CIECULAE No. 6. WAR DEPARTMENT,

SURGEON GENERAL'S OFFICE,

"Washington, November 1, 1865.

REPORTS

ON THE

EXTENT 1ND NATURE OF THE MATE LS

AVAILABLE FOR THE PREPARATION

OF A

MEDICAL AND SURGICAL HISTORY

OF

THE REBELLION.

PRINTED FOR THE SURGEON GENERAL 'S OFFICE BT

J. B. LIPPINCOTT & CO. PHILADELPHIA.

1865.

ERRATA. Page 9, fifth paragraph, for 604 read 104.

Page 41, fifth paragraph, for "fractured wounds" read "punctured woun< Page 43, line fifteen, for "internal carotid" read "internal maxillary.'''

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Surgeon General's Office, Washington, D. C,

November 1st, 1865.

The following Circular is published for the information of the Medical Officers of the Army.

JOSEPH K. BARNES,

Surgeon General.

CIRCULAR NO. (5.

Surgeon General's Office, Washington, D. C ,

October 20th, 1865.

BREVET MAJOR GENERAL JOSEPH K. BARNES,

Surgeon General U. S. Army.

General: —

In response to your inquiries relative to the nature, extent, and value of the sur- gical data that have accumulated in the department of your office under my charge, and in regard to the progress that has been made in arranging these materials, I have the honor to make the following report :

The materials in the office relating to the surgery of the late war consist of the reports of the medical officers engaged in it, and of illustrations of these reports in the shape of pathological specimens, drawings, and models. The documentary data are of three kinds : first, the numerical returns, in which the number alone of the different forms of wounds, accidents, injuries, and surgical diseases is given; secondly, what may be called the nominal returns, in which are furnished the name and military description of each patient, and the particulars of the case, with more or less of detail; and thirdly, the miscellaneous reports. To the first class belong the "classified return of wounds and injuries" which every medical officer has been required to furnish imme- diately after every engagement, the " tabular statement of gunshot wounds," and the portion of the "monthly report of sick and wounded" referring to surgical diseases and accidents. The second class comprises the "quarterly reports of wounded" and the "quarterly reports of surgical operations" required of all general and post hospitals, the quarterly "sanitary reports" of regimental surgeons, the "nominal lists of wounded" forwarded by medical directors after every general engagement, and extracts from "case books." In the third class are included the reports of medical directors of armies

l

9.

INTRODUCTION.

in regard to the operations of the Medical Department, and the succor given to the wounded; reports and dissertations on new methods and modes of treatment, and modifications of surgical apparatus and appliances ; pathological researches on morbid processes pertaining to surgery, as hospital gangrene, osteomyelitis, pyaemia, and the like; plans for ambulance organization, and the transportation of the wounded by land and water.

The extent of these materials is simply enormous. The returns are of as huge proportions as the armies that have been engaged in active operations for the last four years. The great body of the medical officers have made the reports required of them with commendable diligence and promptitude, and their zeal is the more deserving of praise when the engrossing nature of their field duties is considered. The result has been the accumulation of a mass of facts and observations in military surgery of unprecedented magnitude.

It is as yet impracticable to determine with accuracy the number of wounds received in action during the late war, though data for a near approximative estimate are accessible. But a comparison of a portion of the returns with the complete statistics of other armies will sufficiently indicate the vast numbers that are dealt with.

In the British Army in the Crimea, during the entire war there were 12,094 wounded and 2755 killed, or a total of 14,849.*

In the French Army in the Crimea, of a total effective force of 309, 2G8, according to the report recently made by M. Chenu, there were 39,868 wounded and 8250 killed, or a total of 48,118, although in his report of injuries of different regions M. Chenu records but 20,681 cases.f

In the late war, the monthly reports from a little more than half the regiments in the field give, for the year ending June 30th, 1862, an aggregate of 17,496 gunshot wounds. The reports from rather more than three-fourths of the regiments, for the year ending June 30th, 1863, give a total of 55,974 gunshot wounds. The battle-field lists of wounded for the years 1864-65 include over 114,000 names. But these returns are to be completed by collating with them the reports of general hospitals, where many wounded were received whose names the recorders of field hospitals or regi- mental medical officers failed to obtain, and by adding the names of those killed in battle.

In comparing the numbers of cases of some important injury, as, for example, gunshot fractures of the femur, it is found that in the French Crimean Army there were 459 such injuries, and in the English Army 194, while over 5000 such cases have been reported to this office. Or if one of the major operations is selected for comparison, as excision of the head of the humerus, the Crimean returns give 16 of these excisions in the British, and 38 in the French Army, but the registers of this office contain the detailed histories of 575 such operations.

* Medical and Surgical History of the British Army which served in the Crimea, during the war against Russia, in the years 1854, 1855, 1856. London, 1858. Vol. ii. p. 259.

t Rapport au Conseil de Sante dcs Armees sur les Resultats du Service Medico-Chirurgical aux Ambulances de Crim6e el aux Hopitaux Militaires Francais en Turquie pendant la Campagne d'Orient en 1854, 1855, 1856. Par • '.('. Chenu, l».M., Mi'decin Principal, Bibliothecaire de l'Ecole Imperiale de M6decine Militaire, Oflicier de la Legion d'Honneor, etc. Paris: Victor Masson et Fils, 1865.

INTRODUCTION.

3

The surgical specimens of the Army Medical Museum number 5480; and not only in specimens of recent injuries, but in illustrations of reparative processes after injury, of morbid processes, of the results of operations, and of surgical apparatus and appli- ances, this institution is richer, numerically at least, than the medico-military museums of France or Great Britain.

The value of these materials has been foreshadowed in referring to their nature and extent. It may be emphatically said that they throw much light on some of the great moot points in surgery; that they comprise on some subjects, as, for example, on the question of the propriety of excising the head of the femur for injury, fuller data than are now extant in the entire range of surgical literature; and that it may be hoped, without temerity, that they include the elements for the solution of many grave surgical problems.

To render intelligible an account of the progress that has been made in collating and classifying the surgical records of this office, and the collections of the Army Medical Museum, it is requisite to review briefly the measures that have been adopted by the Medical Department to gather and preserve the observations of the medical officers of the Army, and to compile, in an available form, the results of their inquiries and of their vast surgical experience in the iate war.

