be applied when it is decidedly indicated, before the inva- sion of inflammatory symptoms, which show themselves more or less promptly, according to the idiosyncrasy of the patient, his age, and the cause of the wound ; and when it is developed, the opera- tion should be delayed till those symptoms cease. If this second period does not present itself, it is better to abandon the patient, devoted to certain death, than to try a useless remedy which can only hasten his last moments." ■f-Thc late period at which dangerous symptoms may be set up, the total absence of any irritation caused by foreign bodies im- pacted in the brain, which is occasionally observed, are well shown in a case related by M. Manoury in his report on Roux's service during the year 1841. A student, with suicidal intent, shot himself by the mouth. Tho ball tore the jaw, but there were no head INJURIES OF THE HEAD. 71 that in the majority of these cases the pus is so situated that it can- not be evacuated by the trephine. It is either diffused over the brain, between its membranes, or collected in depots deep within its substance, or at parts distant from the seat of in- jury. In a considerable number of cases, however, it lies su- perficially, when its formation has been occasioned by a concen- trated blow like that of a ball, and may be found collected be- neath the place of injury. It is only in these latter instances that any good can be got from the use of the trephine; but such cases are sufficiently numerous in their occurrence to indicate its employment in all instances in which distinct signs of purulent collection set in at a late date. " It is plainly an abscess of tho brain," says John Bell, "and as it is an abscess which cannot burst or relieve itself, though the trepan may fail to relieve the patient, yet without that help he will infallibly die." In this is expressed the true reason for its use in these most hopeless cases. It is, in fact, a last resource, which we are not justified in refus- ing to avail ourselves of. Besides this, it is also true, that in a considerable number of cases in which the pus has not been found immediately beneath the seat of injury, it has been discovered, post mortem, but slightly removed from it, within the brain substance—so near that very little would have effected*ts evacuation ; and it is also well known that success has followed the bold expedient, first practised by Dupuytren, of plunging a knife into the brain when the abscess was .not found on its surface. The case will end fa- tally to a certainty, if the matter is not evacuated, and in the event of the attempt failing, such a step, if conducted with pro- per circumspection, will not add to the gravity of the case. The following case is mentioned, not only because of the late appear- ance of urgent symptoms, but also because of the position of the abscess found after death, which was situated as above re- ferred to: A private in the 29th was hit by a ball above the eye. The frontal bone was smashed, and the ball was lost apparently in the brain. No head symptoms whatever followed. Somo loose pieces of bono were removed, but two parts which were de- pressed were not interfered with. The antiphlogistic treatment was decidedly maintained. For three weeks no symptoms ap- peared to create alarm ; at tho end of that period, however, a good deal of local inflammation was set up, and the depressed portions of the bone, being found loose, were removed. Very little disturbance followed this step, and ho was finally dis- charged, about four months after the receipt of the injury, appa- symptoms. On the sixteenth day he was so well as to ask for his discharge from hospital, while on the' eighteenth head symptoms set in, and rapid death ensued. The wad and the ball were found in the brain, and yet for a fortnight not the least sign appeared of irn ation, or of the presence of such formidable bodies. 72 SURGERY OF THE CRIMEAN WAR. . rently quite well. A month after dismissal he returned into hos- pital, complaining of feverishness, headache, and ^ hurried and excited manner. There was nothing particular found at the seat of injury. The cicatrix was in the same condition's wlien he left the hospital. The brain pulse was evident, as it had been since the bone was withdrawn. Coma occurred shortly after his admission, ending in death sixty hours from the first bad symp- tom. When the head was opened, the hiatus in the bone re- mained unchanged, only that the edges of the aperture were smoothed and beveled off, and somewhat darker in color than tho rest of the calvarium. The dura mater was thickened, but en- tire, and adherent at the place of the wound. The other brain coverings were highly inflamed, and sero-purulent effusion ex- isted between them. A small abscess was found in the substance of the brain, immediately below the place of injury, and behind this, but separated from it by a thin partition of cerebral sub- stance, was a larger abscess in the anterior lobo of the brain, which communicated with the lateral ventricle of the left side. The small abscess had a distinct sac, but the larger one had not. Dr. Taylor, who reports the case, adds: " These collections of pus might have been of some standing, yet the patient had not a bad symptom up to sixty houjs, before death." It is veryvpossi- ble that dissipation after dismissal occasioned the sad and fatal result. A soldier of the royal artillery was admitted into the general hospital on the 15th of November, on account of a shell wound dividing the scalp over the inner and anterior angle of the left patrietal bone. He walked to the hospital, assisting a comrade who was more severely hurt than himself, and he complained so little that it was with difficulty he could be persuaded to go to bed. A piece of bone about the size of a shilling was found on examining his head, depressed to the extent of about an eighth of an inch at the seat of injury. He was purged, put on low diet, and his wound dressed simply. In five days he was allowed to rise and assist in the business of the ward, being put inad- vertently, by the surgeon under whose care he was, on full diet and a gill of rum. No bad symptoms showed themselves for ten days. His bowels were permitted to get costive. His wound was nearly closed. On the morning of the fifteenth day from ad- mission, he complained of giddiness, his pulse was rapid, and his face flushed. Leeches and cold were ordered to the head, and a purgative administered. He rapidly grew worse. The wound, now dry and unhealthy, gave out but a slight gleety discharge. He made many attempts to vomit, which was encouraged by an emetic. His pupils became widely dilated, but remained sensible to the action of light. A fortnight after the setting in of these symptoms, he was found to be hemiplegicon the left side. I saw him at this period for the first time. His respiration was sigh- ing, aua numbered twenty-two in the minute. His pulse was INJURIES OF THE HEAD. 73 ninety, and contracted. His mouth and tongue were drawn to the right side. H« was sensible when romsed, but lay in a half state of sopor when not addressed. The next day the trephine was applied to the seat of injury, and the depressed bone re- moved or elevated. The dura mater was covered by a pulpy mass of lymph. No pus was found. Some spiculas of the inner table which lay on the dura mater were withdrawn. His symp- toms in" 'no way improved. His tongue was next day drawn to the left side, but his mouth was unaffected. He had several se- vere convulsions over both sides of his body, and he died two days after being trephined. The skull was found fractured across the sagittal suture into both parietal bones. The dura mater was little detached round the seat of injury; but it was there dark and pulpy, having a semi-organized clot on -its surface. The brain was softened at the pla^e of injury, and had a clot as large as a walnut lying on it; while at two points on the opposite hemisphere, at the end of the longitudinal fissure, soft spots were found, about as large as a sixpence. Pus existed abundantly be- low the membranes, and bathed the surface of the right hemis- phere, as well as extended to the base of the brain, between the hemispheres and under the cerebellum. The neglect as to diet and the maintenance of the secretions, were probably the causes of death in the above case. It is cer- tainly not always easy to maintain as careful a supervision on these points as is necessary, when no functional disturbance whatever is present, and the injury seemingly slight; but this is only one of the many examples which might be adduced to show the neces- sity of the long and careful watching which such cases require. The above was one of the only two instances in which the tre- phine was employed in the general hospital, and both ended fa- tally. In the other case, it was used by one of my colleagues for signs of compression setting in early, with bone much and exten- sively depressed. Finally, judging of this question from o,n examination of the writings of our great masters, the conclusion which presents it- self is, lhatas the symptoms calling for the use of the trephine have been so variously interpreted by men of experience ; that as the operation has failed as often as it has succeeded in removing the dangers apprehended; that as the good which has occasionally followed is ascribable, in many cases, to other concurrent circumstances, and not to the removal of the bone; and finally, that as the operation, per se, is not devoid of danger, we should never have recourse to the trephine unless the indications for its use are very decided, have been present for some considerable time, and have not been assuaged by other remedial measures. Further, I am disposed, not only from reading, but also from the observation of not a few cases which fell under my notice during the late war, to conclude, regarding the cases and symp- 4 74 SURGERY OF THE CRIMEAN WAR. toms which demand operation—that primarily, operative i n ter- ference (under which term is included the use of the trephine, saw, or elevator,) in gun-shot wounds of the head, should never be had recourse to except (1) in cases of fracture with great de- pression—cases in which the bone is forced deeply into the brain, especially if it is turned so that a point or an edge is driven into the cerebral mass ; or (2) unless we clearly make out the impaction of spiculae, balls, or other foreign bodies in the brain, which cannot be removed through the wound by means of the forceps ; that secondarily, the cases which call for operation are (1) those in which a foreign body is at this period discovered irritating the brain, and which cannot be extracted without a piece of the bone being removed; or (2) those in which signs of com- pression set in after a well-marked rigor, continue to increase in in- tensity notwithstanding treatment, and have lasted for some time. In the treatment of gun-shot injuries of the head, operative proceedings form the least important items', as they can com- monly be avoided if the rest of the management be judicious, and their success will chiefly depend on a careful attention to less im- posing, but more important measures. In their examination the finger should alone be employed, and that even with much caution. They should not be enlarged, unless a more important object be held in view than to clear up doubtful points of diagnosis. If the bone be so extensively de- stroyed and depressed as to demand early interference, it will make itself sufficiently evident without its being necessary to in- cise the scalp for the purpose of making the distinction. Stro- meyer fitly recommends the application of a piece of wet linen to the wound, which, as it adheres to the scalp, excludes tho air. Cold—ice, if possible, or if it cannot be had, simple water- should be applied over this ; the patient put to bed in a tent by himself; an active purgative administered, and a most meagre diet allowed. The utmost quiet should be enforced, and in short, the antiphlogistic treatment very decidedly and completely car- ried out. He should be visited frequently, and if any signs of inflammatory or excited action supervene, instant and copious bleeding should be put in force. " Of all the remedies in the power of art," says Pott, "for inflammations of membranous parts, there is none equal to phlebctomy, and if anything can particularly contribute to the prevention of the ills likely to fol- low severe contusions of the head, it is this kind of evacuation; but then it must be made use of in such a manner as to become truly a preventative—that is, it must be made use of immediately and freely." 1 never saw any good arise from the use of tartar emetic in these cases. Cold locally, purgatives, low diet, and early bleeding, repeated freely when signs of disturbance showed themselves; these, with the application of leeches in some cases to the head, seemed always sufficient, as they are the most useful means of treating such patients. INJURIES OF THE HEAD. 75 As to the extraction of balls when lodged in the brain, the rule, I believe, almost universally followed in the army, is to ex- tract them if they can be at all got at. It is true that masses of a far more formidable nature than balls have remained on, and even in the brain without mischief, and that balls have been dis- covered encysted years after their entrance. But these cases form a mere fraction of the number in which the presence of the ball has determined fatal complications; yet they are the "ignes fatui" by which some would mislead us from the plain path of duty, which inculcates the removal of such foreign bodies, if at all practicable. Sir B. Brodie, arguing from an analysis of the published cases, advocates their abandonment unless superfi- cially placed; but from this view nearly all'military surgeons dissent. In our proceedings, however, " boldness must not par- take of temerity." Few would have the courage or confidence of Larrey, or Sir Charles Bell, to follow and extract the ball from the side of the head opposite to the place of entrance, or, like Sedillot, pursue it to the depth of several inches in the cerebral substance ; yet all reasonable attempts ought to be made for its extraction. " Nothing," says Sir George Ballingall, " will induce me to countenance the practice of leaving it there, except the im- possibility of finding it;" and again, "lam of opinion that it ought to be extracted even at the risk of some additional injury; in short, the prohibition of violence ought rather to apply to the search after balls, than to the operation of extracting them." " Wo have already cited several cases," says Quesney, " which teach us that foreign bodies may remain a long time in the brain without causing death; but with this knowledge we must also hear in mind that it is our duty to extract these bodies, which, sooner or later, almost always prove fatal to the patients; and when we have reason to suspect from the events, from the instru- ment which inflicted the wound, or from the state of the fracture of the skull, that such bodies are retained and concealed in the substance of the brain, we should make the necessary examina- tions for the discovery." If the ball has penetrated deeply into the brain, it is a matter of little moment what steps are taken. Perhaps the best line of conduct is to let the man die in peace. I have never known a case of perforating gun-shot wound of the head recover. Some Buch are, however, on record. Cases in which pieces of loose bono remain on the dura mater, do not always require to be interfered with. Many surgeons of largo experience in the Crimea, preferred leaving them to be thrown out by the natural effort, and were not particular even about keeping the wound- open. However, I believe this prac- tice to be often dangerous, and that loose portions of bone should always be cautiously removed. The evil effects of leaving them, as well as the injurious influence of too early a recurrence to a stimulant diet, were well marked in the following case : M'Louch- 76 SURGERY OF THE CRIMEAN WAR. lin, a privato in the Connaught Rangers, aged 19, was admitted into the general hospital on the 8th of September. He had been knocked down, and rendered insensible, by a blow from a piece of shell in the final assault on the Redan. A scalp wound two and a half inches long, was found extending from before baok- wards over the vertex of the head, and a small piece of bono was observed to be depressed at its anterior oxtremity. The patient didsoft parietes of the chest take to heal, especially when they are "en gouttiere." This he accounts for by the con- stant motion imparted to the walls by the movements of respira- tion. If the blow from a ball be forcible, or strike directly on tho chest without the intervention of any strong substance, then frac- ture of one or more of the ribs will probably be caused, and nos- • Unpublished records of the Medical department. / WOUNDS OF THE FACE AND CHEST. 8(J sibly pleural or visceral inflammation, as well, from the effects of tho blow, or tho presence of spiculae driven inwards. These fragments are at times long and sharp, and may be totally de- tached from the rib, and carried deeply into the lung substance. The cartilage of a rib, although torn by a ball, is seldom driven into the parenchymatous tissue, but remains so attached that its fragments can be easily restored to their proper position. It occasionally happens that a ball is arrested between two ribs. This happened in the following case. Cassay, a private in the 38th regiment, was admitted under my charge, into tho general hospital, on the 18th of June, suffering from a gun-shot wound of the left side of the thorax. The ballra large conical one with a broad base, was much spent when it struck him. It did not force itself into the cavity, but lay wedged between the cartilages of the second and third ribs, on the left side, about an inch from the sternum. On withdrawing the ball, the cavity of the chest was found to be fairly opened, and tho lung was visible as it expanded and contracted. The patient had a severe attack of pleurisy a few days afterwards, for which he was repeatedly bled. Effusion, to a limited extent, followed, and his gums were touched with mercury. For five weeks the wound continued to suppurate freely. The lung became adherent to the parietes. This patient had subsequently a short attack of bronchitis, but ultimately made a gcod recovery. He went to England in August, at which time he still complained of a severe pain in the left clavicle and shoulder, which extended down to his hand, and was attended by numbness and want, of power. The pain was in- creased by touching the arm, and had continued since he was wounded. In this case the cavity was opened, but the lung es- caped injury. The non-collapse of the lung was well seen in this, as in some other instances which fell under my notice. The natural mode of repair, by adhesion between the lung and tho walls of the chest, and the troublesome affection arising from injury to the nerves of the arm, were both illustrated in the above case. Pieces of shell, not unfrequently, open the cavity, but spare the lung, while sometimes the reverse happens, and the lung may be injured without the pleural si.c being opened. The following was a curious instance of this latter accident, without the thorax being opened. The case occurred under the charge of my friend Mr. J. II. Ilulke, assistant-surgeon to King's College hospital, to whom I am indebted for the details. Private Jeremiah O'Brien was admitted into the general hospital on the 15th November, 1855, having been wounded by a piece of shell when the right siege train exploded. His-left arm and fore-arm were extensive- ly shattered, and he had-two small irregular wounds on the left side of his chest, one just below the lower angle of the shoulder blade, and the other on the same level, but about two inches nearer the sternum. His breathing was quick and laboured, and 90 SURGERY OF THE CRIMEAN WAR- bright florid blood was bubbling from his mouth. His face was pale, his pulse flickering, and very feeble. Ho spoko with a firm voice, and begged his arm to bo cut off. No communication could be detected between the wounds on the chest and the cavity within, but two ribs were found to be broken. His wounds were dressed simply, and his chest fixed. Beyond dressing, nothing was done to the arm, as he.was not in a condition to undergo any operation. By night the breathing was easier, and he brought up less blood. Next morning his pulse was fuller, but intermit- tent. His spit still contained blood. His chest was naturally resonant as low as the fourth rib, but below this, by percussion and auscultation, dullness and friction sounds were discovered. He was cheerful, but, as he had not slept, half a grain of mor- phia was administered. He subsequently rallied somewhat, but died suddenly next afternoon, without any return of the bleed- ing. On examination after death, the Bixth and seventh ribs were found fractured without displacement. The pleura costalis was entire. The part of the lung below the level of the fracture was entirely adherent to the ribs and diaphragm, while, in tho upper part of the pleural sac, a small quantity of bloody serum was found. Opposite the position of the fractured ribs, the lung Bubstance was extensively lacerated. A large rent ran inwards from the external surface towards the root, downwards towards the base, and upwards towards the apex. A large branch of the pulmonary artery was seen with an open torn mouth in the rent," while many other vessels stretched across it. The right or unin- jured lung was ecchymosed at numerous spots on its surface, and in part emphysematous. Ecchymosed points were seen also on the surface of the heart and pericardium. The mitral valves, and endocardium of the left ventricle, were of a rosy hue. The seg- ments of the tricuspid valve were bound together by a fibrinous clot, which narrowed the passage to the size of a small quill. Blood was found in the small intestines, but not in the stomach. Mr. Ilulke remarks the arrestment of the bleeding by the mode in which the chief vessel was torn, as well as the conservative act of shutting off the rent in the lung, and the torn bronchi from the pleural sac by the formation of adhesions. It is seldom that a conical ball will be found to lodge in a rib, as a round one has been seen to do, or yet'to run round under the integuments, or at all to lodge within the chest. In fact, it very rarely fails to penetrate deeplv, or pass quite through the entire cavity. Non-penetrating wounds are more dangerous at some points of the thorax than at others. Thus, when a ball strikes a large bone like the scapula or the spine, or in those places where the large blood-vessels and nerves are situated, as in the axilla and upper part of the chest, the danger is greatly increased. 1 he gravity of penetrating wounds depends very much on their direction and their point of entrance, as when, with an in- WOUNDS OF THE FACE AND CHEST. 91 cidencc very oblique to the surface, they enter at some parts of the chest, they may traverse a portion of the cavity without touching the contents. So it happened in the following case. Fontaine, a private in the 90th, wounded on the 8th September, was admitted into the general hospital on the same day. The bull, after passing through the flesh of his left arm, which was at the moment in advance of his body, bad entered the thorax in the axilla, and escaped at the inferior angle of the scapula, frac- turing it, along with two of the ribs, at the place of exit. No im- mediate disturbance followed,- but in twenty-four hours signs of acute pleurisy appeared, and required decided treatment. The ball had entered the cavity of the chest, but the substance of the lung had evidently escaped. Bone exfoliated by tho wound of exit, which continued to suppurate long after that of entrance had closed. No bad symptom arose after the attack of pleurisy above referred to was subdued. I have seen this man lately in perfect health. The finger is the only probe permissible in examining wounds of the thorax. If we thereby discover the projection inwards of fragments of a rib, or portions of it impacted in the lung, we should take immediate steps for their removal, even though the wound has to enlarged in order to allow of its accomplishment. The ribs are best fixed, and the wound left free, by means of strips of adhesive plaster passed from the spine to the sternum, and from above downwards, so placed as to embrace the wounded side only. Men wounded in the lungs require all the breathing space we can give them, and this is best managed by having the sound side free. It is a singular circumstance connected with wounds of the walls of the thorax, that an intercostal artery is -seldom opened. I neither saw nor heard of such a case during the war, so that we were spared the adoption of any of those operative procedures for its closure, which, Boyer remarks, are more numerous than the authentic cases of the occurrence of the accident. Balls passing in front of the chest from side to side may causo very grave injury to the parietes, without absolutely wounding either the heart or lungs. This occurred in the following most interesting case:— Fleming, a private in the 18th regiment, was admitted on the 18th of June into the general hospital, under Mr. Rooke. This lad was struck by a Minie ball, a little above the right nipple, as he stood sideways towards the enemy. Tho ball escaped below the left breast. The sternum was fractured and comminuted by the ball in its transit. Severe dyspnoea followed together with a Blight attack of haemoptysis. Repeated attacks of inflammation occurred over parts of both lungs, and the subsequent superven- tion of pericarditis necessitated bleeding and the use of tartar 92 SUROERY OF THE CRIMEAN WAIS. emetic, and subsequently cf mercury, so as to touch the gums. The soft parts between the wounds of entrance and exit sloughed, and the sternum to the extent of about one and a half inches, to- gether with the cartilaginous ends of the ribs thereto attached, came away in fragments, or were absorbed ; so that~by the 12th of July, a profusely supourating wound had formed, 6 inches long by 2£ broad, across the front of the chest, laying open tho anterior mediastinum, together with the right thoracic cavity, the opening into which was, however, sealed by the adhesion of the lung to the parietes. At the left extremity of the wound, and at its lower part, tho heart was plainly felt only covered by the pericardium. A to-and-fro sound accompanied the motions of the heart, but these were not sufficiently pronounced to prevent the recognition of the two natural notes. Hectic fever, harass- ing cough, and emaciation supervened. By the middle of July the wound had begun to granulate, and the patient seemed to improve. An attack of diarrhsea, however, prostrated his little remaining strength, and ultimately proved fatal. Before death, the pus with which the wound was filled receded on inspiration, and welled up when the lungs were empted, as if it sank between the lungs when they expanded. On the morning ol the day on which he died, a new sound was heard to proceed from the region of the heart, to which we never before heard any similar. It was exactly like the "clanking" note which accompanies tho working of a pump when its gear is loose. There was the suck- ing in, and expulsion sound, together with this sharp peculiar note, which it is impossible to describe, but which immediately suggested the probability that the pericardium had been opened, and that the pus which filled the wound was alternately being Bucked into and ejected from its cavity. On examination this view was confirmed, as a small hole was found at the inferior and left lateral aspect of the wound through which the pus appeared to be drawn in, and thrown out, during the action of the heart. After death, it was found that this aperture led into the pericardium, which was much thickened, and adherent to the heart, for a space of two inches by one, at the anterior and mid- dle part of that organ. The opening mentiened led into a pouch formed by the pericardium round the roots of the great vessels, and which pouch communicated freely on the right side of tl.e heart with the sac of the pericardium, at the base of the heart below the adhesion. Pus was freely effused into the pericardium, and the surface of that membrane, as well as that of the heart, was of a drab colour, and thickly coated with lymph of a low type of organization. The heart itself was healthy. The lungs were somewhat congested, and their anterior surfaces were adherent to the parietes. The coats of the stomach were un- healthy, but beyond this nothing was observed. The noble struggle made against death by this poor boy, the very extensive injury, the opening of the pericardium, and the WOUNDS OF THE FACE AND CHEST. 