In 18G1, and during the first eight months of 1862, the "case book" and "regis- ter," made obligatory by regulations, the monthly and quarterly reports of sick and wounded, and the sanitary reports required of regimental surgeons, and of the surgeons in charge of hospitals, were the channels through which medical officers communicated such professional facts as they desired to place on record. These sources of informa- tion have been decried in some quarters, and in an official report to this office,* in July, 1863, it was declared that previous to September, 1862, "the surgical statistics of the war were absolutely worthless," and that " the only information procurable is such as can be derived from the examination of a mass of reports, all of which present merely certain figures under the vague and unsatisfactory heading, 'Vulnus sclopeticum.' "

That the surgical records of a period including the casualties of the first and second battles of Manassas, the battles on the Chickahominy, Ball's Bluff, Cedar Mountain, and Shiloh, and in which the returns from about one-half of the regiments in the field give an aggregate of over thirty thousand cases of gunshot injury, were deserving of such emphatic censure would be a source of grave regret, and it is gratify- ing to be able to state that a careful re-examination of these records proves that they contain a large amount of material that is far from valueless. The reports of the Washington, Fort Monroe, Baltimore, and Philadelphia hospitals of the treatment of the wounded from the Peninsular campaign, are replete with interest; the reports of the hospitals at Alexandria give voluminous materials in regard to the wounded from Cedar Mountain and the second Bull Run. The surgical records of the Fort Donelson campaign are very complete. The returns of the casualties incurred in the operations in North Carolina are satisfactory. The extracts from the case books of Surgeons Page and Clements, and Assistant Surgeons Peters and Billings, of the Army, and of Sur-

„* Consolidated Statement of Gunshot Wounds. Washington, July 1, 1863. Octavo, pp. 1 1.

4

INTRODUCTION.

geons Neill, Bontecou, and Bently, of the Volunteers, give a multitude of observations that throw light on some of the most important subjects in military surgery.

On May 21st, 1862, it was enjoined upon medical officers, by a circular order from the Surgeon General's Office, to enter upon the monthly reports details in regard to the surgical cases that came under their care, and to forward pathological specimens to the Surgeon General's Office, with the view to the establishment of an Army Medical Museum.

In June, 1862, a "tabular statement of gunshot wounds" was appended to the monthly report of sick and wounded. A consolidation of these tables for the months of September, October, November, and December, 1862, was published. The tabular statements of the first two quarters of 1863 have been consolidated also, but it has not been deemed expedient to publish them, because materials are on hand in which fewer sources of error exist.

On March 25th, 1863, Circular No. 4, of the Surgeon General's Office, established the "classified return of killed and wounded in battle."

On November 4th, 1863, by General Order 355, War Department, medical direc- tors of armies in the field were directed to forward to this office duplicates of their reports of killed and wounded; and, in promulgating this order, you instructed medical directors to detail suitable officers to collate and prepare all obtainable statistics and data in connection with past or future operations in the field that might be useful in the accurate compilation of the medical and surgical history of the war, and you directed the attention of all medical officers to this subject, and urged their co-operation in the work.

Circular 26, of November 26th, 1863, S. G. 0., called the attention of medical officers in charge of general hospitals to the importance of preserving representations of the results of surgical operations for the Army Medical Museum.

It was found that the details in regard to wounds, accidents, and injuries, inserted in the monthly and quarterly reports of sick and wounded, were insufficient, and that, although the defects in the reports were supplied by those officers who diligently recorded their cases in the registers and case books, yet such fidelity was not univer- sal, and the histories of many cases were meagre or imperfect, or omitted altogether. It was considered that the register in use was too bulky for field service, and too small for the requirements of general hospitals. A board of medical officers was accordingly directed to recommend a new form of register. The recommendations of the board were approved, and small portable registers were issued to medical officers in the field, while to each general hospital two large folio volumes were distributed, one as a register of sick and wounded, the other as a register of surgical operations. These registers contained minute directions as to the form in which cases should be entered under appropriate headings. The form of the register of sick and wounded is illustrated in the portion of this report that refers to injuries of the head, and the form of the register of surgical operations is given in connection with the subject of excisions of the head of the femur. To assist in the compilation of these registers, a new form of bed-card was adopted. Blank forms of quarterly reports of wounded and of surgical operations corresponding with the registers were prepared, and, on December 26th, 1863, b$ a special circular from this office, the officers in charge of general hospitals were

INTRODUCTION.

5

required to fill up these forms for the months of October, November, and December, 18G3. In January, 1864, the new registers were introduced in all the general hospitals, the "consolidated statement of gunshot wounds" was discontinued, and a quarterly transcript from the registers of all cases of wounds or of operations was required.

The new system has been found to work well, and the surgical records of the last quarter of 1863, and for 1864-65, are believed to possess a higher degree of statistical accuracy than has heretofore been attained.

Early in 1864, the new forms of reports of wounds and operations began to arrive at this office, and the work of transcribing and classifying their contents began. The cases of wounds were recorded in ten books, the new hospital registers being used for this purpose. The classification was as follows: nine volumes of gunshot injuries, viz.: 1. Wounds of the Head and Face. 2. Wounds of the Neck and Chest. 3. Wounds of the Abdomen, Back, and Spine. 4. Wounds of the Perineum and Genito-Urinary Organs. 5. Fractures of the Upper Extremities. 6. Fractures of the Lower Extrem- ities. 7. Flesh Wounds of the Upper Extremities. 8. Flesh Wounds of the Lower Extremities. 9. Wounds of Arteries, Veins, and Nerves; and a tenth volume embrac- ing Sword, Bayonet, and Miscellaneous Wounds. The cases of operations were recorded in five books, viz.: 1. Amputations in the Continuity. 2. Amputations in the Con- tiguity. 3. Excisions. 4. Ligations. 5. Miscellaneous Operations. On September 1st, 1864, there had been transcribed upon these registers the histories of 30,435 wounds, and of 1179 operations.

It was objected to this mode of registration, that injuries of the gravest and most trivial nature were confounded, and that the great mass of materials contained in the special reports, which medical officers had been encouraged to forward, was entirely omitted from the records. The least important cases received as much attention as the most serious, or even more, because the patients with trifling wounds were more likely to be transferred from hospital to hospital, and their histories were traced with greater difficulty. Moreover, the registers, though well adapted to the requirements of hospitals, were unsuitable for permanent records, the space being inadequate for the requisite details of important cases, or for summaries of the treatment and results in cases protracted through several quarters.

It was therefore determined that an effort should be made to arrange the records in a form more convenient for reference and study. In the first place, the early returns of the war were examined, and cases of the more important injuries were gleaned from them, and tabulated upon the new form of surgical reports. This work was of neces- sity performed by medical officers, or by clerks possessing a competent share of surgical information. In October, 1864, suitable books of record having been procured, the task of revising the surgical records began. It was decided to make numerous sub- divisions, and, while avoiding impracticable refinements, to group together similar classes of injuries. On the new registers were entered, in the first place, the cases extracted from the early reports. Then the registers in use were examined, and the category in which each case should be placed was indicated; or, if from lack of pre- cision in the report this was impossible, additional information was sought from the source from which the report had originated. Thus the cases recorded in the register of gunshot wounds of the head and face were distributed in six registers, viz.: those

INTRODUCTION.

of Fractures of the Cranium, of Fractures of the Bones of the Face, of Fractures of the Vertebrae, of Scalp Wounds, of Flesh Wounds of the Face, and of Flesh Wounds of the Neck. Especial attention was given to collecting all the information on file in the office in relation to gunshot wounds of the three great cavities, gunshot fractures of the femur, and the less common surgical operations. The histories of several thousand specimens at the Army Medical Museum, that had been forwarded prior to the adop- tion of the new system of reports, were tabulated upon the proper forms and tran- scribed upon the records; and, on the other hand, the records were found to furnish histories for many later specimens that had been forwarded without memoranda. An endeavor was made to co-ordinate and harmonize these data.

The following classification of wounds and their results and of operations was finally adopted. It is less elaborate than that employed in the British statistics of the surgery in the Crimea, and more detailed than that followed by M. Chenu, in the French sur- gical report of the Crimean war. The appended figures give the number of cases of each class that were revised and corrected upon the new registers on September 30th, 1865.

Classification of Wounds and Injuries, and their Results, followed in the Division of Surgical Records S. G. 0.

Gunshot Fractures and Injuries of the Cranium....

Gunshot Fractures of the Bones of the Face

Gunshot Fractures of the Spine, not involving the

Chest, or Abdomen

Gunshot Fractures of the Ribs, without injury of

the Thoracic or Abdominal Viscera

Gunshot Fractures of the Pelvis, not involving the

Peritoneal Cavity

Gunshot Fractures of the Scapula and Clavicle,

not implicating the Thoracic Cavity

Gunshot Fractures of the Humerus

Gunshot. Fractures of the Radius and Ulna

Gunshot Fractures of the Carpus and Metacarpus.

Gunshot Fractures of the Femur

Gunshot Fractures of the Patella and Knee-joint..

Gunshot Fractures of the Tibia and Fibula

Gunshot Fractures of the Tarsus and Metatarsus... Gunshot Penetrating Wounds of the Chest, and in- juries implicating the Thoracic Viscera

Gunshot Penetrating Wounds of the Abdomen, and

injuries involving the Abdominal Viscera

Gunshot Scalp Wounds

Gunshot Flesh Wounds of the Face

Gunshot Wounds of the Neck

Gunshot Wounds of the Thoracic Parietes

Gunshot Wounds of the Back

Gunshot Wounds of the Abdominal Parietes

Gunshot Wounds of the Genito- Urinary Organs

Gunshot Wounds of the Upper Extremities

Gunshot Wounds of the Lower Extremities

Gunshot. Wounds of Arteries

Gunshot Wounds of Veins

Gunshot Wounds of Nerves

Sabre Wounds

Bayonet Wounds

Simple Fractures, and Miscellaneous Wounds and

Injuries

Cases of Tetanus

Cases of Secondary Haemorrhage

Cases of Pysemia

Total 87,822

1108 157U

187

180

397

389 2408

785

790 1957 1220 1050

629

2303

565 3942 2588 1329 4759 5195 2181 468 21,248 25,152 44 3 76 106 143

2883 363

1035 754

Classification of Surgical Operations followed in the Division of Surgical Records S. G. O.

Amputations of the Fingers

Amputations at the Wrist-Joint

Amputations of the Forearm

Amputations at the Elbow- Joint

Amputations of the Arm

Amputations at the Shoulder-Joint

Amputations of the Toes

Amputations of the Foot (Partial)

Amputations at. the Ankle-Joint

Amputations of the Leg

Amputations at. the Knee-Joint

Amputations of the Thigh

Amputations at the Hip-Joint

Excisions of the Head of the Humerus

Excisions of the Elbow

Excisions of the Wrist ,

Excisions of the Ankle

„ . . „ ,. f Shaft of Humerus..

Excisions m the Contin- „ ,.

., e TT ,-, Radius

uity of the Upper Ex- { Ulna

tremities | „ ,. ,'VtV

[ Radius and Ulna...

Excisions of the Shafts of J

the Tibia and Fibula.

Fibula

Tibia and Fibula.,

Excisions of the Knee

Excisions of the Shaft of the Femur

Excisions of the Head of the Femur

Excisions of Bones of the Face or Trunk

Trephining

Ligations of Arteries

Extractions of Foreign Bodies

Operations for Surgical Diseases

Operations not included in other categories

Total.

1849 40 992 19 2700 437 802 160 73 3014 132 2984 21 575 315 34

695

220

11

68 32 101 221 404 726 443 23

17,125

INTRODUCTION.

7

Some observations on each of these classes will be offered in another portion of this report.

The several circulars requesting medical officers to forward preparations to the Army Medical Museum met with very general and liberal responses, and, in January, 1863, a numerical list of 1248 surgical specimens was published by this office. Shortly afterwards, a suitable building was procured, and cases were erected in it for the recep- tion of specimens. Several artists were engaged: a colorist to prepare illustrations of surgical pathology and representations of remarkable injuries; a draughtsman to make maps and plans; and two engravers. The requisite workshops were connected with the Museum. A medical officer was detailed to describe and classify the preparations. In short, this branch of the office was rapidly augmenting in importance. At the end of 18G4, the number of specimens had quadrupled. Among the later specimens a large pro- portion of illustrations of reparative and morbid processes and of the results of operations were included. A valuable collection of drawings had been accumulated; draughtsmen having been sent to battle-fields and hospitals to portray the effects of recent wounds, or the results of surgery. A photograph gallery was now established at the Museum. Typical specimens were reproduced, and the photographs, accompanied by brief printed histories, were distributed to medical directors, to be shown to the medical officers serving with them, in order that the knowledge to be obtained from a study of these instructive examples might be generally disseminated. Other preparations were pho- tographed for the use of the engravers. Many of them are reproduced in this report. Numerous patients in hospitals were photographed, and the Museum now possesses four quarto volumes, with over a thousand photographic representations of wounded or mutilated men. Meanwhile the work of describing and classifying the collections at the Museum has been steadily pursued, and the descriptive catalogue is now nearly ready for publication.

To state, then, in brief, what the records of the surgery of the late war are, and what progress has been made in their arrangement, over 40,000 monthly regimental reports of sick and wounded are on file, which furnish, under Class V.,* the total number of wounds, accidents, and injuries in the army, and the resulting mortality, as ascertained by the regimental medical officers, and which, having served their purpose of informing military commanders, month by month, of the extent of the losses in their commands, by the casualties of war, are now available for estimating the entire losses of the army from diseases and wounds. These reports have been consolidated for the first two years of the war and for the greater portion of the third year. But, as a certain number of regimental medical officers failed to make the required reports, it is necessary to correct these results by other numerical returns. Prior to September, 1862, these are only to be sought in special reports and case books of hospitals, and in the reports by medical directors of battles and minor engagements. It is found that these supply the deficiencies of the regimental returns to a satisfactory degree. For the latter part of 1862, and the whole of 1863, the "tabular statements of gunshot wounds" give the number of such injuries, separated according to regions, and the

* The form of the Report of Sick and Wounded being printed in the accompanying Report on the Medical Statistics of the War, it is not inserted here.