93 sealing of both sides of the thorax by the pleural adhesions, were all points of much interest and no little instruction.* The two following cases show how small a difference in the place of transit of the ball may determine the question of life or death :—A Zouave was struck at the Alma by around ball, which entered the parietes close to the right nipple, and escaped at a cor- responding point on the left side. The ball passed in front of the sternum, which it fractured. Curiously enough, no inflammation whatever of the contents of the thorax followed, and he was in a short time discharged well. The points of entrance and exit dif- fered little in this and in the case of Fleming; but the projection of. the sternum being less in this patient, the result was very dif- ferent. A Russian soldier lay close to tire Zouave just referred to, who, in the same battle, had been struck by a ball about a quarter of an inch to the outside of the right nipple. The ball had then passed behind the sternum, fracturing it badly in its course, and escaped close to the left nipple. Double pneumonia and pericar- ditis followed, and he died. The whole contents of the thorax were found implicated in one %ast inflammation, Not being pre- sent at the post mortem examination, I did not learn bow far the pleurae or pericardium were injured (as I understood they were) primarily. When a ball fairly enters the chest, and either penetrates or traverses the lung, the danger is most imminent. These injuries, however, are not so fatal, on the whole, as similar wounds of the head or the abdomen. The younger Larrey and Meniere both record the circumstance, that the majority of the killed in the civil commotions of 1830 in Paris, succumbed from penetrating wounds of the thorax. The immediate danger will depend upon the depth of penetration, and the part implicated. If the heart or great vessels are wounded, death will in general be instanta- neous. When the lung is only superficially wounded, then the vessels which are injured must be of small calibre ; but the deep- er the ball penetrates, the larger are those encountered, and, con- sequently, the more mortal is the wound. The patient may be suffocated at once by the blood, or it may escape in such quanti- * John Bell (2nd Discourse on Wounds, p. 302) refers to a casg re- lated by Galen, in which part of the sternum was removed, the pericardium opened, and the man cured. He thus comments upen 'it—" Here, then, we have, upon that authority which has been al- ways respected, a case exceeding in the miraculous all that has ever been recorded by the patient Vander Wiel, or gathered by Schenkius, or any German commentator among them,—a man with a slow suppuration, confined matter, a carious sternum, and the heart absolutely exposed and bare." In Fleming's case we had all the unfavourable symptoms, but unfortunately not the recovery. 94 "- SURGERY OF THE CRIMEAN WAR. ty as to cause death, within a short time, by exhaustion. If the wound be at all severe, the shock is very great, and blood generally passes from both the mouth and the wound. That from the mouth is frothy, while that from the wound is darker- coloured in general. The wound beiQ£ high in the walla of tho thorax, will make the escape of blood by the orifice less in quan- tity than if it be situated low down, and such situation will ren- der the evacuation of the effused blood, or serum, more difficult afterwards. Air, as well as blood, will generally escape by the wound, and thus the presence of these two signs—blood by the mouth, and blood and air by the wound—are unequivocal proofs that the lungs have been injured, although their absence does not prove the opposite. The dangers which attend'a penetrating wound of the lung, are thus, primarily, haemorrhage and collapse, as well as those from suffocation, if the bleeding be profuse. The haemorrhage and the fainting are, by a sort of paradox, both the patient's danger and his safety. Secondarily, the danger of such wounds proceeds from inflammation and its products, the exhaustion which attends prolonged exfoliations and suppuration, together with that which arises from the organic diseases that are thereby bo apt to be engendered. A short, tickling, harrassing cough, attended by bloody expec- toration ; a cold and bedewed surface; a pale anxious face; a weak trembling pulse; palpitations of the heart; oppressed breathing, arising in the first instance, according to Hunter, from the pain occasioned by the action of the wounded lung and mus- cles, and afterwards from the inflammation and effusion—these are the usual symptoms which attend penetrating wounds of the lungs. At a later date, if the bleeding cease—a circum- stance which will be evidenced by the disappearance of the col- lapse, the return of the heat to the surface, and of strength to the pulse, as well as by the length of time which has elapsed since tho infliction of the wound—then those symptoms which result from inflammation appear. We have thus two stages or periods which demaud separate attention in our treatment—that during which there is intornal haemorrhage with collapse, and that which follows and is accompanied by reaction and inflam- matory action ; to these I might also add that of convalescence. The collapse which follows penetrating wounds of the lung, though dangerous, is yet, if not very profound or prolonged, the best guarantee for the patient's safety. To such cases the obser- vation of Ilewson is peculiarly applicable: " Languor and faint- ness being favourable to the congelation of the blood, and to the Cfmtraction of the bleeding orifices, should not be counteracted by stimulating medicines, but, on the oontrary, should bo en- couraged." With our modern notions on bleeding, it is often difficult to reconcile the necessity, which experience shows there is, for energetic depletion when reaction sets in. The majority WOUNDS OF THE FACE AND CHEST. 95 of our patients were certainly noT; subjects in which this remedy could be pushed so far as Guthrie and Hennen would appear to recommend; but I think it was very generally observed that those cases did best in which early, active, and repeated bleedings were had recourse to. It is well known, that in sieges general- ly, soldiers do not^ show their usual tolerance of bleeding, and when their health is so much undermined as it was at Sebastopol, the surgeon is often placed in a most unpleasant dilemma. That many most excellent^ recoveries were made without having re- course to the lancet is undoubtedly true ; but not a few, I fear, died from want of it. When the loss of blood by expectoration and by the wound has been very free, of course the necessity for abstracting it otherwise will be much less. The system is then far more easily reduced to that which favours the formation of the "caillot tutelaire." We must, in cases where venesection is required, be especially careful to bleed by a large orifice, and be guided by effects.* This, with perfect rest, the lowest diet, cool- ing drinks, and possibly digitalis, must form our means of managing the early stage. Any return of the oppression will bIiow the necessity for further depletion. In wounds from gun- shot, the patient should be allowed to lie in the position which he chooses; but if the wound be a stab, the position prescribed should be that which will favour the adhesion of the pleurae; and when there is effusion within the thorax, that which will allow of its escape. To determine whether the blood which flows from a wound in the thorax proceeds from a wounded intercostal or from the lung, has called forth more acumen and research than it would appear to merit. The difficulty will be greatest when a knife has been the instrument, and the wound made is very oblique. In large wounds, Sanson lays down the following means of diagnosis: 1. Whether the blood be arterial or venous; 2. By turning out with forceps the lips of the wound, and seeing whether the blood pro- ceeds from one of these lips; 3. By compressing the superior lip of the wound with the finger, i. e. pressing upon the inferior border of the upper rib, where the wounded intercostal may bo placed. He objects to the use of a roll of card introduced in the Bhape of a gutter, because whon that can be done we may be able *" Until the danger of immediate death from, haemorrhage is over," says Hennen, "we must not think of employing anything except depletion by the lancet; it, and it only, can save the life of the wounded man." " It is only by these repeated bleedings," says John Bell, "that the patient can be saved. The vascular system must be kept low in action, and so drained as to prevent the lungs from being oppressed with blood. One thing is very clear," he adds, "that if the surgeon bleed only when the cough and bleeding from tho lungs return, he never can do wrong." 96 SURGERY OF THE CRIMEAN WAR. to see the wounded vessel with the eye ; but the examination of the wounding instrument will often show whether it could pene- trate deep enough to injure the lung. Bleeding from the lung makes itself apparent by both rational and physical signs. • Some of these are common to all. haemor- rhages, external or internal, wh\le others are present in intra- thoracic effusions of whatever description. Of the rational signs, paleness of the face, coldness of the surface, a small, concentra- ted, and quick pulse, giddiness, and cyncope are those referable to the loss of blood; while the dyspnoaea,* sometimes amounting almost to suffocation, the feeling of weight in the chest, tho anx- iety, restlessness, and the decubitus on the wounded side belong to all effusions. The physical signs are also common to all effu- sions. They are—a dilated chest, little moved during respira- tion, bulged intercostal spaces, dullness on percussion, and the absence of vesicular breathing. If there be air also present, Ave will have added those signs which are peculiar to such a compli- cation, and which are recognizable by percussion and ausculta- tion. The peculiar ecchymosis described by Valentin, and which results from the escape of blood into the subcutaneous cellular tissue^seldom appears; but if it does, it is according to many a valuable, sign of haemorrhagic effusion.-^ If, then, after a gun- shot wound of the thorax, we have those signs present which would indicate the loss of blood, as well as those Vhich indicate the existence of fluid in the pleura, embarrassing the functions of the contained viscera, the diagnosis is plain. If blood escape by the external wound during respiration, or after a cough, the opinion will be strengthened that blood has been poured out, and occupies the pleural sac. The danger from haemorrhage is greatest during the first twelve hours, "and is pretty well over by the second day. A flow may however continue, in greater or less quantity, for eight or ten days, but then it is seldom to any serious amount. If the * Sabatier mentions having seen patients perish of hasmorrhagic effusion in whom the breathing was not disturbed,and who could lie in any position. f Luez remarks upon this point—"Valentin pretends that the ecdhymosis which is observed on the loins, in wounds of the thorax, is a pathognomonic symptom of effusion into the pleura, ajid that its absence is a counter-indication to paracentesis. Larrey says he constantly observed this fact, as do many other practitioners, such as Louis, David, &c. However, after the observations collected by Degranges, Chaussier, Callisen, Saucerotte, and otheis, we cannot look upon this phenomenon as a certain sign of haino-thorax; be- cause, in many circumstances where the effusion really exists, it has not been observed, and it has followed non-penetrating wounds. WOUNDS OF THE FACE AND CHEST. 97 - quantity of blood effused be small, it will probably bo absorbed ; but if it is in large quantity, and especially if air is also present, the gravity of the lesion is much augmented. So soon as all fear of a renewal of the bleeding is over, the effused blood, if in quantity, should be evacuated by operation; but, as Sanson says, it is better to be a little late than too early in taking this step. There is no question connected with wounds of the chest so difficult to 6olve, as that which has reference to the management of internal haemorrhage. The embarrassed state of the lung demands the evacuation of the fluid, and yet, if we allow it to escape, the bleeding from the lung is renewed, and death results. So it was in tho following case:— llannihan, a private in the Royal Irish regiment, was admitted into my wards in the general hospital on the 18th of June. While lying on the ground, with his head towards the enemy, he was struck above the left clavicle by a rifle ball, which traversed his lung from its summit to its base, and was found lying quite 0 superficially in the left lumbar region, from which position it was removed. The dyspnoea, on admission, was very great, and the haemoptysis most profuse. The surface was cold, and be- dewed with cold perspiration. The pulse was weak and tremu- lous, and the decubitus was on the wounded side. The removal of the'ball was followed by a tremendous gush of blood from tl.'a incision made, and the blood continued to flow in such quantity that I had to close the wound to prevent immediate dissolution. The necessity of guarding against a suddenly fatal event, was for the moment paramount to the indication' of freeing the em- barrassed lung of the effused blood; and as the haemorrhage, moreover, appeared to be active, I wished to try to check it by the pressure which would result from the blood being allowed to accumulate in the thoracic cavity. The patient was twice largely bled, and he had atsetate of lead and opium given him. These measures appeared to afford him some relief. Next day he had rallied considerably. His pulse was better, and his look was less distressed. By-the afternoon of that day, the dyspnoea be- caiie so urgent that I allowed a considerable quantity of the col- lected blood to escape. This gave him, for a time, decided relief. The severe exhaustion which, however, 60on followed this step, and the return of the dullness on percussion to its former level, Bcenied to intimate a renewal of the haemorrhage; hence I did not reopen the wound, but determined to abstain from all inter- ference till the bleeding vessel had had time to close. The patient was so completely prostrated by the haemorrhage which had evi- dently taken place internally, that I could not have recourse to auy further depletive measures. The stethoscopic examination of the chest discovered amphoric breathing over the upper part of the left lung, while over the whole surface of the right chest the respiration was harsh and loud. Dullness existed on the left side from the base of the lung up to an inch and a quarter above 5 • 98 SURGERY OF THE CRIMEAN WAR. the level of the nipple. There was suppression of urine for thirty hours after admission. This patient died on tho fifth day, without any change in his symptoms from those noted above. The left side of the thorax was found more than half full of blood, for the most part fluid. The lung was half solidified and compressed against the spine. Lymph was effused to a limited extent on its surface. The ball had traversed the lung in a direc- tion from above downwards and backwards. Its track was rng. ged and coated with lymph. The three upper and the three lower ribs were fractured. The patient's back, on the wounded side, was ecchymosed before death, and gave him much pain. This discoloration bore much resemblance to that ecchymosis de- scribed by Valentin ; only it appeared at too early a period, and was not sufficiently pronounced to accord with his description. I am not in a position to determine whether the retention of the blood in the cavity can really exert so great a pressure on the wound in the lung as to arrest the bleeding; but such was the opinion of Valentin, Larry, Sanson, and Dupuytrer. I am • disposed to think that, in such cases as the foregoing, it would be better practice to open the cavity freely by enlarging the wound, so as to allow the blood to escape freely, and thus favour the contraction of the lung and the closure of the vessel; but in Hannihan's case such a step would have been attended with much danger, from his great prostration. If the lancet be employed in such cases, it is a matter of the greatest nicety, and requires the utmost discrimination and judg- ment, to abstract exactly the quantity of blood requisite for producing the desired effect without exhausting the patient, whose system has been already so much drained by the internal haemor- rhage. Haemoptysis does not always occur in penetrating wounds of the lungs, and dyspnoea may be but slightly marked at first The following case was an example of this:—M'Kennah, private 77th regiment, was admitted into the general hospital, July 27th. When in one of the advanced trenches, a Minie ball struck him obliquely from the left side at the middle of the supraspinous fossa of the left scapula, and lodged. On admission, a couple of hours after the receipt of the wound, slight dyspnoea was the only observable symptom, and the only thing the patient himself complained of. The finger passed into the wound showed the direction of the ball to have been towards the centre of the body, but nothing was detected except some roughness along the posterior border of the s.-apula. In the evening the dyspnoea was more marked, and the pulse had increased in frequency. The decubitus was dorsal throughout. Emphysema appeared 27eJ thtrsurface of the riSht s5de of the sheet. He was largely bled. Next day the above symptoms were notably exaggerated, and dullness was added on percussion on the right side, posteri- orly and laterally. The respiration was puerile over the anterior WOUNDS OF THE CHEST. 99 superior half of the right, and over the whole of the left lung. The bleeding was repeated, digitalis ordered, and nothing allowed in the way of food but milk and cold tea. On the 29th, the dull- ness had invaded the inferior and lateral aspect of the left lung. The dyspnoea became very urgent, and was not relieved by any treatment, depletory or otherwise, and he died on the 30th. Fluid blood, seemingly the product of oozing, was found in both pleural cavities, and some air also existed on the right side. Both lungs were much diminished in volume, and floated towards tho upper part of the cavities. The ball had passed through tho second rib, near the posterior superior angle of the scapula, and perforated the apex of the left lung with a transit of one and a half inches. It had there pierced the body of the second dorsal vertebra, fracturing and partially displacing forwards its anterior half. It had then entered the right pleural cavity, traversed the apex of the right lung, struck and fractured the second rib on the right side about its centre, and finally fell spent within the pleural cavity. The lungs were gorged with'blood, and their outer and inferior surface were coated with lymph. If one lung only had been wounded, the ball and the effusion might have been both got rid of by operation; hut when both lungs were implicated, such interferences would only Jiave hastened death. The emphysema which was present in this case, was probably due to the oblique direction of the wound. It was a very rare occurrence in the chest wounds which I had an opportunity of witnessing. The inflammation which fallows gun-shot wounds of the lungs, requires the same treatment as that which is given to inflamma- tion from any other cause. When only a small part of the lung has been penetrated, then the pneumonia may be at first local- ised ; but it will soon spread if not promptly subdued. During convalescence, the great point which demands attention is to guard against all sources of relapse, as inflammation is very apt to be re-established, and if it dues reappear, the danger of its giving rise to purulent effusion is very considerable. Serous effusions often cause much annoyance in cases of wounds of the chest. According to Guthrie, such effusions take place, in general, from the third to the ninth day, and, if large, impera- tively demand early evacuation. I fear this rule was not always attended to during the" late war. It is difficult to know what is the best period of the disease to put it in practice. The strictest regimen should be maintained fur ten days or a fortnight after the infliction of a gun-shot wound of the lung. Any irregularity in diet, cr indulgence in ardent spirits during convalescence, it is most apt to cause dangerous, if not fatal relapses. Not a few were lost in th« East from such careless- ness. Opium is of much use in allaying the troublesome cough, which often continues for a long time. Iler.nm speaks of * a 100 SURGERY OF THE CRIMEAN WAR. sense of stricture and considerable pain in raising the body to on erect posture, with great anxiety on walking up an ascent," ns being frequent consequences of gun-shot Wounds of the cheat; and at another place he says, "diseases which, although we can- not, call them pulmonary consumption, agree with it in many points, particularly in cough, emaciation, debility, and hectic, are often the consequences." Veritable phthisis has, however, as is well known, been cured by the rough medication of a gun- shot wound. Wo hiid no opportunity of watching the remote results of these woui ds, as the patients passed from under our care too soon for then- development. Of wounds perforat. iig both sides of the chest, I met with four examples only. In all these the wound was inflicted by grape, and all died in a very short time. Balls are well known, occasionally, to become sacculated in tho lung. ^ This circumstance, as well as the very small amount of irritation which the presence of such a body may give rise to, was illustrated in the following case. The case was first related to me by my friend Deputy Inspector-General Gordon, C.B., and I afterwards found the particulars of the early symptoms in tho medical reports of the regiments serving in India :—A soldier of the 53rd, serving in the Punjab, received a ball on the left side of the thyroid cartilage, which coursed round the neck, entered the apex of the right lung, traversed it to near its base, and lodged. Violent dyspnoea, urgent cough, and bloody sputa fol- lowed. Ine patient, from the fear of suffocation, could not lie down for several days. These symptoms were allayed by treat' ment, and in two months the man was discharged, feeling no inconvenience from his wound. This patient died six months afterwards of a contagious fever, when the ball was found clo.-ely sacculated in the lower lobe of the lung, at the apex of which a small puckering was seen, but no trace could ba discover?! of the ball's track from the apex to its place of sacculation. The lung was free of disease. In the following case the position of the bnM was not discovered:—A soldier of the Buffs, wounded on the 8th September, received a ball on a level with, hut slightly external to, his right nipple. Profuse haemoptysis, faint- ing, great dyspnoea, oozing of blood from the wound, and the escape of air followed. He was largely bled, and his symptoms the'-cby relieved. Ten hours afterward*, a return of the diffi- culty of breathing called for further depletion, and the use of antimony.' Pneumonia followed, which implicated the lower half of the wounded lung. The treatment was "that for pneu- monia generally. The wound suppurated, and ultimately closed. When the patient left tho hospital in December, the lung acted well throughout, except for a short distance round the wound, where it was dull on percussion, and seemingly impervious to air. The vocal resonance was notably increased over the upner pare of the wounded side of the thorax. WOUNDS OF THE CnEST. 101 The direction taken bjithe ball, and its position as found after death, give interest to the following case:—At the Alma a soldier was struck by a musket ball, on the outer side of the left shoul- der. His arm was by his side at the moment he was wounded. It was observed that the ball had passed through the head of the humerus, but its ultimate position could not be ascertained. Nothing was done for the arm. The ball was. supposed to have made a clean hole through the bone. A severe attack of pleurisy followed, and on the subsidence of this, pus was found to point both below the clavicle, and in the axilla of the wounded side. Much bone came away. Pus flowed copiously by the openings which were made in the axilla, and below the clavicle. The patient be- came hectic and died. It was then found that the ball, having passed through the head of the humerus and the glenoid cavity, had entered the chest between two of the ribs, and having run forwards within the cavity, and between the walls and the pleura, had lodged in the anterior mediastinum, where it was found coated with lymph. The chest symptoms, the surgeon in charge informed me, had been very slight, and the presence of the ball had given rise to no uneasiness. If the joint, which was the main source of irritation and hectic, had been excised early, a more favourable i-esult might have followed. The four following cases are further illustrations of most severe gun-shot wounds implicating the lung:— At the Alma a soldier was struck by a ball near the centre of the left axilla. The bullet escaped on the same level as that at which it had entered, and within an inch and a half of the spine. Profuse ha3morrhagc by the wound and by the mouth followed immediately, and caused the patient to fainj. He was bled at night, as well as next morning, to relieve the dyspnoea, which was urgent. A severe attack of pneumonia followed, which, though subdued, recurred on two subsequent occasions. By December the lung had recovered, except at its base, where it was impervious to air. The respiration at the summit was ex- aggerated. There was in the hospital, at the same time, another man, whose wound and its results were exactly similar, only that the ball had entered by the right axilla in place of the left, and had escaped a very little lower than in the last case. In this case the liver escaped injury. A sergeant was struck at the Alma by a musket ball, on the right side, between the sixth and seventh ribs, close to theii angles. The ball traversed the lung, and escaped close abova the inner angle of the clavicle of the same side. The man said that, on the receipt of the wound, his mouth filled with blood, and that he fell downwind thought he was killed. Pro- fuse haemoptysis continued for some days after his admission into hospital. Ho was largely bled a few hours after being wounded, and also on the two succeeding days, when the diffi- culty of breathing, from which he suffered, became severe. 