8

INTRODUCTION.

number of operations to which they gave rise. These tabular statements have been consolidated for the entire period, and the results for 1862 have been published. After March, 1863, consolidated classified returns of wounds and injuries were rendered, after every engagement, by the medical directors of armies or detached commands. This series is very complete. It serves as a check upon the monthly reports, and as a basis for estimating the frequency and fatality of wounds according to regions, and the total losses of the army in killed and wounded for the period covered by the returns. These results are not yet worked out, although satisfactory progress has been made towards their attainment. Throughout the war, many medical directors had trans- mitted to this office nominal lists of the wounded in battle; but after November 4th, 1863, this was made obligatory. After October 1st, 1863, all general hospitals reported by name all wounded men received, and gave full details of their injuries. From these two sources nearly complete lists of the wounded for the last two years of the war have been procured; for the names of those who died before reaching the base or general hospitals are found on the battle-field casualty lists. The progress that has been made in classifying and collating these returns has been already indicated. It will appear, hereafter, that the additional information afforded by case books and special reports has not been neglected.

The formal reports of medical directors of armies give a general view of the oper- ations of the Medical Department. For the Army of the Potomac, the reports of Med- ical Directors Tripler, Letterman, and McParlin furnish a connected narrative of the services rendered by the medical staff. For the Western armies, the reports of Medical Directors McDougall, Murray, Cooper, Perin, Moore, and Hewit afford similar informa- tion. These papers will guide the future historiographer of the surgery of the war, and enable him to put in evidence the immensity of the task that devolved on the Medical Department, and to vindicate its achievements, in showing the extent of the succor given to the wounded in despite of almost incredible obstacles. Besides these authoritative documents, there are on file in the office, to serve as supplementary reports, individual narratives of observations in active service from each member of the regular or volunteer medical staff. The remaining papers for reference are the reports of boards on surgical improvements and appliances, or methods of transport for the wounded; 17,000 descriptive lists of surgical cases; 4200 reports from the manu- facturers of artificial limbs of cases of recovery after amputation ; and the surgical essays and dissertations that have been contributed. All of these have either been bound, or indexed and filed in a convenient and accessible form. Lastly, the great treasures of the Army Medical Museum, comprising over five thousand illustrations of military surgery, have been so far classified and arranged as to be available for scientific inquiry.

ON SPECIAL WOUNDS AND INJURIES.

It is now proposed to review briefly the records of special wounds and injuries, of some of their complications, and of the operations which they have rendered necessary.

GUNSHOT INJURIES OF THE HEAD.

In this important class of injuries, the utmost pains has been taken to secure com- pleteness and accuracy in the records. The registers have been copied by experienced clerks, and have been supervised by a medical officer. Exclusive reliance has not been placed upon the field and hospital reports; but in a large proportion of cases, specific inquiries in regard to the extent and results of individual injuries have been made by letter.

All, or nearly all, cases of gunshot injuries of the head that have been reported to the office from the commencement of the war to October 1st, 1864, have been entered in the records. They number 5046, and have been recorded in two classes ; first, the gunshot fractures and injuries of the cranium, including the perforating and penetra- ting and depressed fractures, the fractures without known depression, and the contusions of the skull resulting in lesions of the encephalon; and, secondly, the simple contusions and flesh wounds of the scalp.

It is quite possible now to establish subdivisions in the first class; but to have attempted this heretofore, would have been premature, and likely to produce confusion.

In the first class 1104 cases are recorded. Of 604 of them, of which the results have been ascertained, 505 died and 199 recovered. In 107 of these terminated cases the operation of trephining was performed, of which 60 died and 47 recovered. In 114 cases fragments of bone or of foreign substances were removed by the elevator or forceps, without the use of the trephine; and of these 61 died and 53 recovered. When operative procedures were instituted, the recoveries were 45-3 per cent. But it must be apprehended that this favorable exhibit will be materially modified when a larger number of results are ascertained, and that a great proportion of the field operations of trephining, in which the results are stated to be undetermined, were lost sight of, and terminated fatally. In the 483 cases treated by expectancy, the ratio of recovery is only 20-5 per cent. But the latter group of cases includes nearly all of the penetrating and perforating fractures, and it would be unwise to base on these figures an argument in favor of operative interference.

The gunshot contusions and wounds of the scalp that have been entered on the records number 3942, of which 103 terminated fatally. It is altogether probable that in all of these fatal cases some undiscovered injury was done to the cranium or its contents; or that the pericranium was removed, and death of bone ensued, with con- secutive lesions of the encephalon. The histories of many of these cases are now under investigation. So far as ascertained, the fatal results have depended upon concussion or compression of the brain, or upon the formation of abscesses in the liver or lungs, in

2 (9)

10

ON SPECIAL WOUNDS AND INJURIES.

Fig. 1. — Section of a cranium, exhibiting five trephine per- forations tor- the evacuation of pus, the result of a gun- shot contusion of the right parietal. Spec. 2000, A M. M.

consequence of inflammation in the veins of the diploe. Compression has resulted either from extravasation of blood, or inflammation of the brain or its membranes, or from suppuration. The following is an example of a scalp wound, followed by inflam- mation of bone and meningitis :

Private Joseph R . Co. E, 151st New York Vols., received,

in a reconnoissance near the Rapidan, November 27th, 1863, a gunshot wound of the scalp. The nature of the missile was unknown. The patient was removed to Fairfax Seminary General Hospital near Alex- andria. There were no cerebral symptoms at the time of his admission, and it was hoped that the pericranium had escaped uninjured. He was up, and apparently well on December 13th, 1863, when he was suddenly seized with convulsions, which were followed by coma. Surgeon D. P. Smith, U. S. Vols., laid bare the calvaria at the seat of injury, and finding the bone diseased, applied the trephine. Matter was found immediately beneath the bone and oozing from the diploe. It was thought expedient to make five perforations with the trephine, in order to remove the diseased bone and to give free exit to pus. Convulsions did not recur, but the comatose condition continued, and the case terminated fatally twelve hours after the operation. The autopsy revealed diffuse inflammation of the arachnoid and of the dura mater.

The foregoing case illustrates the fallacy of Pott's views in relation to trephining for pus under the skull-cap; and yet, under such circumstances, the best modern authorities advise the use of the trephine as affording the patient the only chance of recovery. The records attest how slight this chance is, and corroborate the observation of Mr. HeAvett, that "the successful issue of a case of trephining for matter between the bone and the dura mater is almost unknown to surgeons of our own time."*

The Army Medical Museum furnishes very ample illustrations of almost every variety of gunshot injury of the skull and its contents. The number of osteological specimens relating to this class of injuries is 246, of wet preparations 22, of drawings, photographs, engravings, and plaster casts 97.

There are 22 specimens of gunshot contusion of the cranium. In these, either necrosis has taken place, with exfoliation of the external table only, or of the entire thickness of the bone, or else inflammatory suppuration has occurred in the diploe or between the skull and dura mater.