103 SURGERY OF THE CRIMEAN WAR. Tartar emetic was given him, and he Was kept exceedingly low for several days. Both wounds suppurated freely. Amphoric breathing was very evident over the upper part of the wounded lung; but there was no marked change on percussion anywhere, for a week after the receipt of the injury. He complained of Bevere pain in the injured lung during the whole period he con- tinued in hospital. Three weeks after being wounded, there was a deficiency in the respiratory murmur all over the right side, which deficiency was balanced by an increase on the left. Bron- chophony was marked nt the upper part of the right side. There was dullness now on percussion all over the right lung, but chiefly at its upper part. The expectoration was profuse and purulent. Cough severe and painful. Pulse high and irritable, His gums were sore with mercury, and blisters had been repeat- edly applied to the surface of his chest. He gradually recovered, under the influence of a generous diet; and when he went to England, about four months after being wounded, both wounds were closed, tho anterior having cicatrized first. At that period the right side of his chest was somewhat contracted and flat- tened. The respiratory murmur was fair over the upper two- thirds of the right lung, but faint towards the base. Percussion gave a normal-note, except at a small point just at the apex and at the base, where the sound was dull. A good deal of bone had been discharged by the wounds during convalescence. A French soldier had a Minie ball driven through his right chest at Inkerman. It entered an inch below the nipple, be- tween two of the ribs, and escaped behind, exactly opposite the place of its entrance, within two inches of the spine, fracturing one rib, and chipping another. Severe haemoptysis and bleeding from the wound followed. He was bled frequently, and kept very low afterwards. Most violent inflammation set in, and effusion took place into the pleural cavity. The fluid was not evacuated; but while it was being absorbed, the wound of entrance having closed, a most violent and prolonged attack of trismus seized him, which, for a couple of days, threatened to cause death, but which ultimately yielded to large doses of opium, without the spasms becoming general over the body. This patient perfectly rc^ covered, and was sent to France. A soldier of the Guards was struck at Inkerman by a rifle ball, which was fired at a short distance behind him by one of our own men. It entered below the angle of the right scapula, and escaped between the fourth and fifth ribs, chipping the upper edge of the latter. The haemoptysis was very profuse, and much blood escaped by the wounds. lie sank down exhausted, almost immediately on receipt < f the Wound, and lost consciousness shortly afterwards. He lay a considerable time, he could not say how long, before he recovered. When he was received into hospital, blood continued»to ooze from his wounds, he spat con- stantly, and his breathing was greatly impeded. He was bled WOUNDS OF THE CHEST. 103 twice during his stay in tho Crimen, and when I saw him, a month afterwards, he had in a great measure recovered. The exit wound had closed, but that of entrance had taken on a phagedenic action for some days, and was not yet healed. The lung acted well; he could lie on either side; and, to all nppear- nnce, he was in a fair'way to a complete recovery. When no adhesions are formed, by which the ball or other foreign bodies driven into the thorax are arrested, they generally are found lying on the dinphram, in the angle formed by it and the costal walls, and close to the vertebral column. The track of a ball through a lung has been occasionally found to become fistulous, becoming lined by a membrane, and con- taining curdy pus. The pulmonary tissues around these tracks becomes indurated, and they may, or may not, have an orifice to the exterior of the chest. A circumscribed abscess may exist between the ribs and the lung, or be in the lung substance itself, and communicate with this track. The perfect manner in which these collections, and the track connected with them, are closed off from the lung, and the evil which may arise from the presence of this pus, make it a question, which the facts before me do not enable me to discuss, whether, or not, it would be advisable to evacuate it by operation, seeing that our modern means of diag- nosis would permit of its detection. This evacuation could be accomplished by such a puncture through the parietes, as would insure the closure of the wound as soon as the object was ef- fected. « CHAPTER VI. GUNSHOT WOUNDS 0? THE ABDOMEN AND BLADDER. The returns of the war, after April 1st, 1855, show flesh contusions and wounds (simple and severe) of the abdomen, among the privates, as having occurred 101 times, with a fatal issue in 17 cases. There were 38 penetrating wounds with lesion of viscera, and 36 deaths in consequence; while 65 times the abdomen was perforated, and 60 deaths resulted.* Four cases of rupture of viscera without wound were fatal. The abdominal cavity, from tho want of a bony protection in front, as well as from its large surface, is very liable to severe injury in battle, and there is no cavity in the body the injuries of which are more serious, or more often fatal. The ribs protect the contents of the thorax from contusions, and wounds from pieces of shell often fail to injure either the lungs or heart; but when a projectile impinges with any force on tho abdomen, the effects are seldom limited to its walls. It is often difficult to tell what influence a certain wound will produce when it affects the abdomen. At times an accident ap- parently severe is followed by trivial consequences, while the most disastrous results may arise from an injury which shows little external indication of its severity. Contusions by round shot are among the most dangerous inju- ries to which the abdomen is exposed. The hollow or the solid viscera, as is well known, may be thus ruptured, and rapid death follow, without much external sign of 60 severe an ^accident. Every campaign furnishes examples of this. A contusion may, however, arise frcm a less ponderous missile than a round shot, * M. Legoust mentions 3 cases of penetrating wounds of the abdomen in the Dolrna Batchi hospital, all of which died. Alcock reports 19, only 1 of which recovered. Meniene mentions 14. in which the ball penetrated, 2 of them being through the side, and all died; while of 7 others, in which the ball passed through the side only recovery followed. In the Indian wars I find the record of 38 penetrating or perforating wounds of the abdomen, of whom 32 died and 6 recovered. Colles states, that in the sieges of Moultan "not one case recovered in which the abdomen was fairly shot into ami the small intestine wounded." Sedillot tells us, that in tho expedition against Constantine, they lost all those whose abdomens were penetrated by gun-shot. WOUNDS OF THE ABDOMEN AND BLADDER. 105 and the injury be not so serious. The state of tension of the wall of the abdomen at the time of the accident, appears to exer- cise no little influence on the effects produced. When a man is lying on the ground, and the muscles are completely relaxed, then the injury inflicted on the contained viscera may be very severe ; but if the muscles are in action and tense, then the force of the blow will be somewhat mitigated. At least such is the only manner in which I could explain several anomalous cases that fell under my notice. Vomiting and pain in the abdomen are the signs of injury to which contusions of the cavity generally give rise; and if no serious damage has been done, all the treatment those cases re- , quire is such as will ward off peritoneal inflammation, which may steal on very insidiously. If any internal rupture has taken place, we can do littlo to prevent a fatal issue. *- Shell wounds of the walls of the abdomen are very commonly followed by extensive sloughing, and the danger of the morbid action laying bare the intestines, or at any rate favouring their subsequent protrusion, is considerable. In one case which fell tinder my observation nearly the whole of the anterior wall of the abdomen was destroyed by the sloughing caused by a shell wound. Guthrie seems to think that a greater amount of destruction occurs in the abdominal walls, than can be accounted for by their mere injury; this loss being probably caused by their absorption. Balls often traverse the abdominal walls for a considerable distance without entering the cavity, and they do this at times by so long a transit as to describe half the cirguit of the body. Of this very many cases occurred in the Crimea. The strong aponeurosis-which protects the front of the abdomen, exercises a great influence in deflecting the ball when it has struck at all obliquely. The track which is thus made requires careful man- agement during cure to get it to close. If it be long, it is good practice to make a counter-opening at its centre, in order to pre- vent the lodgment of p eces of cloth or pus in its interior. This can, however, be necessary only when, neither by syringing nor by the introduction of an elastic bougie, we can get quit of them. Abscesses among the muscles are not uncommon, although very disagreeable complications of gun-shot injuries, and especi- ally of contusions of the abdominal walls. Sewere pain, vomit- ing, and other symptoms which may be mistaken for those of internal inflammation, may be thus set up. If the amount of inflammation caused by contusion or other injury of the abdominal wall be limited, then adhesion will take place between the parieties and the omentum or viscera, and will afford a great safeguard against the effusion of blood or'other matters, into the cavity. If, however, the paries in part slough, bo that the gut is laid bare or opened, the injury is one of great ' gravity. 106 SURGERY OF THE CRIMEA** WAR. It is sometimes very difficult to say whether a ball has perfo- rated the abdomen or not. The relative position, and even the peculiar characters of the two orifices, will not guarantee a de- cided opinion. Far less can we say, from the apparent direc- tion of the wound, that any of the viscera have been injured. It is neither allowable nor desirable that we should make such a search as will determine the question; for if the ball be not easily found, we never " amuse ourselves," as Le Dran expresses it, " by seeking for it," and the treatment ought to be such as will provide for all contingencies. In the following case, the ball appeared not only to have perforated both the abdunven and the • chest, but also the diaphragm; yet probably it ran merely under the the integuments, possibly traversing the diaphragm close to its. anterior border, and wounding none of the abdomi- nal or thoracic viscera. A ball struck a French soldier just above the crest of the ileum, and about four inches from the spine. It escaped close below the inner end of the clavicle on the same Bide. At the time he was struck this man was on his knees, as he was in the act of rising from the ground on which he had been lying. He had hiccough and considerable prostration for" three day's, and also an attack of pleurisy, all of which he had recovered from a fortnight after injury, when I first saw him. The fatality of penetrating wounds of the belly will depend much on the point of their infliction. Balls entering the liver, kidneys, or spleen, are well known to be usually mortal, although exceptional cases are not rare. Wounds of the great gut aro also always recognized as much less formidable than those which implicate the small. Thomson saw only two cases of wounds of the small gut,'after Waterloo, in the way of recovery; but Larrey reports several. Gun-shot wounds of the stomach are also exceedingly fatal. Baudens records a remarkable case of recovery, although complicated with severe head injuries. The syncope which followed the severe haemorrhage in this case lasted for ten hours, and doubtless assisted, along with the empty state of the stomach at the moment of injury, in preventing a fatal issue. The extraordinary manner in which, not only balls, but also swords and ramrods, may traverse the abdominal cavity, and yet not wound any viscus, has been often dwelt upon by military sur- geons. The escape of the viscera in the following case, which occurred in India, was most remarkable. A soldier of the 28th regiment endeavoring to commit suicide, leant ovor his muskot, and drew the trigger with his toe. The ball passed into the Ab- domen, on a level, but a little to tho left, of the umbilicus, and escaped through the centre of the crest of the left ileum behind. He died in a month. The intestines were found matted together, and large portions of them were gangrenous, but no perforation of the gut could be discovered. The surgeon, Dr. Young, adds n his report,—" This examination, however, in some particulars WOUNDS OF THE ABDOMEN AND BLADDER. 107 unsatisfactory, has at least established the fact that the intestines were not perforated by the ball; but how they escaped defies any conjecture I can form on the subject." In another case which occurred at Meanee, the ball was ascertained to have gone fairly through the abdomen, yet not to have injured any of the viscera, It is impossible, however, to be certain of such a circumstance, unless an after-death examination verify a supposition we are too apt to form. The just and perfect support afforded by the abdominal viscera to one another, and the manner.in which they fill their contain- ing cavity, supply a safeguard against effusion after wounds, which has ever been the astonishment and admiration of obser- vers. The smaller and less torn the wound in the gut is, the more likely is this favourable result to occur. Littre's celebrated case of the madman, has ever served as the type of such wonder- ful acts of " conservative effort." The pressure, too, favours that adhesion between the viscera which is so potent a preservative against evil. The following case, reported by Dr. Taylor when surgeon of the 80th, affords an example of a gun-shot wound injuring the smaller gut, while at the same time it shows the effects of such a wjmnd, and also the state of the parts'a considerable period after the infliction of the injury. It is ttken from the Records of the Medical Department:— Private Paul Massy was shot through the abdomen at Feroze- Bhali. Very slight symptoms followed", so that it was supposed the ball had coursed round the cavity, and had not penetrated. He mentioned having passed some blood in his stools after re- ceiving his wound. The ball had escaped near the spine, having entered in front. He recovered slowly, but perfectly, except that ho continued subject to bowel complaint, and finally died of spas- modic cholera, a considerable time (exact period not specified) after being wounded. For a year before death he was almost constantly under treatment for dysentery. When examined after deat'i the following was the condition found. I give it in Dr. Taylor's own words. " Cicatrix of a gun-shot wound in the left linea semilunaris, about four inches above the crest of ileum; and on the same plane posteriorly, another cicatrix an inch to the- left of the spine. Omentum firmly adherent to the internal sur- face of anterior cicatrix, and gathered into a fold or knot at that part. The intestines were neither there nor elsewhere morbidly ndherent; but the fold of intestine immediately opposite to the cicatrix presented a line of contraction, as if a ligature had been passed tightly round the gut. The fold of intestine immediately above presented the same appearance, and on the first fold, four inches from the first-noticed contraction, and in a line below the umbilious, was another similar appearance. These three con. traded places were of a darker hue and moro vascular, than other portions of the small intestine; having, however, through- 108 SURGERY OF THE CRIMEAN WAR. out an arborescent vascu'arity, and being in the sodden state con- stantly seen in sudden cases of spasmoJic cholera. The mucous membrane of the small intestine was generally of a pale pink colour. No ulceration of the large gut. Upper part of the co- lon attenuated, and contracted in situ. Rectum thickened." When a ball merely enters the gut, it may be thrown out by stool. Such a case occurred in the 19th regiment in the Crimea, and is reported by the surgeon in the Lancet, vol. 1, 1855. If a vascular viscus be wounded, or a large blood vessel open- ed, then haemorrhage may-take place within the abdomen to a very serious arid fatal extent. The mutual pressure of the vis- cera does much to prevent bleeding from the former source, and the lax attachment of the arteries in general enables them to escape. If blood be poured out suddenly and in quantity, it will partly escape by the wound, and partly collect at the must de- pendent part of the abdomen, or in the pelvis. Baudens men- tions as a certain sign of a quantity of blood being collected in the pelvis, the incessant and insupportable desire to micturato caused by the pressure on the bladder, and which is set up al- though there is no urine in the viscus. Besides the immediate danger which proceeds from the loss of blood, such effusion** if in quantity, fail to become absorbed, decompose, set up inflam- mation, and cause death. The quantity must be small which will insure its absorption. It is therefore a matter of some im- portance to evacuate such accumulations by reopening the wound, rather than.to attempt its removal by operation afterwards The symptoms of penetrating wounds of the abdomen are those which belong to the accident proper, and those which result from its consequences. The collapse is generally very severe, and this is the case, too, in many instances in which the injury appears at first very superficial and trivial. While, in general, this shock and alarm are indicative of deep and serious lesion, they are often excited by no apparently adequate" cause. If some haemorr- hage, or the effusion of any of the secretions, as bile, or the con- tents of any of the hollow viscera follow the injury, then the collapse will not only be severe, but will coutinue. The subsequent symptoms of these wounds will partake of two characters—those common to all inflammations of the abdoine'ri, and those arising from, the inflammation of the particular organ injured. The inflammation which is so certain to occur in the" peritoneum requires very careful watching, as it often sets in very slowly, and deceptively. "The consciousness of imperfec- tion induced in the cavity," of which Hunter speaks, makes it peculiarly apt to take on an inflammatory action. The position and direction of the wound, and the concurrent symptoms referable to the lesion of special organs, will lead us to surmise the injury of this or that viscus. The persistent vom- iting, the ejection of blood by the mouth or by stoof, or with the urine, the escape of special secretions, as bile by the wound, the WOUNDS OF THE ABDOMEN AND BLADDER. 109 peculiar pain or sensation experienced by the patient, will be our chief indications in determining the part hurt.* The treatment of simple, non-penetrating wounds requires but little notice,—the prevention or subdual of inflammation, and the favouring by position of that conservative adhesion between the viscera and the parietes which is desirable if sloughing should set in, so as to endanger the opening of tho cavity. The management of penetrating wounds is not much more difficult, but the results are very much less satisfactory- When the penetration has been occasioned by a ball, it is not often that we have an opportunity of verifying the fact of viseral lesion. No attempt should be made to follow the ball. The wound should be lightly covered, the patient placed in such a position as will relax the abdominal walls, fomentations applied by. means of the lightest possible material, opium freely given by the mouth ; and, if inflammation set in, then leeches and even general blood-letting may be had recourse to. "All wounds that enter tho belly," says Hunter, "which have injured some viscus, are to be treated according to the nature of the wounded part, with its complications, which will be many ; because the belly contains more parts cf very dissimilar uses than any other cavity of the body, each of which will produce symptoms peculiar to itself and the nature of the wound." " It cannot be too frequently repeated," says Dr. John Thomson, " that copious blood-letting, and the use of the anti-phlogistic regimen in all its parts, are the best auxiliaries which the sur- geon can employ in the case of all injuries of the visera, con- tained within the cavity of the abdomen." With us in the East the state of our patients necessitated a much more cautious use of the lancet in these and in .all other injuries, than is common. Opium, however, was the chief reliance in these leVions, as it al- layed that pain aud anxiety which might, without it, have been interpreted into a call for depletion. The most extreme .absti- nence from food is certainly one of the m >st important points in treating penetrating wounds of tne abdomen. Purgatives by the mouth will do harm only, but clysters, especially of warm oil, are especially useful and agreeable to the.patient. • Hunter says of the blood passed by stool:—" If it is from a high part of an intestine, it will be mixed with faeces, and of a dark colour; if low as the colon, the blood will be less mixed and give the tinge of blood;" and of the character of the feeling, he adds— lithe pain or sensation will be more or less acute according to the intestine' wounded ; more of the sickly pain the higher the intes- tine, and more of the acute, the lower." It wOuld be a matter of some moment that we could rely on this sign. We can seldom, however, distinguish the character of the pain from the patient's statement, and it does not always ailbrd us a true guide when it i-j recognized. 110 SURGERY OF THE CRIMEAN WAR. Few cases occur in military practice which demand the use of the suture to the intestine. Such cases are generally fatal. To those in which its employment is notdistinctly indicated, Hun- ter's remark particularly applies :—" I should suppose the very best piwctice would be to be quiet, and do nothing except bleed- ing, which, in cases of wounded intestine, is seldom neces- sary." Early protrusion of the gut is rare, unless the wound has been occasioned by a large ball, as a grape-shot. Its careful return is, of course, the rule of practice when it does occur. Guthrie has shown the propriety of leaving protruded omentum to act as a plug in the wound. It is in wounds of the abdomen that the treatment by " de- bridement" retains its last footing. The fear of Singulation by the strong fasciae, or between the muscles, is assigned as the claim it has to adoption in these wounds. But experience, whilo it has overthrown this cause of anxiety, has shown that a posi- tive evil is occasioned by the practice, in so far as that the ab- dominal walls are weakened by it, and hernia the moro apt to ensue. This 6tep then is abandoned here, as in all other regions, unless an absolute necessity arise for its adoption. In the case of narrow wounds through the deep muscles of the .back, by which faffces ooze, but cannot get a free escape, in similar wounds; penetrating the bladder, or in cases in which a large amount of blood has been effused into the abdomen, it may be necessary to enlarge the wound, in order .to prevent ulterior consequences oft more gravity than those which can follow from the step itself. If a.false anus result from a penetrating wound by gun-shot, the cure will in most cases take place in time spontaneously. Of this I observed, with much interest, two cases at Constantinople, both of which" very quickly got well. A plastic operation at a late date will probably supply what is deficient in the effort of nature. Where the destruction of soft parts has been considerable, the danger of ventral protrusion will require attention during after- life, and no little trouble is often caused by the ir-regular action of the viscera, by pains which either wander throughout the cav- ity, or localise themselves at the point wounded. These uneasy sensations are increased by any distension, such as that which follows a full meal, and they continue to distress the patient du- ring digestion. Dupuytren dwells on the effects of that chronio inflammation which may bo set up by a contusion of the gut, and which, he says, may bring about a stricture of the intestinal canal, or its cancerous degeneration. I had fewer cases of penetrating wounds of the abdomen un- der my notice in the East, than of almost any other serious inju- ry. The following arc given as among tho most interesting of th >se of which I have retained notes : Cousins, a private in the 77th foot, aged 18, was admitted into WOUNDS OF THE ABDOMEN AND BLADDER. Ill the general hospital, under Mr. Rooke, on the 8th of June. When standing in one of the advanced trenches sideways to the enemy, his right arm being stretched out in front of his hip, he was struck by a round shot or large piece of shell, which com- pletely smashed his right forearm, and fractured the ileum of the same side, causing at the same time a lacerated wound of the right iliac region about 5 inches long by 3 broad. The wall of the abdomen, including the peritoneum, was destroyed to the extent mentioned, and a coil of intestine was laid bare. No pro- trusion took place, nor was the gut seemingly injured. Besides the fracture and destruction of the crest of the ileum, the ante- rior superior spinous process of that bone was quite detached, and the grea'. trochanter was also fractured. The log on the wounded side was shortened very considerably, and the foot was everted. As from the extent of tho injury sustained and the collapse present, it was supposed that this patient would die shortly after admission, nothing was done for him beyond sim- ply dressing his wounds and giving him stimulants in small quantities. Next day, however, he had so far rallied that some hopes were entertained for him, but it was not till the second day that he had sufficiently improved to allow of his arm being amputated. This was of course done under chloroform, other- wise it is questionable whether the operation could have been performed at all, the patient was so much depressed. He had at this time no abdominal uneasiness, and his bladder acted free- ly. By the attentive administration of mild nourishment and opiates, this patient_gradually improved. No tenderness or other untoward symptom appeared in the abdomen. The wounds as- sumed a sloughy look for some days, and deep cellular inflam- mation in the upper part of the thigh made incisions necessary. On the fifth day, his bowels were for the first time moved by the aid of warm-water enemata. At this time the wounds were granulating kindly, and the stump was healing well. The coil of intestine was still visible at that date. The ala of the ile\im, which had been laid bare, granulated over, but most of the crest became loose, and was removed at different times. The bowels came to act naturally, and without any stimulation, and by the end of July the wound on the abdomen had completely healed by granulation. The femur, if fractured (and of this there was every symptom, though the state of the pelvis prevented a care- ful examination being made,) became consolidated, but remained two inches shorter than the other. The simplest dressings, and almost no internal treatment, were followed throughout the pro- gress of tho case. This patient had never a bad symptom, but made a most excellent recovery ; and when he went to England in September, all his wounds, had healed with the exception of two small sinuses,, leading to dead bone, on either side of the great trochanter. Below Poupart's ligament, and external to tho emoral artery, a hard mass was traceable»by the touch, which 112 SURGERY OF THE CRIMEAN WAR. appeared to be some part of the pelvis driven down into that sit- uation. It did not give him any annoyance. The limb, though shortened, was fully moveable at the hip-joint, without causing pain, and he could raise his knee, but not his heel, from the bed. The shape of the hip was destroyed, the projection of the crest of the ileum gone, but that of the great trochanter was unnatu- rally increased. O'Neil, prfvate in the 38th regiment, was admitted, under my charge, into the general hospital in June. A ball entered his left lumbar region, about three inches from the spino, as he was lying on the ground in one of tho advanced trenches, with his feet towards the enemy's works. The ball lodged. The finger went deeply inwards and somewhat upwards, but detected noth- ing of the ball, the situation of which could by no means bo made out. In the evening, his abdomen became a little tender, his pulse hard, and his face flushed. He was once bled, opium administered freely, and a fomentation applied to the belly. Next day the uneasiness had gone, and for eight days there was no return of it whatever. His alvine evacuations were, in the meantime, regulated by the use of mild clysters. No blood ap- peared by stool. The wound suppurated healthily. He was kept on very mild and easily-digested diet. On the eighth day scvero pain suddenly set up in the left iliac region. This pain was in- creased by pressure, but was very limited in its extent. He vom- ited frequently, and his pulse rose to 110 per minute. His bow- els had acted freely the day before. His tongue was dry and furred. He had a dozen leeches and repeated fomentations ap- plied to the abdomen. Dover's powder, in doses of gr. x., waa ordered every second hour. Next day the pain had quite left, and all treatment was stopped. His bowels did not act without the use of a clyster. He got plenty of mild nourishment, and, after a time, cod-liver oil. Though without any uneasiness or symptom of ailment, he became much emaciated, but ultimately rallied, and made a good recovery, the position of the ball never having been discovered, though the direction and depth of the wound would appear to favour the view that it had penetrate^d the cavity. I saw a patient in one of %the French hospitals at Constantino- ple whose abdomen had been traversed from behind, forwards, by a ball at Inkerman. The bullet h.ad entered near the spine of the last dorsal vertebra, and had escaped near to, but slightly to the left of the umbilicus. The gut protruded for some days at the anterior wound, but did not appear to be injured, nt least no intestinal secretion showed itself at either orifice. Hardly any bad sympton seemed to have followed. The gut was re- turned, the man kept low, and opium freely administered. He made a most excellent recovery. In another patient in the same hospital, a wound of exactly the same description had been in- WOUNDS OF THE ABDOMEN AND BLADDER. 