The Museum possesses eight examples of that rare and interesting variety of

gunshot fracture of the cranium, in which the external table is unbroken, while the vitreous table is fissured and some- times depressed. One of the most perfect of these specimens '(No. 15G8, A. M. M.) is figured in No. 94, Photographic Series, S. G. 0. An abstract of the case is subjoined:

Private David P , Co. C, 35th Wisconsin Vols., was wounded at Tupelo,

Mississippi, July 18th, 1864, by a musket-ball, which struck the skull obliquely, and apparently inflicted a scalp wound merely, between the sagittal suture and the left parietal protuberance. There were no signs of cerebral disturbance. The wound was dressed simply, and the patient was conveyed to Memphis, Ten- nessee, and admitted into the Adams U. S. General Hospital on July 23d. He was then perfectly rational and free from head symptoms. Two days subse- quently, indications of compression of the brain were observed, and on the after- noon of the 25th they had rapidly become aggravated. The pulse was slow, the respiration labored, the pupils dilated, the sphincters relaxed. A very careful exploration of the wound was made, but, of course, no cranial fracture could be detected. The treatment was limited to cold applications to the head, scarified cups to the nucha, and brisk purging. ( >ii the 26th, the patieut gradually became comatose. The discharges from the bowels and bladder were involuntary.

Flo. "2.— Section of skull-cap, exhibiting a de- pressed fracture of the vitreous tahle. Spec, 1508, A. M. M.

* A System of Surgery, Theoretical and Practical, in treatises by various authors, edited by T. Holmes, M.A. Cantab. London, 1861. Vol. ii. p. 101.

GUNSHOT INJURIES OF THE HEAD.

11

Km. ::.

-Exterior view of the foregoing specimen.

No further particulars of

Fig. 5

The patient continued to sink on the 27th, and died at 1 a.m. on the 28th of July. At the autopsy the internal table of the left parietal was found to be fractured and depressed at a point corresponding with the wound in the scalp. The dura mater was wounded, and there was a large abscess in the left cerebral hemisphere.

In a specimen which is believed to be unique, without any apparent lesion of the external table, a fragment of the vit- reous plate of the frontal bone was found to be completely detached and depressed upon the dura mater. The history in this case is unfortunately imperfect.

Private A L , Co. C, 78th New York Vols., was wounded by a co-

noidal musket-ball, at the battle of the Wilderness, May 6th, 1864, and entered Armory Square Hospital, at Washington, on May 12th. He was in a comatose condition when admitted, and died on May 24th, eighteen days after receiving the injury.

the case could be obtained. At the autopsy a fracture was discovered of the inner table of the frontal bone, near the coronal suture, to the left of the median line. There was no solution of continuity in the outer table; but it was softened where the pericranium was destroyed by the ball. A frag- ment, an inch and a half in length and half an inch broad, was completely detached from the vitreous table. The speci- men was forwarded by Surgeon D. W. Bliss, U. S. Vols.

In a case which was observed by Sur- geon Bontecou, U. S. V., who had examined the specimens above referred to, the proba- bility of a depression of the vitreous table was inferred, and the diagnosis was verified, during life, by the application of the trephine. Unhappily, an abscess had formed in the brain, and the operation, though performed as soon as evidence of compression existed, was too late to save the patient.

Private D S , Co. E, 2d Virginia Cavalry, aged twenty-one, was

wounded at Appomattox Court House, April 6th, 1865, and admitted to Harewood Hospital, at Washington, on April 19th, with a gunshot wound of the scalp, just below the coronal suture. The bone was denuded of its pericranium, but there was no apparent fracture. Prior to his admission, the patient had chills, which recurred at intervals of twelve hours, until April 25th, quinia having no appre- ciable influence upon the paroxysms. There was no pain in the head nor disturb- ance of the cerebral faculties until April 26th. On the 25th, inflammation of the lower lobe of the right lung was observed, and on the 26th, there was endocarditis. At 10 p.m. of the 26th, the patient became unconscious. Shortly afterwards he was trephined. When the external table was passed, pus exuded from the cells of the diploe. A depressed fracture of the inner table was discovered, and the detached fragments were removed. The patient did not arouse from his comatose state, and died the next morning, April 27th, 1865. A photograph of this patient, prior to the operation, was preserved at the Museum. (Photo. Surg. Cases, vol. i. No. 58.)

Specimens 3639, 340G, 622, 1922, and 616, A. M. M., afford other examples of this rare form of injury, to which S. Cooper,* Guthrie,f Hennen,J Hewett,§ Williamson, || and Legouest^ allude, illustrating their observations by a case examined by Mr. Dean, of Cambridgeshire, a specimen in the Dupuytren Museum, which is figured in M. Legouest's work, and specimen No. 2893 of the Netley Collection.

Exterior view of the fore- going specimen.

Fig. 4. — Fracture of the vitreous table of the frontal bone, without frac- ture of the external table. Spec. 2313, A. M. M.

G. 0. — Section of cranium, showing a de- pressed fracture of the vitreous table. There was a contusion only of the outer table. Spec. 4344, A. M. M.

* S. Cooper, Dictionary of Practical Surgery. I Hennen, Military Surgery, p. 326, ed. 1829. || Williamson, Military Surgery, pp. 29, 30. H Legouest, Traite de Chirurgie d'Armee, p. 283.

f Guthrie, Commentaries, paragraph 262. I Holmes' System of Surgery, vol. ii. p. 114.

See also Compendium de Chirurgie, t. ii. p. 573.

12

ON SPECIAL WOUNDS AND INJURIES.

Lai

FIG. 7. — Section of the frontal bone exhibiting a flss\ire over the left supra-orbital region. Spec. 24, A. M. M.

Fig. 8. — 1 nternal view of the foregoing specimen, show- ing the extensive splintering of the vitreous table.

It is believed that this accident results, in most instances, from a small projectile striking the cranium very obliquely, or possibly, in some cases, from a comparatively slight blow from a body with a large plane surface.

Closely allied, clinically, to the foregoing cases are those in which a ball produces linear fissure of the external table with displacement of the inner table. Specimen No. 24, of the Army Medical Museum, affords an excellent illustration. The following is an abstract of the case:

Private M. L. H , Co. B, 21st Virginia (Rebel) Regiment, aged twenty years, was wounded and taken pris- oner in one of the later engagements prior to the capitulation of the Army of Northern Virginia, and was admitted

into the Lincoln General Hospital, at Washington, on March 25th, 1865, with a wound over the left supra- orbital ridge, inflicted apparently by a glancing musket-ball. There were no cerebral symptoms when the pa- tient was admitted, and he seemed to be doing well for several days, being quite free from pain or any febrile movement. The pulse was normal and the bowels in good condition. On April 1st, he complained of a dull deep-seated pain over the left eye. Later in the day he was feverish and restless, his countenance was pale, and his pulse slow and weak. On April 2d, he failed rapidly. On the night of the 3d, he was delirious. On the 4th, there was violent raving, which continued until his death, on the afternoon of April 5th, 1865. At the post-mortem examination, a fissure was found extending into the right orbit, and upwards beyond the left frontal prominence. The vitreous table beneath was largely depressed. There was a small abscess in the anterior lobe of the left cerebral hemisphere.

Of fractures without depression, the cases in which the mastoid process is knocked off by a ball afford ex- amples. Specimen 183, A. M. M., is a very perfect illustration of this accident. The mastoid cells were opened. After a fortnight, meningitis supervened. Specimen 3451 was furnished by a fortunate case of recovery after a fracture of the mastoid process.

Private William F , Co. G, 98th Pennsylvania Vols., was wounded

near Fort Stevens, Washington, July 12th, 1864, by a glancing shot from a conoidal musket-ball, and was admitted into Mount Pleasant Hospital on the following day. A little above the right auditory meatus was a scalp wound an inch and a half long. A piece of the mastoid process was chipped off, and a fracture extended into the petrous portion of the temporal. The patient did well with simple

dressings and rest and gentle cathartics till the 20th of July, when the wound began to slough. Applications of nitric acid, creosote, etc., failed to arrest the sloughing, which presently gave rise to repeated haemorrhages from branches of the temporal artery. The gangrene continued to spread until August 9th, when the eschars sepa- rated, leaving a space five inches in diameter on the right lateral region of the head, denuded of integument, fascia, and muscles. During this long period, the patient complained of no inconvenience at the seat of fracture, though there was at times acute frontal pain. Early in September, it was evident that the exposed portions of the temporal and parietal bones were necrosed, and on September 6th a fragment of the squamous portion of the temporal was removed. Two days subsequently other fragments were detached and extracted. After this the wound began to cicatrize rapidly, and on December 3d, 1864, the patient was reported to be entirely out of danger, and in fact nearly well.

Several cases of undepressed fracture are reported in which a ball gouged out a small portion of the external table. A number of instances are recorded in which con-

Fig. 9.-

iiun-li.it fracture of right temporal. Spec. 183, A. M. M.

Fig. 10.— F.x foliation from the right pari etal anil temporal, resulting from gun- shot injury. Spec. 3451, A. M. M.

GUNSHOT INJURIES OF THE HEAD.

13

siderable portions of the calvaria have been removed by explosions of shell, without depression. Very rarely a musket-ball produces the same effect, as in the following remarkable case. The patient is represented in Photograph No. 58, A. M. M. :

Private Edson D. Bemis, Co. K, 12th Massachusetts Vols., was wounded at Antietam by a musket-ball, which fractured the shaft of his left humerus. The fracture united kindly, with very slight angular displacement and quarter of an inch shortening. Promoted to be corporal, Bemis received, May 6th, 1864, at the battle of the Wilderness a wound from a musket-ball in the right iliac fossa. He was treated in the Chester Hospital, near Philadelphia. There was extensive sloughing about the wound, but it ultimately healed entirely, leaving a large cicatrix, parallel with Poupart's ligament. Eight months after the injury, Bemis returned to duty with his regiment. On February 5th, 1865, Corporal Bemis was again severely wounded at the engagement at Hatcher's Run, near Petersburg Vir- ginia. Surgeon A. Vanderveer, 66th New York Vols., reports that the ball entered a little outside of the left frontal protuberance, and passing backwards and upwards, removed a piece of the squamous portion of the temporal bone, with brain substance and membranes. When the patient entered the hospital of the 1st Division of the 2d Corps, brain matter was oozing from the wound. Respiration was slow; the pulse 40; the right side paralyzed; insensi- bility total. On February 8th, the ball was removed from the substance of the left hemisphere. In a few days paraly- sis disappeared. The patient was transferred to Fort Richmond, New York Harbor. He recovered perfectly, and on July 15th visited Washington, and was photographed at the Army Medical Museum. The wound in the head was then nearly healed. There was a slight discharge of healthy pus from one point. The pulsations of the brain could be felt through the integument. The mental and sensory faculties were unimpaired. The corporal had been discharged from service, and recommended for a pension.

From the numerous instances of fracture with depression of both tables of the

skull, a very few are selected. The first is an example of a common class of cases, in

which symptoms of compression of the brain depend upon extravasation of blood, or

inflammation of the membranes, and come on tardily.

Private Leonard L -, Co. F, 74th New York Vols., was wounded at the battle of Williamsburg, May 5th, 1862,

and was admitted into Broad and Cherry Streets Hospital, at Philadelphia, May 13th, 1862. A musket-ball had struck near the left parietal emi- nence, and, producing a slight depression of the outer table, had lodged under the scalp, whence it had been removed by a surgeon on the field. The wound had a healthy aspect when the man was ad- mitted, and there was no cerebral disorder. This favorable condition continued unaltered till May 20th, when a febrile movement set in, accompanied by nausea and vomiting ; drowsiness and stupor followed, and the patient died comatose on May 23d, eighteen days after the injury. At the autopsy, a small clot was found beneath the depressed portion of the vitreous plate; the dura mater was uninjured; the arach- noid, near the seat of injury, was opaque, and studded with deposits of lymph ; the gray matter of the brain was softened.

Private George Y , Co. C, 84th New York Vols., was wounded at Chancellorsville, May 3d, 1863, and admitted

into Carver Hospital, at Washington, D. C, on May 7th, 1863. His injury was supposed to be a simple scalp wound

from a musket-ball. It was situated over the right parietal protuberance, and, on admission, was granulating kindly. Ten days subsequent- ly, the patient, after a walk out of doors, had headache and nausea, and the wound gaped, and its edges ulcerated. On the 18th of May, the probe detected denuded bone; but no frac- ture was discovered. There were no febrile or cerebral symptoms. On May 20th, a depres- sion of the outer table of the skull was de- tected. At night there was delirium, and the following day the pulse became feeble and irregular, the stomach irritable, the tongue heavily furred. The patient died on May 22d, 1863, being conscious and rational to the last. At the autopsy, extensive inflammation of the dura mater was observed, and softening of the middle lobe of the right cerebral hemisphere.

Fio. 11. — Portion of left parietal, showing a slightly depressed fracture of the outer table. Spec. 224, A. M. M.

Pig. 12. — Interior view of the foregoing specimen, exhibiting extensive splinter- ing of the vitreous table.

FlG.l

3. — Gunshot fracture of the right pari- etal bone. S2KC. 1257, A. M. M.

Fig. 14. — Interior view of the foieg< specimen.

14

ON SPECIAL WOUNDS AND INJURIES.

The next case is an example of the classical "punctured" gunshot fracture of systematic writers.

•'-X

A

Fig. 15. — fracture of the fron- tal bone by a pistol-ball Spec. 1(573, A. M. M.

. l'i. — Interior view of the foregoing specimen.