113 flirted. The same symptoms and result followed, except that the gut did not protrude, and that recovery was slower. The following was a very remarkable case, which, though not strictly a wound of the abdomen, I mention here as I do not in- tend to refer to gun-shot wounds of the rectum. I saw the pa- tient at Scutari, towards the end of 1854, under the immediate charge of Mr. Price, now assistant-surgeon of the 14th regi- ment. A ball entered the front of a soldier's left thigh, three inches above the patella, as he was mounting the heights at Alma, and passed upwards deep among the muscles of the thigh. It then turned round the limb, traversed the muscles of the left hip, crossed the perineum deeply, and escaped on the right hip, having passed through the rectum some way above tbe anus. The wound of exit closed, and for several days before death fasces passed by the wound above the knee. Sloughing and irri- tative fever set in, and he sank rapidly. To prevent the infiltration of faecal matter in these cases, Lar- rey has recommended the use of a tube in the rectum. The bladder has been wounded by a gunshot several times during the past war, but the returns fail to tell us how often. Balls at times pass through the pelvis, and yet spare the con- tents.* Thus, in one case, of which I have notes, it passed in by one sacro-ischiatic notch, and out by the other, without doing more mischief than contusing tho rectum. When the bones of the pelvis are broken, the injury is very serious, from the.ir deep position, neighbourhood to important vessels, and thick covering. Stromeyer has called attention to the great liability there is to pyooinui af^er such injuries. If the ball passes through the peri- toneum, then the risk of violent inflammation is so great as to render the wound generally fatal. The bladder may be wounded in many directions, but the pas- sage of the ball in an oblique line from above downwards, and to either side, seems the most common course for it to take. Oc- casionally its superior fundus is opened by a ball passing across the abdomen from side to side, close above the symphysis pubis. The gravity of the wound will depend mainly on whether the peritoneum has been injured or not. If it has not been opened, then the prognosis will, in some measure, ha\ig upon the empty or fnli condition of the viscus at the moment of penetration. If the direction of the wound permit of the infiltration of urine into the peritoneum, then the fatal issue will not be long delayed. These are the case3 whose hopeless nature probably gave rise to * In the case of a man wounded at Chillianwallah, a six-pound grape shot passed through the pelvis, and yet he survived four days. 114 " SURGERY OF THE CRIMEAN WAR. the oft-quo'.ed Hippocratic nxiorti, " cui pcrsecta vesica lcthale ;" as gun-shot wounds, at any rate, implicating those parts of the viscus which are uncovered by serous membrane, arc by no means so mortal as they were so long supposed. Dr. John Thom- son saw in Belgium alone, fourteen cases in a fair way of re- covery. A ball may lodge either in the neighbourhood of the bladder" or entering its cavity, remain there. This latter result will he most apt to occur when the bladder is full of urine, or the ball much spent at the moment of contact. In rare cases a ball, when very small, has been passed with the urine, and it has been known to escape by the formation and opening of an abscess in tho perineum. T4io urine may escape by the wound at once, or at a later pe- riod when the eschar separates from the wound; or it may not escape at all. It is seldom, however, that it fails to pass in some quan- tity at the time of injury. The swelling which takes place in the lips of the wound prevents in a great measure the flow of tho secretion by the opening; but it is by no means always sufficient to do so, as we would be led to suppose from Larrey's statement. The urine may, and does at times escape by both wounds if the ball has passed out; but from the greater amount of bruising and swelling which takes place at that of entrance, it may fail to ap- pear there, even although it be the more dependent, and flow only from the wound of exit. The early passing and retaining of an elastic catheter is a most important part of the treatment of these cases, as it prevents the urine, in traversing the canal of the wound, from becoming infiltrated among the divided tissues. Larrey, recognizing the existence of this danger only'at the pe- riod of separation of the eschars, did not employ a catheter early, but was particular in its use at the period when he thought the accident referred to was most apt to occur. Moreover, the fact that the slough is by no means the barrier to infiltration which he supposed it to be, is now well recognized, as well as that the exact period when its- separation is to be looked for, we know, cannot be relied on. The irritation and straining which the un- cvacuated urine occasions, may prematurely force off the slough, and allow the urine to become effused, and so the mischief may be done before we are ready to combat it. Unless the woundjm- plicate the neck of the bladder, the presence of a gum catheter will create but little irritation, and should be enjoined from the moment Of injury. The catheter had best be retained till the urine begins to flow by its side, as the formation of abscesses with their disagreeable and dangerous consequences are thus more safely guarded against. Larrey, with the object of obviating infiltration and venous engorgement, had recourse to scarifications, so as to enlarge th* WOUNDS OF THE ABDOMEN AND BLADDER. 115 wound, and prevent all retention of secretion in its track. This step will, however, be perfectly uncalled for, if the catheter be re- tained from an early period. Rest, low diet, mucilaginous drinks, enemata, it may be leeches, and fomentations, or hip baths, will comprise the rest of the treatment in the majority of cases. The employment of morphia suppositories will also be found, u/ider certain circumstances, most useful. If any urine does escape into the tissues, its early evacuation will of course be neces- sary. The posterior or lower wound commonly closes before the an- terior; but neither ought to remain long open if the catheter be made to remove the urine so soon as it enters the bladder. If the part through which the ball has passed be deep, the external orifice of the wound may close before the rest of the track—a re- sult which should be avoided. The position of the bladder, its depth from the surface, it size internally, the want of correspondence which takes plate between the external wound and that in its walls, from their contraction after the passage of the ball, make the extraction of a ball by the wound a matter of impossibility, without such an enlargement of the orifice as would be injurious. If th,e ball remains in the bladder, it becomes a matter of mo- ment to remove it. Balls, pieces of cloth or bone so introduced, form the nucleus of calculi; so that the sooner they are got quit of the better, provided the immediate irritation and inflammation caused by the wound have subsided. Many cases are now on re- cprd in which the bladder has been opened, and calculi, having balls as their nuclei, have been removed. Larrey operated suc- cessfully on the fourth day after the introduction of the ball, and mentions a case in which Langenbec succeeded in removing a similar body ten years after its introduction into the bladder. Morand operated twice. Deuiarquay mentions a case in which the nucleus was a piece, of shell. Baudens successfully removed the ball by an incision above the pubis; Guthrie by the lateral ope- ration. Hutin mentions two cases in which a ball or foreign body was removed by lateral incision, one after thirty-two years', and the other after nineteen years' residence in the bladder. In one of these cases tltree calculi were removed, having pieces of cloth as their nuclei. Besides these, Mr. Dixon, in the 33rd vol- ume of the JUedico-Chirurgical Transactions has given the par- ticular* of ten other cases in which balls were successfully re- moved, and three in which the attempt failed. Nearly all of these patients were operated on years after being wounded. In the Medical Examiner for 1855 a case is recorded in which a large ball, driven into the bladder, was not found till two years after, < n the death of the patient. It formed tho centre of a large calculus concretion. The following case I find detailed in the Report from the sani- HG SURGERY OF THE CRIMEAN WAR. tary depot at Lapdour for 1849-50.* Private West was wounded on the hip by a grape shot at Chillianwallah. The ball was lost, and the wound healed kindly in six weeks. A day or two after being wounded, he experienced a scalding sensation in the urethra on micturating, and he showed marks of a urethral dis- charge on his linen, which he thought was a return of an old gonorrhoea. He was treated under this idea fur a time, the symp- toms of inflammation in the bladder being ascribed to the gonor- rhoea. The attacks of cystitis became so severe as to cause his bladder to be examined, when a hard substance was discovered. The introduction of the instrument gave great pain, and it was only on the second trial that a foreign body was detected. IJy the lateral operation a grape shot was found and extracted, "slightly incrusted with a sandy deposit." He recovered per- fectly. No bone was injured by the ball. '* After the operation the patient remembered that he used to pass blood and pus in his faeces after*he was wounded. Hence it is probable that the ball entered by the sciatic notch, and traversed the rectum, entering the bladder at its back part." The following is a fair example of a penetrating wound of the bladder:— Griffith, private 57th regiment, was'admitted into the general hospital in the summer of 1855. A ball h^d entered his left hip, close to the tuber ischii, and escaped on the abdomen, two inches above the symphysis, a little to the light of the middle line. Urine escaped by the anterior opening. A catheter was passed into the bladder and retained there. He had no bad symptoms of any kind for twelve days. His urine passed by the catheter, and also by the opening on the abdomen. His pulse remained quiet, and his abdomen without uneasiness. His general health was unimpaired, and his bowels acted regularly. The posterior wound, through which urine never passed, closed rapidly. On the twelfth day, he had severe pain in the abdomen, which was, however, relieved by a dose of opium, and he never afterwards had a bad symptom or uneasy feeling, except the irritation oc- casioned by the urine flowing on the abdomen, which could not be altogether prevented. His urine was loaded with mucus and pus during the period of cure, and he passed several small pieces of bone, both by the urethra and by the abdominal wound. At the end of six weeks he could retain his urine, and pass it at pleasure by the natural passage, in a full stream. For a month he had been unable to prevent his urine flowing constantly away. In about two mouths from the period of his admission the wound * Unpublished Records of Medical Department. This case is re- ferred to by Guthrie, and has been recorded by Mr. MPherson, in connection with Mr. Dixon's paper, but with some variation from the account given in the text. WOUNDS OF THE ABDOMEN AND BLADDER. 117 on the abdomen was completely closed by the use of nitrate of silver. His strength, which had somewhat failed, was at that time quite restored, and he was walking about the ward conva- lescent. At this period he passed from under my notice; but I learned that the wound on the abdomen had reopened, and that he could pass his urine, without any pain, through thia opening, in a continuous stream, but that ultimately, before he went to England, it had permanently closed. The following case is curious, as showing how large a body may descend into the pelvis, and yet very slightly injure the vis- cera. A soldier at the Alma was wounded by a piece of shell, which struck him over the symphysis pubis, and desceffding into the pelvis, was lost. No bad symptom whatever supervened, and he made a rapid recovery. The surgeon in charge of the case thought that the missile lay impacted deep in the pelvis, behind the pubes, but this he could not satisfactorily determine. Hero the bladder escaped most miraculously. The injury was much mbre severe, but the result little less fortunate, in the following case. A French soldier of the line was struck at the Alma by a piece of shell, above the symphysis pubis, which fractured the bones, passed downward, and was removed in the perineum from the side of the urethra. The rectum and urethra were both lacerated. Deep abscesses forme*, the patient's strength gave way, but no a,cute attack of inflammation seized any of the viscera. A communication was established between the bladder and rectum, and between the bladder and the abdominal wall, so that gas and small pieces of faeces escaped at times on the abdomen. Blood frequently passed by the urethra. The last time I saw this man was in January, 1855, when he was recovering rapidly. In tho next case the missile penetrated the pelvis from below, and it is interesting chiefly, from the manner in which the peritoneum escaped. A French artilleryman was wounded nt the battle of the Alma by a piece of .'hell, which struck him on the perineum, and penetrated between the rectum and blad- der, establishing n fistulous communication between these parts. The peritoneum was not opened. No bad symptom followed, but when he was sent liome he was dying of phthisis. There is a case related in one of the Indian reports, which il- lustrates in a curious way the severe injury which the perineum may undergo. A soldier of the 14th light dragoons had the pommel of his saddlo struck by a round shot at Gocjerat. The ball passed under and betwecn'him and his horse, which escaped injury. The rami of the ischium and pubes_ were fractured on the left side, the perineum extensively lacerated, but the scrotum was only slightly abraded, and the urethra was uninjured. He had much pain afterwards in passing his urine; the soft parts of the prrineum sloughed, and his testicles atrophied; but other- wise he made a good recovery. CHAPTER VII. COMPOUND FRiCTURES OF THE EXTREMITIES, GUN-SHOT INJURIES OF THE HAND AND FOOT. In the returns of the late war, from April 1st, 1855, 2198 cases of gun-shot wounds of" the lower extremities appear among the men, and 166* deaths therefrom. Of these, 1628 cases and 55 deaths were mere flesh wounds, and 43 cases and 2 deaths, wounds with contusion and partial fracture of long bones; 23 cases and 1 death, simple fracture of long bones by contusion of round shot; 1"74 cases and 64 deaths from compound fracture of the femur; 66 cases and 9 deaths from the same injury of the tibia or fibula alone ; 144 cases and 27 deaths from compound fractnro of both bones of the leg; 88 case.s and 7 deaths from perforating or penetrating wounds of the tarsus. Besides those who died directly from the injury, 96 cases of compound fracture of the femur, and 91 jcases of compound fracture of both bones of the leg were submitted to amputation. There were 1237 cases and 8 deaths from flesh wounds of the up- per extremity ; 102 cases and 12 deaths from contusion and par- tial fracture of the long bones (including the clavicle and senpu- la); 27 cases and 2 deaths from round shot simple fractures; 169 cases, 15 deaths, and 104 submitted to amputation, from com- pound fracture of the humerus; 66 cases, 2 deaths, and 41 am- putations from compound fracture of the bones of the forearm, In 113 cases the structures of the carpus were penetrated or per- forated, and 48 of these cases were subjected to amputation. Of all the severe injuries received in "battle, none are of more frequent occurrence or of more serious consequence than com- pound fractures. They cause peculiar anxiety to the Burgeon, from the manner in which their extent and gravity are so often masked, and from the uncertainty-which still prevails as to many points in their treatment. This ambiguity as to their manage- ment arises in a great measure from the many varying causes connected with the state of health of tho patient, and the means at h^nd for his treatments-circumstances which fluctuate wifh every campaign. In the Crimea, these injuries were peculiarly embarrassing and extraordinarily fatal. In the management of no accidents was so much expected from modern improvements, and by none were we so much disappointed in the results. It was'confidently hoped, that in very many of those cases which, in the old wars, would have been condemned to amputation, the limb would now be preserved, either by the exercise of greater care in the treat- COMPOUND FRACTURE OP THE EXTREMITIES. 119 ment, or by having recourse to some of the modern expedients by which limbs are so often saved at home. But, unfortunately, a sad experience only confirmed the hopeless nature of compound fractures of the thigh by gun-shot, and their very uncertain and dangerous character when the leg vr arm were implicated. In the following remarks on compound fracture, I propose to refer chiefly to those cases in which the femur was broken, and I will notice afterwards similar injuries of the leg and arm. It can hardly be doubted, that the great striving after conser- vatism which influenced all the surgeons of our army, was one main cause of that mortality which attended these injuries. Wo were not prepared to believe how hopeless they were, till the unwelcome truth was forced upon us by an ever-recurring expe- rience. We were disposed to judge of compound fractures by gun-shot as we would of accidents, similar at least in name, seen in civil life. Full of the, promise of the schools, we would not admit that any injury apparently so slight could withstand the assiduities of a wise conservatism. In trying, however, to save limbs we lost many lives, thus fulfilling the prophecy of one of the greatest surgeons. Cases of promising appearance were re- served for the trial—the very cases, in fact, which would have made the best recoveries ft" operated upon early, and tho inevita- ble amputation was delayed till the patient's constitution had be- come so depressed as to be beyond reaction. Two circumstances seem to have had chiefly to do with the irreparable^character and mortality of compound fractures of the thigh in the Crimea—first, the state of health of the men when wounded ;*and, secondly, the effect on bono of the new kind of ball with which most of these injuries were inflicted. As to the state of health of our patients, it was not merely that they were in so a/iaemic a condition that suppuration and irritation quickly prostrated them ; nor was it that their stamina and " pluck" had bee"h destroyed by hardship and suffering ; nor that the means of treating them in front, during the early period of the war, were totally wanting ; but the chief cause of the re- luctance shown by nature to repair the osseous breach was the Bcurvy-poison which held command in their systems. This it was which mainly opposed recovery. Callus was not thrown out at all; or if it was, it refused to consolidate. I myself examined the limbs of a large number of men who died at Scutari during the early part of the war, and in not a single instance almost did I observe the slightest attempts at repair ; but, on the contra- ry, invariably found a large sloughing chamber filled with dead and detached fragments of bone, shreds of sloughing muscle and destroyed tissue into which the black and lifeless bones projected their irregular extremities, and across which, lying in every di- rection, but seldom in the axis of the limb, were dead and de- tached sequestra, the " fracture-splinters" of the accident. The depressed condition of body to which the hardships of the 120 SURCERY OF THE CRIMEAN WAR. war had reduced the men, made a severe.compound fracture of the femur synonymous with death ; so that wo might with per- fect appropriateness use tho words of Ravanton—" I exhausted many times the resources of'art without success,—incisions, re- moval of the fragments, early bleedings of sufficient magnitude, sparo diet, dressings, position, infinite care, nothing could pro- tect them against an inevitable death." Most of our patients, as I before remarked, had either suffered from dysentery or were on tlu vergo of falling into that disease. The vast majority of them hart" ulcerated intestines, and were thus in a condition of health which did not bear disease. When men in this state re- ceived a severe compound fracture, and their constitutions were taxed to repair the injury, there was no reserved fund on which to draw. They had been, living up to their income of health, and so utter failure was the sure result of increased expenditure. If when injured they had beeu taken into the ward of a London hospital, I doubt whether they would in most cases have ended more fortunately, cither by preserving the limb or by amputa- tion ; how much less, then, when they had to undergo treatment in a camp ! Many of our patients looked very well at first—appeared, per- haps, strong enough, and expressed such a confident pope in the result as almost to deceive their surgeon. The injury might not appear very severe; the bono was undoubtedly broken, but it might not be much comminuted ; and thus we flatterod ourselves, and began a trial hopefully which always ended in,disappoint- mont. The golden opportunity was allowed to pass,_and so we entered on a road whidi led to death, whether through" the portal of amputation or any other. The struggle soon began. Suppu- ration set in. The disease which lurked in " Ulood' and bono" . showed itself. Diarrhoea appeared and.would not cease. The patient's stomach refused the only food which could be procured. He got emaciated, weak, and irritable. A suspicion was awaken- ed that the bone had been more severely injured than was atfirst supposed. Things went on from bad to worse. Hectic claimed its share of the waning strength ; and whether we operated late or not, the great regret remained that it was not done at first, ai the invariable result demonstrated the uselessness of any other proceeding. During the greater part of the siege, the means of treating these accidents, whether as regards food, beddiYig, clothes, or shelter, did not exist in camp ; and to transfer them to the rear only made the fatal result the more certain, from the pyoemic poisoning which was sure to be set up by tho transport. Thus then, it came to be, that up to the period when things were im- proved in the camp hospitals and in the transport service, recov- ery from a compound fracture of the thigh was impossible, or nearly so, and that the best hope lay in an early amputation. The only exception to this I will afterwards allude to. • COMPOUND FRACTURE OF THE EXTREMITIES. 121 N,ow, while it may with seeming truth be said, that as most of these circumstances were peculiar to the" Crimean war, the principles dcdue&le from them are not of universal application; still many of them are inseparably cojinected with warfare. It is essential to the successful treatment of compound frac- tures, that the patient be supplied with suitable food, that his broken limb should be retained for a certain time immovablyfix- ed in a proper apparatus, and that it Jje carefully and regularly dressed. But how can these things be guaranteed in war ? In a siege they ought to be more feasible than in any other^nd of campaign ; but how was it with us ? Besides the privations which most armies undergo, there is the inevitable shifting of its position, and of the wounded, unless the plan Jjlsmarch tells us they adopted in Ilolstcin be followed,-and the patients left to fall into the hands of the enemy in order to obviate the necessity of transport; but I fear there are few medical services which could afford to do as he proposes, viz., leave a certain number of their body to be taken prisonejjs, iri order to secure the unremitting and careful treatment ofthe cases.