:yHl

Private James K , Co. G, 6th New York Cavalry, was

wounded at the battle of Gettysburg, July 3d. 1863, by a pistol-ball, which produced a punctured fracture of the os frontis. He was con- veyed to a hospital at Baltimore, and from thence to Carver Hos- pital, at Washington, on July 24th. He stated that, at Baltimore, he walked about and felt no inconvenience from his wound. On July 27th, he had a convulsion. The wound, which was nearly healed, was laid open, and depressed bone being detected, an effort was made to elevate it. Several small necrosed fragments were re- moved, and a small quantity of fetid pus escaped. The patient had become comatose, and the operation had no influence in relieving the symptoms. Death took place a few hours subsequently. At the autopsy, the extended depression of the inner table was discovered, and a large abscess of the brain.

Instances were not uncommon of the splitting of round musket-balls in striking the skull at an acute angle. The following is an example :

Corporal John N -, aged eighteen years, Co. H, 159th New York

Vols., was struck on the left side of the forehead, on April 14th, 1863, at an engagement at Irish Bend, Louisiana, by a round musket-ball. He was admitted to the University Hospital, at New Orleans, on April 17th. The ball had been removed on the field. Several depressed frag- ments of bone were removed, and cold water-dressings were applied. The case progressed without a bad symptom until April 30th, when there were clonic spasms, which, after a few hours, were followed by a semi-comatose condition, which continued until death, on May 2d, 1863. A necroscopic examination revealed extensive meningitis, and a large abscess of the left cerebral hemisphere. The lateral ventricles were filled with sero-purulent matter. The surfaces of the pons Varolii and of the medulla oblongata were covered with lymph. The specimen was forwarded by Assistant Surgeon P. H. Conner, U. S. A.

Conoidal balls were less liable to split after this fashion, yet such instances were occasionally observed.

Private C. C. W , Co. I, 6th Wisconsin Vols., aged twenty-one years, was wounded at Spottsylvania, May

12th, 1864, and was admitted to Douglas Hospital, in Washington, four days subsequently. It was ascertained that

the cranium was fractured, but the symptoms were not urgent, being limited to slight paralysis of the right upper extremity, and operative interference was deferred. On May 31st, a conoidal musket-ball and several fragments of the left parietal were removed by Assistant Surgeon Wm. F. Norris, U. S. A. One large fragment of the vitreous plate was pressing on the dura mater ; this was elevated and removed. The next day symptoms of compression of the brain were manifested. An explo- ration of the wound was made and a quantity of pus evacuated. On J une 4th, 1864, twenty-three days after the injury, the case terminated fatally. At the autopsy, the arachnoid was found little altered. There was an abscess in the posterior lobe of the left hemisphere near the longitu- dinal sinus, of the size of a walnut. Its walls were of a greenish-yellow color. It communicated with the lateral ventricle. The right ventricle was filled with sero-sanguinolent fluid. There was a deposition of lymph at the base of the brain, extending from the medulla oblongata to the bifurcation of the optic nerves. The specimen and facts connected with it were contributed by Assistant Surgeon William Thomson, U. S. A.

The depressed fractures produced by cannon-balls, or by the explosion of large shells, were commonly attended by frightful comminution and disjunction of the sutures, and were almost always immediately fatal, and hence had little surgical interest. A single example is given :

.7. — Section of ti Irontal bone, with a split musket ball. Sjiec. 1293, A. M. II.

FlO. IS.— Skull-rap. exhibiting gu vertex, by aconoidal musket-bal the lauiiua of the left parietal.

ishot fracture near the which has split against Spec. 3543, A. M. M.

GUNSHOT INJURIES OF THE HEAD.

IT)

Fig. 19. — Cranium fractured by the explosion of an 11-iucn shell. Spec. 2871, A. M. M.

21. — Exterior view of the foregoing specimen.

A Confederate soldier was wounded in the demonstration on Washington, July 17th, 1864, by a shell from one of the large guns of Fort Stevens, and was admitted into Lincoln U. S. General Hospital, on that day, and died two hours after admission. Over the anterior superior angle of the left parietal bone there was an extended scalp wound. On reflecting the scalp, multiple depressed frac- tures of the vault of the cranium came into view. The point of greatest depres- sion is an inch to the left of the median line, near the coronal suture. The depressed fragments measure from before backwards two inches, and from right to left three inches, and involve both parietals and the os frontis. A fissure runs through the squamous portion of the left temporal, and all the sutures of this bone are separated.

There have been a very few extraordinary and excep- tional recoveries after penetrating and perforating fractures of the cranium, and, in rare instances, the fatal termination has been long delayed. In the following curious case, the presence of a ball within the cranial cavity was unsuspected:

Corporal G. W. S . 12th Massachusetts Vols., aged twenty-nine years, was wounded at the battle of Fred- ericksburg, December 13th, 1862, and was admitted to Camden Street Hospital, Baltimore, six days subsequently. The humors of the right eye had been evacuated by a ball, which had likewise inflicted a slight wound of the lower

lid. The left eye was observed to be unnaturally prominent, but its func- tions were undisturbed. The patient did not comphiin of pain or any in- convenience, except a slight head- ache. There were no cerebral symp- toms, and no one suspected that the projectile had entered the brain. The wound healed kindly, and, after three

weeks, the man walked about the city habitually, with a hospital pass. He appeared to be well, except that he had an occasional pain over the left eye, until February 6th, 1863, when he had a chill, followed by a febrile reaction. No marked cerebral disorder supervened, however, until February 10th, when delirium was noticed at night. On the following day the patient was comatose, and at midnight of February 15th, he died. The autopsy revealed a conoidal musket-ball wedged between the sphenoid and the left orbital plate of the frontal bone, and lying in contact with the dura mater. The orbital plate was pressed inwards and fractured, and a fissure extended through the superciliary ridge. Over the ball, at the base of the anterior lobe of the left hemisphere, was an abscess containing two drachms of pus. The ball was incrusted by callus, and the opening it had made in entering through the walls of the right orbit was greatly diminished by osseous deposition.

In the next case, half of the ball had deeply penetrated the brain :

Sergeant J. N. H , Co. K, 19th Maine Vols., aged thirty-six years, was

struck on the right side of the head, by a musket-ball, in a skirmish at Morton's Ford, on the Rappahannock, February 6th, 1864. The ball was smoothly cut in two, one-half lodging under the scalp, and the other passing into the brain. The patient was perfectly rational until February 11th, when his mind wandered at times. On the 12th, Surgeon Justin Dwinelle, 101st Pennsylvania Vols., ex- tracted the fragment of the ball which had buried itself in the brain. Its track communicated with the right lateral ventricle. The other portion of the ball had been removed from under the scalp immediately after the injury. When the patient recovered from the influence of the chloroform, he was rational, and continued so for twenty-four hours or more. Coma gradually supervened, and death took place on February 15th. The left ventricle was found filled with pus.

A very remarkable case of perforating fracture of the skull, with recovery, is rep- resented by No. 16 of the Surgical Series of Drawings, S. G. 0. The ball entered a little to the right of the occiput, and passed out somewhat below and to the left of the vertex. The intervening bridge of bone was about three inches wide. There had been a cerebral hernia at the wound of exit, and, when the drawing was made, four months after the reception of the injury, there was still a small tumor, covered by half-

Flo. 20. — Conoidal ball embedded between the sphenoid ami parietal bones. Spec. 1141*, A. M. M.