* *, So much ^r the health of our men; let me now refertto the second caus^fchich, I believe, rendered our fractures so unman- ageable. TWre pannot be a doubt*£hat the old round ball, if fired at a cerlain fcange, comminuted #bne, but it is equally cer- tain that at nilonger or shorter distance, it frequently failed to do so. When wed a^rew hundred yards off, it had hardly force to enter the bffl^ but might be diverted, as it has been, by the point of thej|jPs4 If it did enter, and impinge upon bone, it might only djnt u, as may be seen -by an example in the Musee Dupuytren, in IJaris ; or it might groove ic merely, or-penetoat- ing the substiuegflof the bone, it might remain at rest without splitting it, awcawRe verified in ant-museum of a military•h'Ol8' pital. If fired again at close range, the round ball might go through a bone,«i5king a bore as clean and sharp as if formed-T. by a punch. Ofj^niis fact many illustrations can be seen in sur- * gical museums. Now, so far as my observation goes, none of these results follow the stroke of a heavy conical ball, such as that used by the Russians, at whatever .range it is fired. It never rests in a4>one, channels, or perforates its substance, with- out splitting it, like a wedge ; nor does i't ever Come to mark a --------^1------------------------ * "Thus we foresee," says John Bell, "an argument of necessity, as well as of choice, and that limbs which in happier circumstances might have been preserved, must often, in a flying army or in a dangerous camp, be cut off. It is less dreadful to he. dragged along with a neat amputated stump, than with a swollen and fractured limb, where the arteries are in constant danger from the splintered bones ; and where, by the least rude touch of a splinter against some great arteiy, the patient in a very moment loses his life." G 122 SURGERY OF THE CRIMEAN AVAR. bone with any touch more gentle than what occasions its utter destruction. In the Crimea we had ninny opportunities of ob- serving the action of both kinds of ball, and So far as I could judge, their effects were so dissimilar, as almost to justify a clas- sification of injuries founded on the kind of ball giving rise to them.* The longitudinal splitting of the bone is so dcxtrously an^ extensively accomplished by these balls that, while but n small opening may lead to the seat of fracture, the whole shaft may be rent from end to end. I have repeatedly seen the greater part of the femur so split. Stromeyer has shown that this longi- tudinal splitting seldom transgressed the line of the epiphysis, an observation which I can most decidedly confirm ; for though the injury has at times been sufficiently severe to implicate both, yet the rule has been just as he says. Gun-shot fractures of the long bones of the extremities have always been considered dangerous, chiefly on account of the shock, the comminution of bone, and the fact, that the wound leading to it is of such a character that it can heal only by sup- puration, and cannot be so closed as to convert it into a simple fracture, which, it is well-known, we can sometimes accomplish in Buch fractures as present themselves to us in civil practice. The cavity of the fracture is thus kept open to the air; the pus undergoes those changes which Bonnet has shown it does under such circumstances,-and that severe and prolonged inflammation of the deep and irritable tissues which constitutes the chief dan- ger in compound fractures, cannot be avoided; Now, all of these dangerous characteristics of compound fractures have been im- mensely increased by the conical ball. First of till, the shock it occasions is undoubtedly greater than that caused by the round ball, simply because the destruction it causes is much more se- vere; secondly, the comminution of bone is enormously increas- ed. The number of fragments which are quite detached nre much more numerous, and the amount ov^sequestra, which are so far severed as to be ultimately thrown out before a cure can be looked for, is much greater. Thirdly, the bruising of the soft parts is more extensive, so that the suppuration is more prolong- ed, and the chances of purulent absorption so much the more multiplied. The great loss of substance which follows compound fractures by the conical ball, is the source of one peculiarity in their treat- ment. The shortening will be greater should consolidation fol- low, than if the injury had been occasioned by the round ball. * In these remarks f refer merely to the heavy conical ball, as there are balls of the same shape but of less weight, which are by no means so formidable. That used in the Schleswic-Holstein campaigns appears to have been very trivial in comparison to tif large Russian one, of which we had such dire experience. • COMPOUND FRACTURE OF THE EXTREMITIES. 123 The conviction has been strongly impressed upon my mind, by the observation of 'not a few of these cases, that we ought not to keep up extension in their treatment, except in a very modified degree. If we do so—if we drag and haul a£ the bone, as I have often seen done, what is the result? A large hiatus exists, void of organizahle material for forming the bono ; the parts active in repair are drawn far apart, and a tax is made on the reparative process, which I will not go the length of denying may, under the most favourable circumstances, he brought about; but which I am fully certain never could be accomplished with us. In many cases it would, to my mind, be better practice—i. e., it would af- ford better resu'ts in saving life and limb—rather to approxi- mate than draw apart the fractured ends m such cases. Allow the ends of the bones to be drawn by the muscles towards one another, having first removed the sequestra, and attend merely to keeping the limb as straight as possible; or, in other words, do not be troubled with the displacement as to the length, but only us to the thickness of the bone, and I believe our chance of suc- cess would be improved. Deformity we would unquestionably have—shortening and twisting, and f the medical department.. Alexander M'Phail, aged 33, wounded at Dubba, 24th March, 1843, by a matchlock ball, which entered a little above the great trochanter of the right limb anteriorly, and was lost. His leg became powerless. On coming to Colaba on the 26th April, he did not complain of much pain, except when the joint was moved. Slight fullness over the hip was the only symp- tom of injury. Leeches and counter-irritation were employed, and he seemed to get better. On May Gth he was attacked with trismus, and died oh the 9th. The ball was found embedded in the head of the femur, which, with half of the brim of the aceta- bulum, was shattered, and the capsular ligament formed the sac of an abscess which contained a considerable quantity of pas and spiculae of bone. The orifice of the wound, it is added, had closed some time previous to death. Larrey mentions the case of an officer wounded in Fgypt, who received a ball in the neck of the femur. The wound closed, nnd twenty years afterwards, on the death of the patient from disease of the chest, the ball was found impacted in the bone. The kne« when penetrated by gun-shot present-* an injury of the gravest description. Taking much interest in cases of this description, I visited every one I could hear of in camp, and can aver that I have never met with one instance of recovery in which the joint was distinctly opened, and the bones forming'it much injured by a ball, unless the limb was removed; yet the returns show several recoveries after such wounds, some of which, at any rate, I cannot but think are founded on error. I have conversed with many surgeons of large experience on the subject, but never heard of any case recovering without amputa- tion, in which the diagnosis of fracture of the epiphysis was be- yond doubt; yet such cases have been put on record. I remem- ber one case, probably included among the recoveries, in which a ball passed near the joint, causing some effusion and swelling in it, with no constitutional disturbance whatever, and resulting in the man's return to duty within a fortnight, but which the sur- geon in charge put down as a penetrating wound, remarking (as GUN-SHOT WOUNDS OF JOINTS. 137 he well might) on the curious immunity from constitutional or severe local symptoms which had marked the case. Tho following rs a very interesting case, and certainly one of the most difficult to explain of any with which I am acquainted. I never saw the patient, the details have been kindly sent me by Deputy-inspector Taylor from Chatham:—"Private George Hayes, aged 31, 47th regiment, was wounded at the Alma by a grape shot, which entered on the outer side of the ligamentum patella;, and passed upwards through the knee-joint, shattering the patella in its course, and making its exit at the anterior as- pect of the thigh about its middle, partially fracturing it. The greater portion of the petella was removed in the course of treat- ment, as well as various fragments ot the femur (exfoliations?); hut firm union of the latter, as well as anchylosis of the joint, fortunately took place. At the time of his discharge he could sustain his weight upon the limb, and could walk about without crutches." I saw another case very similar to this at Scutari in 1855. In this instance, the ball Had struck the man whet he was about to kneel, and apparently fractured the head of the tibia. The ball was removed from the anterior part of the thigh. Scarcely any bad. symptom followed, except that the joint swelled, was painful to the touch, and ended by losing part of its motion. If the articulation escaped the passage of the ball, the case was'very curious. The round ball sometimes penetrates the lower end of the femur or the head of the tibia without causing splintering, or opening, the joint, or at least with an amount of injury to the capsule which is very light; and such cases may recover, and so shake our conclusions about others of a less anomalous character. Balls, too, may pass very close to the capsule and yet do it no harm, though these cases are put down as penetrating or perfoiatirg wounds of the joint. It is undoubtedly often very difficult to know whether the joint has been opened or not, particularly if the ball is a small one, as was the case in one instance afterwards mentioned ; and it very often occurs that the missile has run superficially under the in- teguments, or coursed round the bones, when it appears to have passed through the nrticuLation. It is to be remembered, also, that the swelling of the joint may be merely the result of a bruise, or of the extension from the neighbourhood of the inflam- mation which has been caused there by injury, and is thus no sign of direct wound of the joint. # Another point which renders these injuries difficult of recogni- tion when the Bones are not much implicated, is the length of time which may intervene before the appearance of severe symp- toms. A week may pass, and yet both the local and constitution- al symptoms may be very slight. Sooner or later, however, the well-known signs of joint-injury arc set up, sometimes with great rapidity and severity. 138 SURGERY OF THE CRIMEAN WAR. It is not difficult to understand the peculiar progress and fatal results of gun-shot wounds of the knee, when we consider how sensitive to injury are shut cavities when enclosed by such a deli- neate membrane as the synovial lining of the knee, and how feel- ingly such cavities resent the introduction of air within them ; bow rapidly they degenerate under the effects of this air; what a mass of closely-compacted tissues become inplicated when di- sease is set up in such an articulation ; how it is that bone, liga- ment, and soft parts participate in the injury; how wide the bony expanse is which entevs into the formation of the joint; and what a large surface is presented for purulent absorption and transmitting inflammation, as well as how difficult it is for foreign bodies or morbid secretions to obtain free *iexit. These are the. chief causes why the injuries under consideration are so often followed by dangerous and fatal results. In.civil life, wounds opening the joint are commonly caused by cutting instruments. Foreign bodies are seldom introduced, and the bones entering into the articulation are little if it at all injured. The wound being carefully closed, often adheres, and, by appropriate treat- ment, little mischief may follow. But if a ball be the wounding agent, foreign bodies are almost sure to be introduced from with- out, or created within by the splinters. The ball's track must suppurate before it closes, and cannot be shut up and retained without the hazard of pus accumulating in the cavity ; air thus .gets admission, and works destruction. Foreign bodies cannot be extracted by so small an opening from a cavity of such a con- struction; and thus these gun shot wounds of the joint, though often apparently very trivial injuries, become the most serious almost of any which can be presented to us. The primary dangers of these wounds are not,great. It is in those which are set up afterwards that the chief hazard exists. The long and wasting suppuration, the tedious and dangertfus ab- scesses, and the purulent poisoning are the principal sources of alarm. These abscesses are most curious occurrences in knee cases. They appear almost invariably among the muscles of the thigh ; and while they may remain long unnoticed, they give rise to the utmost trouble and danger. They burrow along the bone, often stripping it of its covering, and yet are seldom appa- rently in connection with the joint. The escape of some small amount of the acrid secretions into the superficial or deep cellu- lar membrane, sets up renewed inflammation and suppuration there, and thus abscesses form, whose connection with the origi- nal depot it is difficult to trace. These collections almost always occur in the thigh in preference to the leg. At a late period of the case, the joint puts on all the appearances of white swelling— and observation first made by Dr. John Thomson. Military surgeons of all times have recognized the necessity of removing the limb early in these cases when tho articulating ends of the bones have been fractured by a ball, and the experi- GUN-SHOT WOUNDS OF JOINTS. 139 ence of the'late war fully bears out the practice. French and English surgeons were, I think, at one on this in the Crimea. In December. 1854, I saw upwards of forty cases in the French hos- pitals, and all died except those primarily amputated. I have heard incidentally of one case occurring in their army which re- covered, but have failed to learn its details.* It is certainly very disheartening, as well as humiliating to professional pride, to think that we cannot save such cases without amputation. The very small amount of visible destruction which is so often pre- sent, the slight complaint of pain or appearance of disturbance which frequently exists at the period when the limb ought to be removed in order to insure success; the very pardonable unwil- lingness of the patient, especially if he be an officer, to submit to so dreadful an alternative, wheref the joint during the early period of treatment, as so strongly dwelt upon by Stromeyer, its constant support by a splint, even when being dressed; the elevation of it, so as to prevent oedema; its flexure at an angle of 130° to 140°, are all points of importance, both as regards the comfort of the patient, and the after results. Early passive motion before the wound is wholly cicatrized, but at once abandoned if any irrita- tion or signs of inflammation appear, are also indications which late experience has stamped the value of. The hip was resected six times ; five being primary and one a secondary operation. One of the primary alone succeeded. Such success, although small, is yet encouraging, as compared with the results obtained from amputation at the hip, for which ope- 152 SURGERY OF THE CRIMEAN WAR. ration the excisions were substituted ; for, as will be afterwards seen, out of at least 10 amputations at this joint in our army, and some 13 among the French, none survived, and in our cases at any rate the fatal result very rapidly followed the operation. I performed the first operation of excision of the hip under- taken in the East on the 6th July, 1855, on a rifleman, whose case is subjoined :— Couch, a soldier of the rifle brigade, was struck, on the 18th of June, by a ball, close below the elbow-joint of his left arm. The urna was fractured by the bullet, which then struck the femur on the great trochanter of the same side. The trochanter and-neck of the bone was split, and otherwise severely injured. The patient did not come under my care till the 5th of July, when I found a large ragged wound over the-injured trochanter, from which a very profuse discharge of pus flowed. At the bottom of this wound the bone was seen to be hollowed out into a large cavity, and to be split in all directions. The bone was black and dead. The limb was not shortened or distorted. The wound on his arm gave him much annoyance, and the pain from the hip was so great, that he urgently requested some operation to bo performed, which might relieve him. He was brought under the influence of chloroform, in order that the injury might be more completely examined than could otherwise be accomplished from the patient's irritable condition, and also to enable me to get the limb put into a proper apparatus. On enlarging the external wound, so as to make it dependent, and to allow the necessary steps to be taken for the removal of the dead portions of bone, a large fragment of the external part of the femur, which com- prised what remained of the great trochanter, was found de- tached, and a fissure running upwards, apparently into the cap- sule. It was found impossible to remove the dead bone without opening the joint; and, as but a very-thin shell of the shaft was sound, a consultation decided on the propriety of excising the head of the bone, and removing along with it what rfsseous sub- stance was destroyed. This was done without difficulty, the original wound being increased a little upwards. Hardly a drop of blood was lost. The wound was lightly dressed, and the "limb fixed on an inclined plane, so arranged that the large dependent opening retained, could be got at without having to move the patient. The relief from pain and irritation which was experi- enced almost immediately, was very marked and gratifying. Next day the patient's pulse was firmer, his expression very markedly better, and he declared himself as perfectly at ease. The limb, in a few days, was shortened about two inches. Suppuration became established ; his strength improved; hectic disappeared ; he slept well; and his appetite, which, before the operation, was nearly gone, was now restored, and he was totally free from pain or uneasiness. His pulse, on an average continued about 85 beats in the minute, and was of good character. He continued to pro- GUN-SHOT WOUNDS OF JOINTS. 153 gress most favourably for about a week. Part of the wound closed, and the rest of it was clean and healthy. At the end of that period he was suddenly seized with violent diarrhoea, ac- companied by vomiting and severe cramps, and followed by sup- fression of urine, which continued for 18 hours previous to death. lis stools soon assumed the characteristic appearance of cholera evacuations, his strength sunk, he became rapidly collapsed, cold, and blue, and died during the night. Cholera was prevalent in the camp at the time. After death, some crude tubercles' were found in both lungs. There was no symptom of purulent absorption anywhere. Tbe vessels in the neighbourhood of the wound were healthy. There were old ulcerations in the intestine, and recent enlargement of the solitary glands. The left ulna was fractured obliquely up towards the elbow joint. The wound over the hip was sloughy, an action it rapidly took on shortly previous to death, and the cut end of the bone was smooth and unchanged. If I had seen this patient earlier, when the nature of the injury could have been more exactly determined, I would have contented myself with merely gouging out the destroyed portion of bone, trusting to the remaining scale to throw out callus, fixing the limb care- fully, giving free exit to the suppuration, and strenously support- ing the patient's strength. The state of the lungs and intestine, as revealed on post mortem examination, made this patient, at best, but an unpromising subject for operation; but if the fatal disease which terminated his existence, had not supervened, I would have been sanguine of the result. When he came under my care, I feel sure he was in such a condition, if no operation had been undertaken to relieve him from the mass of dead bone which his system was futilely trying to get rid of, and which was setting up further disease all around it, he would, in a very few days, have died, exhausted by suffering. These are, however, points more easily settled on paper than at the bedside. Mr. Blenkins of the Guards, operated on the next case, and has been good enough to send me the following notes of it:— " Private Charles Monsterey, aged 24, third battalion Grena- dier Guards. Brought from the trenches at midnight with a severe shell wound on the outer side of the right thigh. Exami- tion showed tho thigh-bone to be extensively fractured at the up- per part, in the situation of the trochanters and neck, the frag- ments were much comminuted, and the surrounding muscles greatly lacerated. It was at once recognized as an appropriate case for excision, and the operation was performed half an hour after his arrival in camp. The wound was extended in a longi- tudinal direction, to the extent nearly of five inches, and the shaft of the femur sawn through at the junction of the upper fifcli with the rest of the shaft. The muscles were next detached from the trochanter, and the capsule lastly divided. It was in- tended at first to preserve the head of the bone in the socket, but 154 SURGERY OF THE CRIMEAN AVAR. the capsule was so extensively lacerated, and the cavity being filled with blood, it was resolved to remove it. Very little blood was lost during the operation. Examination afterwards of the excised bone showed it to be fractured in fourteen pieces. The trochanter minor informed three, trochanter major three, shaft five, the neck three, besides numerous smaller fragments. The case continued to do well for the first three weeks; healthy granulations sprang up, both from the end of the divided shaft, and the surrounding cavity and acetabulum. At this period pain and swelling of the knee joint of the same limb supervened, the capsule of that joint became filled with purulent matter, the car- tilages eroded, and he sank gradually, worn out with hectic symptoms, at the end of fifth week, in spite of every effort to sup- port him. The case was doing remarkably well, and I had every hope of his recovery, until empyema came on." Staff-surgeon Crerar operated on the third case, a private of the first battalion of the Royals, who was wounded in the Greenhill trenches at mid-day on the 6th of August. Tho wound, in this case, was slightly posterior to the great trochanter, and was not larger than a shilling. It had been caused by a piece of shell, which before it entered his thigh, had first struqk a water can- teen that hung by his hip. A comminuted fracture high up was clearly ascertained; but its exact position or extent was not de- fined previous to operation, although it was supposed to impli- cate the head and neck of the bone. " The trochanter was found broken into several portions, detached and imbedded in the con- tused muscles around, from which they were at once removed. The fracture was found to extend obliquely inwards, about an inch and a half along the shaft of the bone. The femur was now protruded through the wound, and I sawed off the whole of the fractured bone, leaving a smooth clean surface; I then proceeded to disarticulate the head of the femur, which was effected with- out difficulty. Scarcely three ounces of blood were lost, and lit- tle or no shock was induced." This patient was seized with rigors, and died of exhaustion on the 2lst, i. e„ on the fifteenth day from being wounded. The internal viscera do not seem to have been examined, but as to the state of the fenlur, Dr. Crerar says " nature had not made the slightest attempt to repair the loss." The next case, which was the only one where success followed the operation, was that of private Thomas Mackenena of the 68th Light Infantry, operated on by Mr. O'Leary, surgeon of that regiment. The age of tho patient was 25, and he was wounded on the 19th of August, by a fragment of shell which struck him over the great trochanter and fractured it. It was thought that the fracture ran into the joint, a supposition which was disproved at the operation, as the bead of the bone was uninjured. Five inches were in all removed. After operation, the limb was slung to thO beam of the hut. This patient recovered in three months. I have lately heard of this man through the kindness of Lieut.- GUN-SHOT WOUNDS OP JOINTS. 155 Col. Stuart, commanding the pensioners in the Newry district. Dr. Shaw, who signs the report, states " the limb is two inches shorter than the corresponding one, and also considerably small- er ; extension can be carried on partially, but he cannot flex the limb upon the thigh without placing his hand on the glutei mus- cles of the diseased side. Rotation, inwards and outwards, can be performed only to a limited extent. The wound over the jcint is quite healed. The man's general health is good, but he can- not walk without the assistance of crutches." Dr. Hyde operated on another case after the taking of the for- tress. His patient, a private of the 41st had the neck of the bone severely comminuted by a grape shot, and died on the fifth day after operation. The cause of death is not given, nor can I discover it from the report of the case. Dr. Combe of the Royal Artillery performed the sixth and last operation, on account of a gun-shot wound of the neck of the femur, in which, however, the head of the bone was not impli- cated. This operation was not'a primary one, but the patient survived a fortnight, and died of exhaustion ; the most marked feature in the case being, that the pulse remained very high— never below 120—during the period he lived, while his aspect was calm, and such as " might have led one to expect a more st»fedued state of the circulation." Death thus followed in 2 (1?) from exhaustion, in 1 (2?) from pyoemia, in 1 from cholera, and in 1 from a cause that is un- known. It is a remarkable fact, that in these cases the head of the bone so often escaped, when the upper part of the shaft was fractured in pieces, which is probably to be accounted for by its protected position, and perhaps by the same cause as that before mentioned, with reference to the head of the humerus, viz., the non-extension of fracture of tho shaft to the epiphyses. Buyer and others have dwelt upon the depth of the parts, the strong ligaments, the difficulty of turning out the head of the bone, &c, as insuperable objections to this operation ; but actual experience—both in civil practice, where it has recently been so often performed for disease, and especially in our attempts in the Crimea, where the soft parts were in their natural condition, and the difficulty of turning out the head of .the bone increased by the broken state of the shaft—proves that there is no such bar- riers to its easy execution. The greatest difficulty lies in the after treatment. It is desirable to fix the parts thoroughly, and at the same time to allow of some change of position. Mr. O'Leary managed this, to some extent, by means of a canvas sling for the limb. The fixture cannot, however, be satisfactorily ac- complished in this way, whatever power it gives of changing the position of the patient. I adopted the inclined plane in prefer- ence to the long splint, because I believe the position to be an easier one for such a case, and also because it permitted tho free 156 SURGERY OF THE CRIMEAN WAR. discharge of the pus, and the easy dressing of the wound without disturbing the patient. If the idea lately suggested at King's Col- lege, of slinging the whole body, could be carried out, it might afford many advantages in the. management of excisions of the hip. As to keeping the limb in a good position during cure, I fear more important ends are lost sight of in striving after it. The uneasiness and irritation which tho splints and rollers give, do much to prevent success. It matters little what the resulting leno-th of the limb proves to be, if the patient's life is saved ; nor does it greatly matter that it be somewhat out of the right axis. As to the comparative advantages of amputation and excision at the hip in cases of compound fractures of the head and neck of the femur by gun-shot, some hint may be got from our expe- rience in the Crimea. Out of twenty-tbiee cases of amputation which took place, either in our army or in that of the French, not one recovered; and nearly all died miserably, very shortly after operation. All those," on the other hand, on whom excision was practised, living in comparative comfort, all without pain, for a considerable time. Out of six operated on one survived for more than a month, one died from causes unconnected with the operation, and one case recovered entirely. The chance of saving life is thus manifestly on the side of excision, and this is truly the most important aspect of the question. The objection so oftnn advanced to the operation, that the limb resulting from excision is useless, even if true, has nothing to do with the matter. It is a question of deeper and more serious bearing than such an ob- jection would imply. The only point worthy of discussion is, which operation holds out the best chance of preserving life? The little light derived from our Crimean experience is quite con- clusive, so far as it goes. In the one case a life was saved, while, out of four times as many cases of the other operation, not one survived. It is true that many cases submitted to amputation may have undergone more extensive injury than any of those ex- cised, and'it is also true that one case of exarticulation did, to all intents and purposes, recover; yet the shock of excision must be much less than that of amputation, seeing that the great vessels and nerves are not touched, and that those changes in the blood of the limb are not interrupted, which some authori- ties contend is the cause of death after amputation. In all the cases of excision the loss of blood was trifling—a matter of much moment with patients like ours—and the immediate relief from pain and irritation was very marked in all the cases. _ Gun-shot wounds of the hip-joint, are in many, instances par- ticularly adapted for resection, the injury of the bone being often limited, and the soft parts but little destroyed. There are, on the other hand, few accidents which present these conditions in civil life. WThen the shaft of the femur is split below the trochanter major, excision is hardly applicable, although Seutin performed it when he had six inches of the shaft to remove. GUN-SHOT WOUNDS OF JOINTS. 157 Seutin.Oppenheim, and Schwartz have all excised the hip for gun-shot injuries, but not with success, although all seem to hav$ been impressed with its feasibility. Paillard gives an account of Scutin's pase, from which it would appear that the patient sank on the ninth day from gangrene. Six inches of the bone were removed in this case. In Oppenheim's case, the bone was re- moved as low down as the little trochanter, and the patient lived eighteen days. Esmarch relates Schwartz's case. It was a sec- ondary operation. The bone, " to two inches below the small trochanter," was removed. He died of pyoemia on the seventh day after operation. Esmarch refers to another case, operated on by Dr. Ross, and related in the 41st number of the Deutsches Klinik, 1850, which ended similarly. This last operation was performed two years after injury. For disease excision of the head of the femur has been now of- ten performed, and many times with success; the very great dif- ference, however, that exists between the operation as performed for disease and for accident, prevents any comparison being made between their results. Much might have been done, if we had bad another campaign, to determine the exact value of excision, as applied to gun-shot kwounds of the hip-joint. If the cases were selected with care, and the operation early performed, before the vital powers began to flag, and if the after treatment were carefully conducted, much might be expected from'this operation in military practice. "It is often very difiicut to tell how far the destruction of the bone ex- tends, either upwards or downwards ; but if the case should turn out to be too complicated for excision, then amputation may be performed. Stromeyer has shown that, although the splitting of the bone barely extends into the capsule—as it did in my cjtse— yet excision should be at once performed, as suppuration is sure to be set up in the articulation, and death by exhaustion follow. The same surgeon has also shown how it happens that, although the neck of the bone be fractured by a ball, yet the usual signs of such an injury—the shortening and rotation of the foot—may be absent, from " the fragments hanging together better on ac- count of the partial preservation of their fibrous covering," and, in one case which he examined, a considerable power of flexion and extension remained although the neck of the bone was frac- tured ; while, in another case, " the fragments fitted so well to- gether that the patient did not experience the least pain, and the leg could be moved without causing crepitation." The existence of the fracture was only determined in this case by the presence of a profuse discharge. The patient himself may even be able to move his foot, and so mask the diagnosis. Esmarch gives " the extensive swelling occurring rapidly, and the pain on mo- tion," as the only two signs which are nearly always present. It'need hardly be added, that if, in fracturing the" neck of the -158 SURGERY OF THE CRIMEAN WAR. bone, the ball or any of the osseous fragments injure the great blood-vessels, the cause is not one for excision. The knee was only once excised, so far as I know, during the war. The operation was performed in the general hospital by Mr. Lakin, whose notes of the case have been kindly furnished to me. "Henry Gribben, aged 19, a private in the77th regiment, was admitted into the general hospital on September 8th, 1855. While retreating from the Redan on that day, he leceived a mus- ket ball in his left popliteal space, causing him much difficulty in walking ; nevertheless, he succeeded in regaining the advanced trenches, distant about 100. yards. He was a man of average muscular development, and of habitually good health. On ad- mission, a circular wound, with inverted edges, was found at the inner part of the popliteal space, and at the level of the junction of the upper and middle thirds of that space. It was of a diam- eter just sufficient to admit the index finger, which could be pass- ed to its full length in a direction forward, and slightly upward, between the inner hamstring tendons. No fracture nor other injury of the bone was detected, neither could the further course of the ball be ascertained by means of a probe or elastic catheter. It was not considered prudent to use much force with these in- struments, in consequence of the close proximity to the jojnt, and of the absence of any satisfactory evidence that its canity was already opened. There was no aperture of exit, the limb was not altered in shape ; flexion and extension, especially the former, w ere limited, and any attempt to move the limb beyond these limits was attended with much pain, which was otherwise slight. Simply bearing the weight of the body only caused some uneasi- ness, and there was no tenderness on pressure from without. There was no appearance of synovia about the wound, nor was there any bleeding. Under these circumstances it was consider- ed that any operative measures for the purpose of removing the ball were not justifiable." The limb was placed upon its outer side, with the knee semi- flexed that being found the most agreeable posture, and cold dressing was applied. The patient remained almost free from pain, except when the limb was moved, and in good health, until September 20th, twelve days after the injury, when the joint be- came somewhat inflamed, as indicated by increased pain and heat, slight tenderness to pressure, and moderate swelling. Twelve leeches and hot fomentations were applied, and afforded great relief. The symptoms subsided, and remained in abeyance till about the 29th, when they gradually increased, the joint be- coming much swollen and tender, the veins more distinctly visi- ble, and the general health beginning to suffer for the first time, at evinced by slight perspirations, debility, frequent pulse, loss of appetite, thirst, disturbed rest, &c. The swelling of the joint was uniform; and no fluctuation could be perceived in it, though GUN-SHOT WOUNDS OF JOINTS. 159 it was thought that there was some deep-seated fluctuation about three inches above the joint, on the outer side of the thigh. "It was decided in consultation to examine the limb while the patient was under the influence of chloroform, and then to adopt such measures as the examination might indicate ; accordingly, on October 1st, he was placed upon the operating table, and chlo- roform administered. With some difficulty, and by using con- siderable force, the finger could feel a part of the head of the _J.ibia, bare and rough, a small piece of bone having been chipped off its inner and posterior edge, but the site of the ball was not detected, though it was thought to be in the joint, possibly in the space between the condyles of the femur. It was then decided to make such an incision as would admit of the performance of ei- ther excision or amputation, whichever proceeding the condilion of the parts might indicate. This was accordingly done ; and on opening the joint several portions of the cartilage covering both bones were found to be-partially detached from the bone, soften- ed, and their surface eroded. No fracture was found, except the small piece chipped off the inner and posterior edge of the head of the tibia." " Excision being now decided on, and as the necessary steps were being taken, pus escaped from a-cavity which existed in the outer side of the thigh, and partially surrounding the femur. The ball was found to have penetrated the inner condyle. About an inch and three quarters of the femur was removed, as well as a thin slice of the head of the tibia. The patella was also dis- sected out, because portions of its cartilage were softened, and partially detached. The slight oozing of blood was soon stopped by cold water." No vessel required a ligature. The edges of the wound were brought together, and retained by sutures and strapping. The extremities of the incision were left open, to al- low of the escape of pus, &c. Wet lint was applied, and the limb placed in a straight position on a M'Intyre's splint, with a short whalebone splint on each side of the joint, secured by strap and buckles. The patient was placed in bed, and a grain of mor- phia given him. " The portion of femur removed was about one and three-quar- ter inches long, and presented an ordinary round musket bullet, about half embedded in the inner condyle, the bone not being split, but the joint opened." No symptom arose calling for remark up to the 25th, when Mr. Lakin's report runs thus :—" Had continued slowly improving and gaining strength until to-day ; the discharge bad diminished in quantity. Had not accumulated nor bagged. The limb had acquired slight firmness. The wound looked healthy, and had nearly healed across the front. Some difficulty had been found in keeping it in very accurate position, as he twisted about when using the bed-pan, and he is naturally a reckless, troublesome fellow. His bowels were occasionally slightly relaxed, but this 160 SURGERY OF THE CRIMEAN WAR. was soon relieved by a dose of the aromatic mixture. To-day he seems progressing favourably, but has got his limb into a bad position ; bent so as to form an angle externally. A slight dis- coloured patch, as of- a commencing slough, on the outer side of the limb, corresponding to the position of the displaced end of the femur, at the upper extremity of the wound. The plane is readjusted, and the limb secured to it by bandages. The dis- charge is again rather increased in quantity. A bad sore had formed upon the sacrum, but is improving under treatment." Again, on the 27th, the report says, "Complains rather of chilliness this morning, but has had no rigors. Has vomited several times, and his bowels have been purged. Pulse 110. Tongue moist and clean, wound healthy, small slough on outer side not extending, discharge as usual, urine drawn by a catheter." The diarrhoea, although temoorarily checked by treatment, went on, and the sickness greatly prostrated his strength. Mr. Lakin notes as follows on the 28th : "Jtapidly getting worse. Pulse 130. Very low ; evidently sinking; countenance much altered, but simply looking sunken and pale, and not having the peculiar aspect of pyoemia. Died at night." Post mortem 14 hours after death. " Before removing the body to the 'dead tent,' the orderlies had taken off the splint, and the limb had been allowed to hang down, so as to destroy any points of union that there might have been. The wound had healed, except its extremities, the granulations on which had shrunk and assumed a black appearance (post mortem) ; the op- posed surfaces of the bones presented a very similar appearance, and there was no sign of dead bone. They had become moulded to one another in shape. Whether there had been any union towards the centre was not evident; at the circumference there were ap- pearances of some adhesions having been broken. The cavity of the joint contained only a small, quantity of pus. The abscess in the outer part of the thigh had almost healed. No purulent deposits could be found in auy of the organs, nor could any ap- pearance of phlebitis be detected. The viscera were healthy." " I ascertained," adds Mr. Lakin, "after his death, that, on the 20th and 27th, he had eaten some apples which he ha.l bought, and that the vomiting and diarvhoea.came on after that. He had not at all the appearance of a man suffering from pyoemia, but seemed simply to die exhausted by sickness and diarrhoea." " The opening through which the bullet entered remained pa- tent all the time, and a great deal of the discharge "escaped through it; though probably the two extremities of the incision would have been sufficiently on the posterior part of the limb to prevent the matter from bagging." ^ Admiring as I do the brave attempts which have been made in civil practice to save limbs by excising the knee, I regret that it should not also be extended to military prastice; but except iu rare circumstances, I fear that cannot be accomplished, from the GUN-SHOT WOUNDS OF JOINTS. 161 careful after-treatment and the long period of convalescence ne- cessary to effect a cure. Ferguson speaks of more than 100 cases haying been now operated on in civil practice, and Butcher has shown that the mortality is greatly less than what succeeds amputation of the thigh; but it is to be remembered that these cases were of an age and a history which rendered the procedure much more hopeful than it almost ever can be in warfare. A dis- eased joint is a constant source of irritation and depression to the constitution, so that, in the words of Sir Philip Crampton, " by its total excision all those parts which were diseased, and influenced the constitution so unfavourably, are removed from the system, and the injury is resolved into a case of clean incised wound, with a divided, but not fractured or diseased bone at the bottom of it," and thus the powers of the system which went to feed the disease are already so diverted to the part as to build up the loss, so soon as they can work on a proper material. That nice adaptation, however, of the surfaces, that accurate fixture of the limb, the careful attention, nourishment, and perfect repose which such cases obtain in a civil hospital, and which have so much to do with the result, can hardly be attained in the field. Mr. Ferguson, in the last edition of his admirable manual, thus sums up the advantages which his large experience ascribes to the operation : " The wound is less than in amputation of the thigh, the bleeding seldom requires more than- one or two liga- tures, the loss of substance is less, and probably on that account there is less shock to the system ; the chances of secondary haem- orrhage are scarcely worth notice, as the main artery is left un- touched ; there is, in -ihort, nothing in the after-consequences more likely to endanger the patient's safety than after amputa- tion, whilst the prospect of retaining a useful and substantial limb, should encourage both patient and surgeon to this prac- tice." If the operation be performed in the field, the sooner it is un- dertaken the better; for, although primarily free of disease, the articulation soon becomes affected, if it be left a prey to inflamma- tion and abscess; the constitution rapidly sympathises, and that blood-poisoning which is so liable to follow may be established before we well see the danger of delay. Secondary operations too, it should always be remembered, do not hold out the same prospect of success in military as they do in civil practice. The saving of blood, and the absence of any fear of secondary haemorrhage which has been pointed out by Butcher and Fergu- son, are points of much weight in favour of resection when pa- tients are to be dealt with who are so sensitive to any hemor- rhages as those we had to deal with in the Crimea. The resection of parts of the shafts of the long bones was not, to my knowledge, much practised in the Crimea. The lengthen- ed period those cases take to recover, and the trying nature of this ordeal on the vital powers, made such abstinence with us al- 162 SURGERY OF THE CRIMEAN WAR. most a necessity. Several cases resulted very favourably, in which parts of the shafts of the humerus, of the bones of the fore-arm and of the leg, were thus dealt with ; but in more than one case in which I knew such steps taken, too much was ex- pected of the reparative powers of our patients, too large? an ex- tent of the bone was removed, and thus the operation failed. It was towards the end of the war that tho best results were ob- tained from these resections. In the case of tjhe tibia especially, the choice between amputation and resection must be guided chiefly by a consideration of the state of health of the patient, whether or not he is in a condition to withstand a long and te- dious cure; by the extent of destruction of the bone, and espe- cially of its periosteum, and finally, the means at hand for car- rying out the after-treatment. Resections in the continuity of the femur were, so far as I know, invariably fatal. The difficulty of the operation on mus- cular limbs must of itself predispose to disagreeable results. False joints are, as is well known, apt to occur after resection in the continuity of bones of the leg and fore-arm, when the opera- tion is practised on only one of their two bones. CHAPTER IX. I AMPUTATIONS. The relative advantage of primary and secondary amputation has always held the first place among the various problems which the army surgeon has had to solve. With all that has been written on the subject by military and civil surgeons, there still seems considerable reluctance to accept the question as set- tled. The discrepancy of evidence brought to bear on the sub- ject has chiefly arisen from the evident distinction being over- looked between operations undertaken for accident and for dis- ease. Civil hospitals can seldom afford testimony similar to that obtained from the field of battle, and thus it happens that civil surgeons have come to stand in some measure in apparent an- tagonism to their military brethren on the point of practice un- der consideration. Hunter was so much of the civilian as to ad- here to the consecutive operation, although, with very few excep- tions, surgeons who have practised in armies have strongly advocated early interference since the days of Duchesne and Wiseman. The difference which so manifestly exists between the moral condition of the patients who are operated on for acci- dent in civil life, and the soldier in the field, together with the circumstances in Which each is treated after operation, introduce so many different items into the calculation of the question of amputation, that it is almost impossible to make use of the ex- perience of either sphere to illustrate or influence that of the other. Besides this, the severity of those injuries which present themselves in military practice, and which authorize the re- moval of the limb, is so great, that it is but reasonable to sup- pose that an operation which removes so vast a source of irrita- tion and pain at the earliest moment possible, must promise the best results in saving the life. In short, military experience on this point must regulate military practice, and the results of civil experience must continue to regulate civil practice. To military surgeons, the question of primary or secondary amputation is a settled one. The experience of every war has more and more confirmed the advantages of early operation, and that in the Crimea has not disturbed the rule ; in fact, later ob- servation would lead us to go further, and in place of merely ad- vocating interference within twenty-four hours, the prevailing idea at present would be better expressed by saying that every hour " the humane operation " is delayed, diminishes the chances of a favorable issue. 164 SURGERY OF THE CRIMEAN WAR. It is impossible to prove from any returns the full bearing of this question, as the mere number who survived after a given number of operations performed primarily or secondarily, by no means expresses the terms of the question. It would manifestly be necessary to know how many died before the secondary period came round, and to these should be added the victims of delayed interference, with all the pain and suffering which such delay occasioned, before we can arrive at a jujt estimate of the results of either proceeding. The experience in the Crimea in favor of early operation was unequivocal in both armies, and needs no illustration from me.* Chloroform has done much to render the success of primary amputation, as contrasted with secondary, yet more marked. If we believe, as I certainly do, that by the use of this anaesthetic all fear of intensifying the shock is obviated—which was one reason why surgeons delayed operation—then the tendency of military surgery, since the introduction of chloroform, must be to still earlier and more prompt interference. Secondary amputations were much more common during the early than the late period of the war—a circumstance which arose from the deficient means of treating thewounded in the camp during the former as compared with the latter period, and thus the necessity that existed of despatching them from camp imme- diately after being injured ; and this, together with the better hygienic condition of the patients towards the end of the war, accounts for a fact—well known to those who served in the East, but which the range of the returns does not enable me to show in figures—that amputations were much more successful as a whole, towards the conclusion, than at the outset of the war. At first, too, when patienfs were early sent from camp, not a few operations, to my own knowledge, were performed during the "intermediary" period, and, without one exception, those thus falling within my observation were fatal. The tremendous destruction which was at times occasioned by round shot or shell, left little hope from any operation whatever. In the case of many, a " pansement die consolation" was the only alternative, while, in not a few, the injury was so severe that, although amputation was performed, in the vain hope of a possible success, yet the apparent advantage of primary opera- tion thereby suffered, and this circumstance is another of the many which makes it impossible to place this question in a fair light. The most severely injured have their limbs removed early, while the most hopeful are retained for secondary opera- tion, and thus all the advantages of slighter injury—less consti- *I am led to understand, from a very well-informed source, that the Russians also lost two thirds of all their secondary operations, but >aved a fair number of their primary. AMPUTATIONS. 165 tutional disturbance, more promising habit of body, and state of general health—are denied to the early operations. In truth it may be said, that if, with all the advantages under which secon- dary amputations are recorded, they appeared as merely equal in success to primary, then the superior claims of the latter to our attention would be sufficiently clear; how much more marked, then, are the successes of early operations when we find them giving such superior results ! As to the general success of amputations during the late war, it may be safely said that when due weight is given to the many circumstances which have militated against the success of all operations, and which have been fully dwelt upon in the course of the preceding pages, those performed early have afforded a very fair proportion of success; while it cannot be denied but that those undertaken late have been followed by most unfortu- nate results. A siege presents peculiarly favorable opportunities for testing the value of immediate amputations. The men being close to- gether, and acting within a narrow space, can be seen almost in- stantly on being injured. The position of the soldier in such circumstances resembles that of the sailor on board of his ship; so that the experience of naval surgeons, which is so strongly in favor of instant amputation, applies with peculiar force to mili- tary siege practice. Unfortunately, the arrangement followed in our army during the siege of Sebastopol, made the elucidation of this point impossible. Assistant surgeons were alone sent to the trenches, (except during an assault, when a staff surgeon oc- cupied one of tlie ravines behind each division ; but in the hurry and confusion which prevailed at such times, the men he ope- rated on were lost sight of;) and as by the rules which prevail in our service an officer of that rank is not allowed to amputate, except when the surgeon is not with the regiment, no means ex- isted for the due examination of this question. The French ex- perience, if it were available, would be of much use on this point, as they performed many capital operations in their trench am- bulances. Whatever that condition is which is conventionally known as "shock," it seems pretty evident, from the admission of .all, that it is not established for some little time after the receipt of in- jury—an interval which differs in duration, mainly in accord- ance with the severity of the wound, the agency by which the injury has been caused, and probably the constitution of the suf- ferer. The evidence of naval, surgeons, as summed up by Mr. Hutcheson, in reference to the absence of shook immediately af- ter the receipt of a wound, must be conclusive to all unprejudiced minds ; and instances were not wanting during the late war which appeared to support the same view. I know of several well authenticated cases which occurred during the siege, in which the perfect absence of all constitutional prostration after 166 SURGERY OF THE CRIMEAN WAR. an accident so severe as the carrying off a limb, and the non-ap- pearance of such shock for some considerable time after, went to prove the same position. If this precious moment.could be seized at all times, and that operation performed under chloroform, which assists so much in warding off the " enbranlement" we fear, how much more successful would our results prove, than under any other circumstances they ever can be ! It is during this interval, too, that we obtain tho full good of the soldier's moral advantages over tho civilian. "Cut off tho limb quickly," says Wiseman, "while the soldier is heated and in mettle "—and the observation is as old as Pare, that while excited by the combat, and yet within sound of the cannon, the soldier or sailor willingly parts with a limb which a few hours of reflection would make him desire to run the risk of preserv- ing, and upon which he fixes all his attention, so as to magnify greatly the dangers of the subsequent operation. Moreover, the removal of the man, before ope;ation, to any distance from the scene of his accident, lessens somewhat his chances of recovery: as, besides the danger that the irritation and pain of such trans- port, however carefully it may be conducted, will occasion—the constitutional depression we dread ; the mere loss of blood which, although going on in very smalt quantities, is yet flowing in drops, when a drop may extinguish life, are serious objections to the shortest delay. But even although that constitutional disturbance which is the result of injury is present, is it always necessary to wait its sub- sidence before operating? If it be very decidedly marked, and the patient thus much prostrated, such delay may certainly be called for ; but it is an opinion often stated by those who must be well informed on the subject, that such delay is not always ad- vantageous, but manifestly the reverse. Larrey, for example, gives repeated utterance to the following sentiment: " II est done demontre que la commotion, loin d'etre une centre-indication a l'amputation primitive, doit y determiner le chirurgeon ;" and again, " Les effets de la commotion loin de s'aggvaver, diminuent et disparaissent insensiblement apres l'operation; and in this opinion he is by no means solitary, as may be seen by reference to the writings of many naval surgeons, who have manifestly the best opportunities of judging in the matter. The upholding in- fluence of chloroform comes strongly into ploy in such places, and obviates, in a great measure, the dangers which have been prognosticated from such proceedings. If the constitutional de- pression be the result of an injury which remains as a source of irritation, then tho removal of such must manifestly be a great point gained; arid I know it is the opinion of many army sur- geons of large experience, that the presence of shock is no hin- dcnuice to operation (under chloroform) if that condition be not very decidedly marked at the moment of interference. The difficulty which chiefly stands in the way of instant ope- AMPUTATIONS. 167 ration is tho recognition of the cases which demand it, and the certainty that no fatal internal lesion may not have been at the same time sustained, as the accident to the lrmb which necessi- tated its removal. However, it would certainly tend on the whole to the saving of life to operate as soon as possible, not only in all those cases in which the necessity for it was evident, but also in all doubtful cases ; as although a few limbs might thus be be sacrified, I have not the least doubt but that many lives would be saved. The Crimean was afforded a most excellent field for observing the relative value of flap and circular amputations; as, although in our army the former was commonly employed, most of the French and not a few of our own surgeons adhered to what Sir C. Bell termed " the perfection of the operation of amputation." As the advantage, in general, of removing the limb as far as pos- sible from tho trunk is fully recognized.it seems curious that the circular mode of operating, which I think admits of this more than the operation by flaps, should not be more followed. In the lower .part of the thigh this is particularly observed. Protrusion of bone is the great bugbear which terrifies most operators: hence they make unnecessarily long flaps, and remove a much larger amount of the bone than is at all necessary. This was very apparent in many amputations in the East. Mr. Syme has laid down the true principle which should regulate our proceed- ings, when he says, " It is not the length of the flaps which pre- vents the risk of protrusion of the bone, but the height at which it is divided above the angle of union of the flaps." In soldiers, as in many (although not all) cases submitted to primary amputation for accident at home, the proportion of mus- cle to skin and subcutaneous fat is different from what it is in most cases operated on in civil hospitals, and thus modifies^ our appreciation to some extent of the two modes of operating.^ Ic soldiers there is commonly but little subcutaneous fat, and the muscles are large and strong; hence it becomes very difficult, when practising the flap operation, to adapt the parts to one another, so as to fulfil the latter part of the old maxim, " Muscle must cover bone, and integument muscle." It cannot be said that this arose in the East from the maladroit performance of the operation by the flap, as the 6ame circumstance may be seen to occur at home in the hands of our ablest hospital surgeons. The paring and stuffing-in processes which are not uncommonly seen in hospitals, to correct the results of the condition referred to, are no less prejudicial than unsightly. The irritation is thereby increased, and proper adhesion of the parts prevented. In secon- dary amputation the excess of skin removes any fear of similar accidents. Chloroform has refuted the argument in favour of the flap operation, founded on the greater speed of its permance than the circular, as such great speed is now a matter of no moment. Bu t however it be with regard to the question in general, there 168 SURGERY OF THE CRIMEAN WAR. is one fact which any one who had opportunities of watching matters during the early part of the late war will amply verify, viz., that the circular stumps stood the transit to the rear much better than those formed by the flap method, and thus it would seem that the former mode of operating is more advantageous in military practice than the latter. The long heavy flaps were so knocked about during the land and sea passage, that they oftt-n became loose, got bruised, and ended by sloughing; while the firm, compact stumps made by the circular method were little, if at all, injured. When patients can be treated in camp to a ter- mination, the influence of this circumstance is, of course, null. It may be said that the length of the flaps was a mistake com- mitted in the operation ; but, unfortunately, such errors must always be looked for in like circumstances, where there is a large body of operators, most of them without previous experience in operating, and whose chief fear always is to have " too little flap ;" for although it is true what Hammick says, that " it re- quires more practical experience to know when to take off a limb than how to do it," yet the how must also be studied, like every- thing else. In considering the statistics of amputation performed during the Crimean war, the figures refer solely to the period between the 1st of April, 1855, and the end of the war, and consequently exclude all the unfavourable part of the campaign, as well as the greater number of the operations which were absolutely perform- ed during the war. It was found impossible to attain to accuracy with regard to the earlier period, so the field of observation was restricted as stated. It is needless to point out how different must be the lessons derivable from the statistics of this latter period alone, to what they would have been if the whole period of the war ljad been included.* During the limited period I have mentioned, there were 732 am- putations in all parts performed, followed bydeath in 201 instances; of these, 654 operations and 165 deaths were primary, and 78 ope- rations with 36 deaths, secondary ; giving a per-centage of 27'4 deaths overhead—25*22 for the primary, and 46'1 for the secon- dary operations. If we include only the greater operations, viz., amputations of the shoulder, arm and forearm, of the hip, thigh, knee, and leg, then we have a total of 500 cases and 199 deaths, or 39-8 per cent.; of which total 440 cases and 163 deaths, or 37 *In my original papers the figures were intended to represent the period of the whole war. I have reason to think, that although, upon a more careful investigation of the returns than could be made in the Crimea, these numbers have since proved not strictly accu- rate, they yet represent pretty much the results which followed many of the operations as viewed in the more lengthened and legs favourable aspect of the war. AMPUTATIONS. 169 per cent, were primary, and 60 cases and 36 deaths, or 60 per cent, were secondary. The increase of the mortality as we approach the trunk may be shown thus, taking the primary amputations alone as giving the most unbroken series:— SUPERIOR EXTREMITY. Part- Ratio mortality per cent. Fingers,.....................................0-5 Forearm and wrist, ..............,..........1-8 Arm,..................................... 22-9 Shoulder joint,.............................272 INFERIOR EXTREMITY. Part. Ratio mortality per cent. Tarsus,....................................14-2 Ankle joint,..............................22-2 Leg,.....................................30-3 Knee joint,...............................50-0 Thigh, lower third,................_.......50-0 " middle,.............................55-3 " upper,.........'.....................868 Hip joint,................................100-0 The lower extremity was removed at the hip joint seven times during the period included in the returns, and at least three times more previously, giving ten cases, all primary operations, and all ending rapidly in death. One of these cases Was operated on by my lamented friend Dr. Richard M'Kenzie, after the Alma. The French had thirteen cases, primary and secondary, after the Almaand Inkerman, and all died. One of these, a Russian, was op- erated on by M. Legouest on the 3rd of October, 1855, at Con- stantinople. The upper part of femur was completely smashed by a conical ball. The flaps had adhered to a point by the mid- dle of December, at which date I saw the patient walking about the ward on crutches, and looked upon by all as being beyond danger. The' very night on which the order arrived for sending him to France—where he was to be admitted, by special permis- sion, into the Val de Grace—he fell when walking in the corri- dor, and hurt his stump so that it bled profusely. Inflammation was set up, suppuration, renewed haemorrhage, and diarrhoea fol- lowed, and he died on the 9th of February, four months after operation. M. Mounier in the same hospital had three cases, one of which I watched with interest. Two of these died of haemorrhage, one on the fifteenth, and the other on the twentieth day. The third died of cholera. One of these men was a Rus- sian. 8 170 SURGERY OF THE CRIMEAN- WAR. The mortality which has thus followed exnrticulation at the hip during the Eastern campaign, has been very deplorable ; yet, in the cases in which it was performed, no other alternative re- mained, except to abandon them to inevitable death, which many might be disposed to think the more humane proceeding, as they often linger for a long period before death. M. Legouest's case was unquestionably successful; and, although we can hardly hope with Larrey that this operation will ever be performed as readily as his favourite one at the shoulder joint, still the results of operation at the hip for accident have not been so utterly hope< less as to lead us to abandon it. M. Legouest has given, in a most interesting paper on the case mentioned above, a table con- taining most of the recorded cases of amputation at the hip for gun-shot wounds. Of primary operations he has collected 30 cases, all ending fatally ; of intermediate or early secondary ope- rations he finds mention of 11 cases, with 3 recoveries; and of operations performed at a period so late as that " the injury had lost all its traumatic character," 3 cases, with one recovery. Thus, if we sum up the whole, we have 4 recoveries in 44 cases, or a mortality of 90'9 per cent. Some of the primary cases died on the table ; all of them before ten days except 2, which per- ished within a month. The proportion of recoveries among those operated on after the primary period, but before a long elapse of time, i. e., at some period during the existence of " the traumatic phenomena," was the largest, and hence that would seem the best time to undertake the operation. During the Schleswic-Holstein war, amputation at the hip was performed 7 times—5 were operated on by Langenbeck; only 1 of these cases recovered. I find no mention whether these cases were primary or secondary. In the Indian campaigns I find mention of only 1 case of amputation at the hip for a gun-shot wound. It was a primary operation, and took place in the Punjaub. Thus, if wo reckon the whole number of cases operated on for gun-shot wounds, those recorded by Legouest, our own Crimean cases, and the Holstein and Indian ones, we find a total of 62 cases, and 5 recoveries, or a mortality of 9L9 percent. Mr. Sands Cox, recording the experience of civil hospitals, as well as those of military practice, up to 1846, gives in all 84 cases, most of them for injury, with 26 recoveries ; 14 of these successful cases being after accident, and of the unsuccessful, 20 were for injury ; and in the Medical Times and Gazette for April, 1857, there is u further record of 8 cases, of which 2 were for accidents, (1 primary and 1 secondary,) with three recoveries, all after operations for disease. Cox recognizes the difficulty of re- straining the haemorrhage during the operation, and the shock given to the nervous system, as the great sources of danger. The haemorrhage, at a considerable period after operation, would appear even a more common cause of the fatal event, than the difficulty of commanding it at the time. AMPUTATIONS. 171 It will, of course, only be in the event of such destruction to the bone or soft parts, or such other injury to the nutrition of the extremity, as puts resection out of our power, that amputation will be performed. If the fracture of the neck of the bone were Blight, as when occasioned by a small ball, or one striking with little propulsive force, such as that projected by the matchlock, then the case, I conceive, must be viewed more as a compound fracture of the upper part of the thigh, and should be treated ac- cordingly. M. Legouest has recorded 6 cases in which the limb was not removed or resected, and 3 of these recovered. One of these, cases of recovery having occurred in 1812, must have peen wounded by a round ball; the second was injured in a duel, and hence probably by a small light ball; while the third was observed in Africa, where neither the size nor the form of the balls used by the natives is to be compared to the conical bullet. All three were struck on the trochanter. The 3 fatal cases with us which were not interfered with, took place after the Alma and Inkerman, and hence were probably wounded by coni- cal balls. All are agreed that, when practical, the separation of the limb should bo accomplished at or through the trochanter, rather than at the joint, on account of the diminished risk ; and this can be more often executed than would at first appear, as it not uncom- monly happens that the fracture does not extend to the head of the bone, as it seemed at first sight to do ; hence it might be ju- dicious, in all doubtful cases, to make the incisions so low as to suit amputation at the trochanter. The steps necessary for exar- ticulation can easily be taken, if called for afterwards, when the bone is examined. Such a proceeding would certainly not be very " brilliant," but it might save a life. After the 1st April, 1855, amputation in the upper third of the thigh was performed 39 times, with a fatal result in 34 cases. Of the total number only one was a secondary operation,-and it ended fatally. The ratio mortality per cent, was thus 808 for primary, and 100- for secondary. I have never myself seen any case recover in which the limb was amputated beyond doubt in the upper third, and I never met anyone who had, except in one instance, and that man was seen in England. I saw several up- per third amputations, so-called, which was not really so. It is very easy to be deceived on this point. The French and Rus: sians found these operations so hopeless that they almost aban- doned them ; and in fact, as was before remarked, the attempt to save such limbs, hopeless as it was, seemed more promising than amputation in the field. Amputation in the middle third was performed during the pe- riod after the 1st April, 1855, 65 times, of which number 38 died ; 56 of these cases and 31 deaths were primary operations, giving a ratio mortality per cent, of 55*3 ; 9 cases were operated 172 SURGERY OF THE CRIMEAN WAR. on at a late period, and 7 died, or 77*7 per cent. Amputation in the lower third was performed during the same period 60 times, 46 being primary, and 14 secondary operations; of the primary, 23 or 50- per cent, died ; and of the secondary, 10 or 714 per cent. A very great many of the operations classed as "lower third," ought to have been entered as " middle third," as it very frequently happened that, from the operator adhering too closely to tho maxim of Petit, to " cut as little of the muscle and as much of the bone as possible," an operation which was ostensi- bly in the lower, was in reality in tho middle third.- This is a matter of which I have seen many illustrations ; consequently, I believe that at least one-third of the operations and the deaths classed as lower third, should be transferred to the middle third column, and thus the relative frequeucy and fatality of the two operations would be better expressed. Taking amputations in all parts of the thigh, then, we find the number of operations after the 1st of April, 1856, was 164, of which nnmber 140 were primary, and 24 secondary operations. The total mortality was 105, or 64 • per cent. Of the total deaths, the primary amputations yielded 87, or 62'2 per cent} and the secondary 18, or 75* per cent. It must always be borne in mind, that these results only refer to the period of the war when, as was before stated, secondary operations were becoming very rare, and tho state of matters in camp so improved, that tho total mor- tality after amputations was by no means what it had been at an earlier period; so that to say that the average mortality after amputation of the thigh in the Crimea was 64* per cent., does not by any means express the whole truth. However, if we take the later period only into consideration, then our results may be thus contrasted with those obtained in other fields of observation. AMPUTATIONS. 173 TABLE SHOWING THE PER CENTAQE OF DEATHS AFTER AMPUTATION (PRIMARY AND SECONDARY) OP THE THIGH FOR GON-SHOT WOUNDS AND ACCIDENTS. Crimea, British army from April 1st to end of war, Constantinople, French Dolma-Batchi hospital, Mounier,................................... Naval Brigade, Crimea,......................... Indian campaigns,............................ Waterloo,..................................... Spain, Alcock,............................¥... Schleiwic-Holstein, Esmarch,...........^,...... Danish army, 1848-50, Djorup,..........._...... Sedillot, i: Campagne Constantine," 1837,.......... Africa, Baudens,., . ........................... Polish campaign, Malgaigne,.................... Mexican War,................................. Hotel Dieu, 1830,.............................. Cases communicated to the Academy, 1848,....... INJURY. Phillips, ..................................... Parisian hospitals, Malgaigne................... Glasgow, previous to 1848, Lawrie,... ........... " M'Ghie,... .....'..................... " Steele,......................-........ St. Thomas' hospital, South,..................... Hussey,...........................•.......... James, all primary,............................. University college, Erichsen,.. _................. Mortality per cent. 64-0 82-6 65-0 48-7 70-2 62-0 60-15 567 87 5 51-4 100-0 100 0 81-8 77-2 71-8 73-9 75-0 78-6 72-0 85-7 62-5 61-5 60-8 The usual discrepancy which marks" statistical tables is observ- able in the above enumeration. That between the results ob- tained in our army, and those quoted from the French, and which were kindly furnished to me by M. Mounier, is easily under- stood, when it is stated that of the total number of 46 amputa- tions of the thigh which presented themselves in the hospital presided over by that distinguished surgeon, 25 were secondary operations, all of whom perished, while in our returns, and those of the Naval Brigade, there were very few consecutive amputations. Out of 21 primary amputations reported by M. Mounier, 8 recovered. The low mortality among the Indian eases is somewhat difficult to account for. In calculating them, I did not include any case except those the result of which I 174 SURGERY OF THE CRIMEAN WAR. could find well authenticated. To distinguish between primary and secondary operations, in many of the cases recorded by the various authors referred to in the above table, was found impossi- ble, but so far as this can be aceomplished appears in the follow- ing table: Table showing the mortality after primary and secondary (dis- tinguished) AMPUTATIONS OF THH THIGH FOR GUN-SHOT WOUNDS. Crimea alter April 1, 1855,...... Constantinople, Mounier,........... Legouest,......................... Naval Brigade,...................... Indian campaigns.................... Spain, A Icock,..................... Africa, Baudens,.................... Cases communicated to the Academy, 1848, in which the distinction is drawn,........................... Mortality per cent. Primary. Secondary 62- 75- 61-9 100- .. 100- BO- 60- SS- 69- 64-7 60- 13-3 80- 57- 81- Table showing the mortality aftkr primary and secondary (dis- tinguished) AMPUTATIONS OF THE THIGH FOR INJURY. Malgaigne................ Glasgow, Lawrie,.......... " Steele,............ " M'Ghie,......... St. Thomas' hospital, South,. University college, Erichsen, H ussey,................... James,................... Mortality per cent. Primary. Secondary 75- 60- 91-8 66- 65-6 83-6 61-2 96-6 100- 50- 57- "62-5 83- 61-5 . , If a calculation is made of the mortality succeeding amputa- tion of the thigh from gun-shot wounds alone, and the whole number of cases referred to in the above table included, then the average mortality per cent, of primary operations would appear AMPUTATIONS, 175 to be 56.5, and of secondary 79.0, while, if the operations per- formed in civil hospitals for injury are alone calculated, then the average mortality of primary operations would appear as 69.6 per cent., and secondary 75.4, a result somewhat different from what is usually obtained. Amputation through the knee-joint has been performed in our army 6 times primarily, 3 of which were fatal, and once secon- darily with a fatal result. This very old operation has lately been creating some interest in the profession, and was often per- formed by the French surgeons in the Crimea. The opinion they were led to form of it may be supposed to be expressed by Bau- dens, when he says (Une Mission Medicate en Crimee), "It is a truth which the numerous facts observed in the Crimea permit us to affirm, that, whenever it is impossible to amputate the leg, the disarticulation of the knee should be preferred to amputation of the thigh. The former has more often succeeded than the latter." There are not, however, very many cases occurring in the field which-are adapted for this operation, as it should be performed only when the injury is limited to the leg-bone, and the femur re- mains intact; and when this takes place, it often happens that the soft parts are so much implicated as to deprive us of flaps. However, if the posterior flap is destroyed, we can take a long flap from the front, and vice versa. To 4 of the cases operated on in camp, with the details of which I am acquainted, the ope- ration was not applicable, as the femur was more or less injured, so as to call for the removal of part of it: hence the operation, although termed amputation through the knee, was in reality low amputation of the thigh, such as that now employed in white swelling of the articulation. As to the mode of operation, the French mostly adopted Bau- dens' method, but in 5 cases operated on in the general hospital that proceeding was departed from, in so far as that the posterior flap was made from within outwards in place of the reverse, as directed by that welbknown surgeon. The anterior flap, too, was not made so long. Whatever method of operating be adopt- ed, the great point which demands attention is, to have the flap sufficiently broad to cover the expanded end of the femur, which " there requires a large and broad covering. Of the 5 cases ope- rated on in the general hospital, one died of phagedenic slough- ing on the forty-third day; another, a soldier of the 62nd, died of enteritis on the sixty-seventh day, the stump being healed to a point; a third sank from exhaustion on the ninth day after operation ; a fourth never fairly recovered from the shock ; while the fifth and last case recovered, under the charge of Dr. George Scott, who operated on him. This patient, a soldier in the Buffs, was struck on the right knee-joint by a ball, on the 8th of Sep- tember. He thought himself very slightly injured, as the only thing he observed wrong with the joint was his inability to flex it, on account of " something catching in it." A small opening 176 SURGERY OF THE CRIMEAN WAR. was found in the middle of the popliteal space, slightly external to the middle line, from which a good deal of blood flowed. This opening led into the cavity of the articulation, and spicuhc of bone were felt within. A part of the end of the femur was re- moved, but the patella left. A round ball had pierced the exter- nal condyle, and lodged. The posterior flap eventually sloughed, and exposed to the end of the femur; but the bone became sub- sequently covered over with granulations, and though the pa- tient's progress towards recovery was much impeded by the for- mation of an abscess among the muscles of the thigh, which re- quired extensive incisions, he went to England in perfect health in January. His stump was strong and firm, and he had muoh power over its movements. The patella could be felt on the up- per surface, to which position it had been gradually retracted. In several of the cases which I have seen in the French hospitals, where sloughing of the flaps had taken place, as in this case, and exposed the extremity of the femur, the cartilages were alone thrown off, but not a scale of bone. So far as I can judge, the practical advantages of this opera- tion are equal in value to those theoretical ones which its advocates claim for it, and they would seem to recommend its more general adoption in any future campaign. First of all, the shock to the system is less, and we obtain a larger and firmer stump than when the femur is sawn through ; the end of the bone on whioh the patient has to bear his weight is likewise more expanded, and more rounded, and hence calculated to in- spire greater confidence in the'patient in the use of it, and less liable to cause ulceration by its pressure on its coverings.* A false leg can be more easily attached to such a stump, and more power is retained in progression from the muscles which remain undivided, than when the limb is amputated in the continuity. Few now participate in Liston's opinion of a long thigh stump, but, on the contrary, most surgeons try to keep their section as far as possible from the trunk. The non-interference with the medullary canal obviates many of the dangers of amputation, according to Cruveilhier; while the extremity of the femur; which is largely supplied with blood-vessels, being retained, there is less fear of exfoliation than when the dense tissue of the bone * The absorption of the condyles of the femur which may go on after this operation, is illustrated by a case mentioned by M. Legouest (Amputation partielles du pied), in which a soldier had un- dergone amputation at the knee in 1800, in Italy, and " the enor- mous tuberosities had so diminished in volume that no trace of them could be recognized, but the member presented a cone terminated by a point." So completely had the part changed, that it was only after very careful examination they believed the man's story, that he had been amputated at the joint. AMPUTATIONS. 177 has been opened by the saw. The position of the divided artery in the centre of the flaps, and the few ligatures which required, are further arguments in favour of this operation. There is lit- tle fear but that the flaps will adhere over the cartilaginous ex- tremity of the bone—in fact the cartilages soon disappear during the healing process. There is some appearance of force in the objection which some have advanced to the operation, that from the length of the slump no proper space is left the play of art artificial joint; but if it be evident, as civil statistics at least prove, that the fatality attendant on this operation is less than that which follows amputation of the thigh, then any such ob- jection loses all its weight. If then, cases were selected for the operation in which the fe- mur remaining intact, and the legbones being destroyed, a suffi- ciency of flap could be got from the calf, or the front of the leg, and if the amputation was performed early, I firmly believe, with Malgaigne that it is " Encore une de ces operations trop legerement condamnees, et qui lorsqu'on a le choix merite toute preference sur l'amputation de la cuisse dans la continuite." The leg was amputated after April 1, 1855, 101 times, with death following in 36 cases, giving a mortality of 35.6 per cent.; 89 cases, and 28 deaths, were primary operations, and 12 cases, with 8 deaths, secondary—thus affording a ratio of mortality per cent, of 31.4 for the primary, and 66.6 for the secondary. The rule generally followed in our army, has, I think, been to preserve as much as possible of -the limb, but except in those cases in which the operation was performed just above the ankle- joint, the French appeared usually to amputate at the place of election. I saw no instance in which Larrey's operation through the head of the tibia was had recourse to, but I am informed that it was several times successfully performed in the French ambulances. The greatly improved mechanical contrivances of late years have much changed the bearing of the question with regard to long leg stumps. The facility and moderate cost with which ar- tificial limbs can now be fitted to any part of the limb, from the knee to the foot, has obviated many of the reasons which former- ly induced surgeons to prefer the high operation. Larrey's, through the head of the tibia, is a most valuable one when the destruction has extended high up the leg, as it enables us to re- tain the use of the knee joint, as well as diminish the risk to life. That at •* the place of election" will, of course, continue to be employed in cases of injury above the middle of the leg; but when the nature of the accident permits of it, the part of the leo- which appears to combine most of the advantages sought in leg stumps by both the surgeon and the mechanician, is undoubt- edly that in the centre of the middle third. The length of the lever thus obtained, the diminished bulk of the part and consequently of the truncated section, the means of covering 178 SURGERY OF THE CRIMEAN WAR. .the bones, and the room it affords for attaching a limb, are all in favour of this locality. Many most admirable stumps were made in this part of the limb during the war. In operations for acci- dent, as in gun-shot wounds, we can, of course, operate lower in the leg than we can when the operation is undertaken for dsi- ease, from .the absence of the thickened state of the bone, and the changed and bound down tissues which are so common in cases operated on in civil hospitals. * As to the operation just above the anckle, which hajuof late years caused so much discussion on the continent, we had, so far as I know, no experience in our army; but the French had a good number, which, so far as the condition of the stumps went, were by no means promising. This (peration, although revived by the improved method of procedure introduced into practice by M. Lenoir, is yet of sufficiently old date. It is mentioned by Dionis in his " Cours d' Operations," and was practised by Brom- field in 1740, and afterwards by White, Alanson, and Bel), in England. In France, Blandin Often performed it in recent times, but was induced to abandon it, like many others, from the bad results his method of operation yielded. By M. Lenoir's modi- fication,* and M. Martin's artificial limb, the operation promises again to come into favour. This operation appears to me to have a special bearing on military^ practice. Its value will be best judged of by considering, 1st,'its safety, and 2nd, tho usefulness of the resulting stump. As to the first point there can be no question as to its advantage over any other amputation in the leg. The greatly diminished bulk of the soft and hard parts at the place of section, the smaller amount of shock such severance will occasion, and the more rapid closing of the wound, are all incontestable. Its fatality in the cases operated on in France has been only as one-sixth or one-seventh, while the mortality of amputation at the place of election is more than one-half (55 in 100 according to Malgaigne). In some hospitals, as in the Beaujon, the mortality has been even less in the sus-malleolaire operation than that mentioned above: thus M. Iluguier only lost 1 out of 14 cases. So then, as far as the mortality goes, there can be no division of opinion, as there is about the second point, viz., the state of the stump afterwards. The difficulty of retain- ing enough of covering for the bones, the fear of such retraction as will occasion a conicity^ of the stump, the tenderness of the cicatrix, and its inability to stand pressure, the chance of fusi- form collections of pus forming among the tendons, of caries or necrosis of the bones following,—all these are among the ob- jections which have been advanced to the operation. If we, however, carefully examine these by the light of the large num. See Arch. Gen. de Med., July, 1840, and Memoire by Arnal and Martin, Paris, 1842. AMPUTATIONS. 179 her of observations which can now be brought to bear on the sub- ject, we find that the only objections which are of any weight are the scanty covering of soft parts, the tenderness of the cica- trix, and the risk of necrosis. Purulent collections can be easily avoided by careful dressing; and the presence of the other evils, and, in fact, the want of flap also, must be referred to the man- ner in which the operation has been performed. I have examined a considerable number of those amputated in Paris, and am bound to say that, while in some cases the evils spoken of existed, in the greater number of instances good and firm stumps were formed. This was especially the case in several which I saw in M. Lenoir's service, in the'Neckar. Some of the cases which had been operated on in the Crimea were certainly very bad." At the Society of Surgery I saw an Arab, shown by Baron Larrey, both of whose limbs had been removed above the malleoli, in the East. They were both secondary operations, and seemed to have healed well at first; but the cicatrix afterwards ulcerated, and at the period he was shown to the society (nearly two years after operation), he could not use his stumps in any way, from their being in an unhealthy condition. In another case, shown to the same society on a subsequent occasion, the operation had been performed in 1848, and the man bad been an inmate of hospitals on,several occasions during the interval, on account of ulceration, abscesses, and necrosis in his stump. The bones were much thickened, and evidently diseased at the time I saw him. A letter from M. Hutin of the Invalides, which was at the same time read, stated the results of the operation as they had come under his observation, and certainly his evidence was not favourable ; however, the want of a properly constructed artificial limb for the patients, detracted much from the value of his remarks. If the limb cannot be fitted with a false foot, but made to rest on the knee, scarcely anything will make amends for the long and cumbrous stump. Since 1845 M. Hutin had had 5 cases especi- ally under his notice: one could walk, but with difficulty, and would willingly part with his foot; one had been several times in hospital from the state of his stump, and three had to undergo subsequent amputation. Now all this is sufficiently distressing and discouraging, but in military practice I question whether it is conclusive. The limited mortality yet presents itself to us as a great fact, which arrests our attention. If when men die so fast after the ordinary amputation of the leg, as they did during the early part of the war in the Crimea, it becomes a grave con- sideration whether, with all its subsequent drawbacks, we should not adopt this process when practicable. If our choice lay be- tween two operations of equal gravity, then unquestionably we are bound to select that which will provide the most useful stump; but when the chances of death are beyond all comparison greater in the one case than in the other,—when, independently of those dangers which attach to the operation itself, the marked presence 180 SURGERY OF THE CRIMEAN WAR. of an " hospital epidemic" makes it desirable to exposo a small and as rapidly-healing a surface as possible, then I think it may be conceded that the sus-malleolaire operation has many claims upon us. Life must be our chief concern ; convenience a subor- dinate consideration. The complaints of patients about the in- convenience of their stumps, must be considered as affording little evidence in the matter, as the faot that they survive to mur- mur is often due to the very operation against which they com- plain. If the heel remains, then this operation could not be thought of, but it is in those cases, sufficiently frequent in their occur- rence, in which the whole foot has been carried away by round shot, or such like accident, and in which the choice of operation lies only between the amputation above the malleoli or higher up, that the merits of this method can be weighed. The careful study of those cases in which"caries or necrosis has appeared in the bones of the stump after the sus-malleolaire amputation, will be found to have been submitted to the operation for disease, and not for injury, and it will generally be found, besides, that a faulty apparatus has been used afterwards. Everything depends on the careful adaptation of the false foot, and, so far, this is of itself an objection to the operation being performed on the poor; but the view alone I wish to take of it at present, is with refer- ence to military practice, and there it seems to promise many ail-. vantages at times when there prevails a high mortality after operations. Amputation at the ankle-joint was performed 12 times in the Crimea during the period embraced by the returns, and death followed in 2 cases. Of the total number of cases 3 were second- ary operations, and these were all successful. Syme's operation was as useful and as successful in its results as usual: Pirogoff's modification of Syme's method was, I understand, several times tried at Scutari. I saw none of these cases, and am ignorant of the results. In England it appears to have been recently followed by good effects in (i out of 9 cases in which it was performed. Langenbeck is said to approve of its results in a good many cases in which he has tried it; but the history of the 3 cases first re- ported by M. Pirogoff himself, and those more recently put on record by Michaelis of Milan, and various German surgeons, does not hold out much encouragement to repeat the operation, not only from the long period, necessary to a cure, but also from the unsatisfactory nature of the resulting member. It was re- ported in the East that this operation had been frequently per- formed by Pirogoff himself in Sebastopol, but that he had found the calcaneum act as a foreign body in the stump, and was hence disposed to abandon it. lloux of Toulon's operation was per- formed Once in the general hospital in camp, with most excellent results. The chief objection to this operation arises from the vessels and nerves beiDg drawn under the bono; however, it cer- AMPUTATIONS. 181 tainly enables us to form a stump little inferior to Syme's, when the half of the heel has been destroyed. Baudens is said to recommend the flap to be taken from the interior surface of the joint, or even from its external surface, if it can be got no other where, rather than go above the ankle. Chopart's operation was performed primarily 7 times, one case ending unfavourably, while Lisfranc's was successful in the 4 cases in which* it was tried. The step now always followed by Mr. Ferguson, of re- moving the projection of the astragalus in performing Chopart's operation, is an undoubted improvement. The upper extremity has been removed at the shoulder joint, between the 1st of April, 1855, and the end of the war, 39 times, with a fatal issue 13 times, or 33'3 per cent. Of these opera- tions 33 were primary, and 9 deaths followed, giving thus a mortality of 27*2 per cent.; while of 6 secondary operations 4 died, or o6-6 per cent. During the previous period of the war at least 21 other cases of amputation at this joint were performed, beyond the 39 mentioned above, and of that number 6 died, thus presenting a total of 60 cases and 19 deaths, or a ratio of mor- tality of 3L6 per cent, overhead. It is impossible fairly to contrast the results of amputation at the shoulder and that in the shaft of the humerus; as, in mili- tary practice particularly, it very much oftener happens that the trunk has suffered severely in those injuries which necessitate ex- articulation, than those in which amputation of the upper arm alone is required. Not a few illustrations of this occurred in the Crimea. Thus, in at least two of the cases returned as shoulder- joint amputations, besides the injury to the arm, the scapula was carried away or destroyed, and the muscles of the chest torn. In no operation is the advantage of primary over secondary amputation so evident as in that at the shoulder-joint; early ope- ration at this part being an exceedingly successful undertaking, while late interference generally affords a considerable mortality. Thus, if we take Guthrie's experience in Spain, and Dr. Thom- son's observation after Waterloo alone, this point is well illustra- ted : of 19 cases of secondary amputation mentioned by Guthrie as having been performed between June and December, 1813, 15 died, while of an equal number who were operated on in the field, only 1 died. Dr. Thomson again says, " In Belgium almost all of those recovered who had undergone primary amputation at the shoulder-joint, while fully one-half died of those on whom it became necessary to operate at a late period." The same point is illustrated to some extent by our Crimean results, less than a third of the primary, and two-thirds of the secondary perishing. Deputy-inspector Gordon had one case of recovery, in which both the arm and the greater part of the scapula were removed. Mr. Howard of the 20th regiment successfully removed the right arm of one man and the left of another, in close succession, at 182 SURGERY OF THE CRIMEAN WAR. the joint, for injury occasioned by the same cannon ball which had struck between them.* Amputation of the upper arm was performed in the Crimea, from April 1st to the end of the war, 102 times, followed by death in 25 cases, the mortality per cent, being thus 245. Of ^ the total number, 96, and 22 deaths were primary operations. The ratio of the mortality was thus 22*9 for the primary, and 50*0 for the secondary operations. The forearm was amputated during the same period 52 times primarily, and the hand at wrist once, with only one death; while of 7 secondary operations in the same parts, 2 died. These returns do not speak of a considerable number of secon- dary amputations of the arm, which were performed early in the war, and the success of which was certainly such as to warrant us in trying to save, in the first instance, most cases of gun-shot wounds of the aim. It is almost impossible to say what wound of the arm by a ball will not recover ; so that it is a well recog- nized rule to wait, in all but desperate cases, and only amputate if unavoidable at a subsequent period. In military practice sec- ondary amputations are only justifiable when performed on the upper extremity. The mode of managing stumps in the East was that usually followed at home for the promotion of adhesion by the first in- tention. The edges of the flaps were usually united by suture. The observation of this method in the Crimea did not certainly appear to be satisfactory. To wait, as Liston so strongly advo- cates, till all oozing has ceased from the cut surfaces, is unques- tionably a most useful precaution, and one of great moment to their successful and early union. The irritation which tho stitching of the edges Occasions, the want of sufficient room for subsequent swelling, the confinement of pus which is thereby * The following is a most instructive case, as showing how the operation of amputation at the shoulder may be recovered from un- der the most unpromising circumstances. It occurred in the 29th regiment, serving in India, and under the care of Deputy inspector Taylor. Sergeant Ritchie was struck by a cannon ball on the upper part of his left arm, by which the bone, including the head and up- per third of the humerus, was smashed. Both folds of the axilla were carried away, and tho artery was divided. The arm was only kept attached by a portion of the deltoid, and the skin covering it, and of these the flaps were made. This man lay exposed on tho field for three days; yet he recovered completely. "His case is peculiar in two respeo.ts : 1st, no ligature was needed; and 2nd, at least two-thirds of the face of the stump was the surface left by the passage of the cannon ball, and yet it healed very kindly." Dr. Taylor informs me that he recently saw this man in good health. He is on the star! in Belfast. AMPUTATIONS. 188 favoured, all appear reasons against sutures. Strips of wet lint applied like adhesive plaster, always appeared preferable. I never saw one case among our most numerous amputations in which primary adhesion took place tlioughout the whole surface of the flaps. They united readily enough along their edges; but the result of this was, that a large bag of pus was formed within the end of the stump, which continued as a depdt for absorption into the system, by steeping the end of tho sawn bone and the ves- sels in its matter, and it burrowed far and wide in the intermus- cular spaces and along the bone, and ended not unfrequently in causing considerable necrosis of the end of the divided shaft. Unquestionably it may be said that such collections should have been recognized and prevented; but yet it seems to me, that when ample proof is afforded, as it was early in the East, that primary adhesion was the rare exception, and not the rule ; and when the patients were so peculiarly liable to purulent absorp- tion as they were with us : it would have been better practice not to have attempted primary union, but to have adopted such treat- ment as best favou«ed the freest discharge of the matter so soon as it was formed. The method of dressing with compresses, re- commended by Mr. Luke, was most useful in several cases in which I tried it, in preventing the accumulations referred to. The contrast afforded by the heavy dressings for stumps em- ployed by the French and our water dressing was very marked, and may have contributed something to the result which obtained in the less prevalence of purulent absorption in our hospitals than with them. Bad as it was with us, it never became the terrible epidemic it was in the French hospitals. We had no means of trying the method of treating stumps in water, recom- mended by Langenb^k. The ease with which the purulent se- cretion can be got quit of by position in amputations of the arm and leg, contributes, I have no doubt, not a little to the decreased mortality attending these operations, as compared to amputations of the thigh. The Russian surgeons, I am told, when operating by the circular method, which they generally adopt, split the posterior flap, and keep this part open in order to drain off the pus. Such a step would meet with little favour in this country, but it presents many advantages when purulent absorption is so common as it was in the East. M. Sedillot, of Strasburg, I be- lieve, proposes a similar modification for general use. Primary adhesion is, of course, most desirable when hospital gangrene prevails, but it is just at such a time that this result is most difficult to obtain. Cases of secondary amputation of the thigh for injury of the knee, were always those in which attempts at primary union did worse. The long fusiform collections of matter which are so apt to exist in these cases previous to operation, extended, and did every possible harm. Careful bandaging from above downwards 184 SURGERY OF THE CRIMEAN WAR. to the base of the flaps seemed to be highly useful in these cases. Pus poisoning was unquestionably the chief source of our mor- tality in the East after amputation, especially after secondary operations. The resemblance between its early features and those of ague was perhaps more marked among our patients than it even usually is. This seemed especially the case among men who had served during the early part of the war—of this, how- ever, I am not certain. We had many most beautiful examples, post mortem, of veins leading from the stump remaining round, patulous, and filled with pus, and sometimes reddened in their interior. It was not uncommon to trace the pus-filled vein from the thigh to the vena cava. It is a question on which it is difficult to decide whether or not, when pus absorption is so common as it was with us, it would not be justifiable practice to ligature the chief vein at the time of operation. The views of Mr. Travers and others would cer- tainly seem to oppose the adoption of such a step, but we have, on the other hand, the evident absorption of pus into the sys- tem by this channel; and, besides, numerous cases are on record in which the ligature of the vein has not only not been followed by evil results, but has absolutely been the apparent cause of preventing inflammation and pus absorption.* The non-appear- ance of symptoms of purulent poisoning till after tho separation of the threads, makes it generally difficult to say which set of vessels—those ligatured or th^se not ligatured—have been the carriers of the pus. In the case referred to in the note death took place rapidly,"before the ligatures were detached., Hennen expresses himself thus on the danger of tying veins: " When the great veins bleed I have never hesitlfted about tying them also, and it is most particularly necessary in debilitated subjects." Chevalier, too, says—" I know from experience that the princi- pal vein of a limb may be included in the same ligature as tho artery without any disadvantage ensuing." Every hospital sur- geon has seen instances of the same thing. I most firmly be- lieve in Stromeyer's views on absorption by the veins of the bone, from observations which have been presented to me. ^ Independently of all fortuitous circumstances, there can be little doubt but that some constitutions oppose themselves more to pus poisoning than others. This, although a most unsatisfac- tory mode of explanation, yet seems the only way of answering the difficulty which is presented to us in the much greater sus- . * This is particularly well illustrated in a case related by Mr. Johnston, of St. George's hospital, in the Journals of 1857. In that case those vessels which had been tied were free both of inflam- mation and pus, while those not included in ligatures were full of pus, and "much inflamed." AMPUTATIONS. 185 ceptibility of gome to purulent absorption than others. Most die rapidly, while others, not apparently so Well fitted to withstand the assaults of such an invader, though placed in precisely the same circumstances, only yield inch by inch, and others again escape altogether. The presence of typhus fever in an hospital has been supposed to favour the development of pyoemia, and, although it cannot be denied but that the diseases often co-exist, yet it seems more probable that they both proceed from a like source—a lowered vital energy in the patients, or vitiated hygienic arrangements. The secondary deposits were with us, as usual, generally found in the lungs. Beck states, as the results of his observation in Holstein, that such was the seat of the deposition in seven cases out of ten in which patients died of pyoemia. This is not, I be- lieve, an exaggerated average. Some of the French surgeons employed at Constantinople made the remark that they seldom found the pus collected in dep6ts, as they had been accustomed to see it in Africa; but that it commonly was disseminated through the organs, muscles, and bones. The visceral congestions which so often follow amputation, were more than commonly fatal in their results in the Crimea, from the presence in most cases of the seeds of disease in the lungs, kidneys, and intestines. Phthisis and acute dysenteric attacks were not unfrequently the immediate causes of death, and in at least two cases the symptoms of Bright's disease of the kidney were most rapidly developed after thigh amputa- tions. CONTENTS. CHAPTER I. Distinction between Surgery as practised in the Army, and in civil life—Soldiers as patients, and the character'of the injuries to which they are liable—Some peculiarities in the wounds and injuries seen during the late War, - 5 CHAPTER II. The " peculiarities" of Gun-shot wounds, and their general treatment, - - - - 14 CHAPTER III. The use of Chloroform in the Crimea—Primary and Second- ary haemorrhage from Gun-shot wounds—Tetanus—Gan- , grene—Erysipelas—Frost-bite, - - - 31 CHAPTER IV. Injuries of the Head, - - ( - - 57 CHAPTER V. Wounds of the Face and Chest, - - - 84 CHAPTER VI. Gun-shot wounds of the Abdomen and Bladder, - 104 II CONTENTS. CHAPTER VII. Compound Fracture of the Extremities, - 118 CHAPTER VIII. Gun-shot wounds of Joints—Excision of Joints, &c., - 135 CHAPTER IX. Amputation, .... 163 MILITARY BOOKS! PUBLISHED AND FOR SALE BY *♦ W. ftANO0tr»t 121 MAIN STREET, RICHMOND, VJRGINIA. AND FOB SALE BY BOOKSELLERS GENERALLY. Instructions for Officers and Xon-Commissioned Officers of Cavalry on Outpost Duty, By Lieut. Col. VON ARENTSCHILDT, First Hussars King's German Legion. With an Abridgement of them By Lieut. Col. the Hon. F. PONSONBY, Twelfth light dragoons. PRICE, FIFTY CENTS. 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