Fig. 22. — Section of right parietal on which a conoidal musket-ball has split. Spec. 2121, A. M. M.

If, ON SPECIAL WOUNDS AND INJURIES.

Fig. 23. — Skull, exhibitinsr an extensive fracture by grupeshot. Spec. 1318, A. M. M.

formed cicatricial tissue. There was a firm depressed cicatrix at the aperture of entry. There were no evidences of impairment of the cerebral faculties. At the time the drawing was made, the man was employed as an orderly.

The next case illustrates Mr. Erichsen's remark that the greater splintering of the inner table does not depend exclusively upon its greater density and brittleness, but partly on the direction of the fracturing force. At the aperture of exit, the outer table is splintered more than the inner. In the same specimen the bones forming the right orbit are fractured by contre-coup:

A soldier of Longstreet's Corps was killed in a charge upon a Union battery, in the second battle of Manassas, August 29th, 1862, by a grapeshot at short range. The cranium was picked up a year subsequently by Surgeon F. Wolfe, 39th New York Vols., under an abatis near the stone bridge over Bull Run. The missile entered the left parietal near the lambdoidal suture, and made its exit through the squamous portion of the temporal.

According to Mr. Teevan's experimental inquiries,* the aperture of exit in gunshot perforations of the cranium is always larger than the aperture of entry, because it is made by the ball plus the fragments of bone driven out from the proximal table and the diploe. While the number of fatal results after trephining are very great, the examples of success are yet numerous. The data are not sufficiently complete to admit of fair comparative analysis; still it is difficult to avoid the impression that a larger measure of success has attended this operation in the late war, than the previous experience of military surgeons would have led us to anticipate. Surgeon D. W. Bliss, U. S. Vols., alone has reported eleven successes after the use of the elevator or trephine. Even in those almost hopeless cases in which compression of the brain follows a gunshot injury of the skull at a late date, instances of recovery are reported.

In the following case it is not likely that suppuration had occurred, a complication that has rarely presented itself prior to the fifteenth day after the injury; but it can hardly be doubted that meningitis was averted or relieved by the opportune employ- ment of the trephine :

Private John McK , Co. H, 105th Pennsylvania Vols., was wounded at Petersburg, Virginia, June 14th,

1864, by a conoidal musket-ball, which struck the right side of the skull very obliquely, and produced a slightly

depressed fracture of the right parietal bone. He was admitted to Mount Pleasant General Hospital, Washington, on June 24th, with the report that the progress of the case had been so far eminently satisfactory. After ad- mission, he was found to be insensible, and a few hours subsequently, con- vulsions supervened in rapidly recurring paroxysms. Twelve ounces of blood were taken from the temporal artery without apparent benefit. A trephine was then applied to the seat of fracture, and, upon the removal of a button of bone, a portion of the inner table was found slightly depressed. This was elevated, and the patient soon afterwards regained consciousness. On the 28th of June, the wound in the scalp became erysipelatous, and before the inflammation subsided, there was extensive loss of substance of the integuments and pericranium, denuding a large portion of the parietal bone. Necrosis ensued, and embraced the whole thickness of the bone. In September, 1864, a portion of the parietal, three inches by four, had become so much loosened that it was readily removed. Alter this, cicatrization went on rapidly, and, at the date of the last report, December 2d, 1864, the wound had contracted to an ulcer less than an inch in diameter. The patient's mental faculties were impaired somewhat, the ward physician thought, but not to a great extent. The specimen was contributed by Assistant Surgeon C. A. McCall,

Via. 24.— Exfoliation from the i isrht parietal bone Sjkc. 3452, A. M. M.

* British and Foreign Medico-f'hirurgical Review, vol. xxxiv. p. 205.

GUNSHOT INJURIES OF THE HEAD.

17

U. S. A. A colored drawing was made representing the appearance of the parts prior to the separation of the exfolia- tion. (No. 74, Surgical Series of Drawings, S. G. 0.)

The occurrence of hernia or fungus cerebri is mentioned in connection with 18 cases of gunshot fracture of the skull, complicated by lacerations of the dura mater and brain. In 4 of these cases, recovery took place without operative interference with the protruding fungous mass, which, in these instances, gradually contracted, was then covered by granulations, and finally cicatrized. In those cases in which bandaging and compression were resorted to, cerebral oppression was soon manifested, and stupor and coma eventually supervened. In those in which the tumor was sliced off, as usually recommended, at the proper level of the brain, it was commonly speedily reproduced, and death from irritation ensued.

Charles T , Co. H, 63d New York Vols , aged seventeen years, was admitted to Hospital No. 1, Frederick,

Maryland, on September 28th, 1862, with a fracture of the skull. He was wounded at Antietam, September 17th, 1862, by a conoidal musket-ball, which struck at the lower anterior angle of the right parietal, fractured both tables of the cranium, and lodged under the scalp in the occipital region. The scalp was lacerated, and a dark pulsating mass protruded in the wound. The left side of the body was paralyzed. The patient's mental faculties were unim- paired. On September 29th, flaps of integument were reflected by a T-shaped incision. The ball and a number of fragments of bone were removed, some of the latter being embedded in the brain substance. The inner table was found badly splintered, but the fracture of the external table was still more extensive. The pro- truding cerebral mass was shaved off. The rough edges of the frac- tured bone were smoothed by cutting forceps. The following day, the paralysis was more complete than before the operation. There was severe headache. The pulse was slow and weak. On October 3d, the fungus was sprouting and sloughing. The left arm was powerless ; the paralysis of the left leg was less complete. On October 4th, the hernia was again sliced off, and gentle compression was applied. There was great irritability and restlessness. On October 21st, the patient had improved. His appetite was voracious. He was less irritable, and the hemiplegia was much less complete. He was very sensitive to cold. Fl0. 25._Gunshot fi,ict^7^ht parietal, followed by The temperature of the left side was lower than that of the right. The necrosis. spec. 3859, a. m. m.

fungus was of the size of a pigeon's egg. On November 17th, a dilata- tion of the left pupil was first noticed. Sensation in the left leg, and partial control of the muscles had returned. Since the last report the tumor of the brain had continued to grow and slough away, so that it remained of about the same size. On December 7th, the report states that little change had taken place, except a gradual amelioration of the hemiplegia, and improvement in regard to the fretfulness and irritability. On this day there was a severe chill. After this, the patient never regained his accustomed readiness and clearness of mind. The discharge from the wound became watery, unhealthy, and more copious. There was an exacerbation of fever every afternoon. On December 17th, there was a severe convulsion, which lasted half an hour, and was terminated by death.

At the autopsy, an irregular portion of the right parietal, four inches in diameter, was found to be necrosed and detached. The dura mater was much thickened in the vicinity of the fracture, and was adherent to the margins of the healthy bone. Except in the immediate vicinity of the hernia, the brain matter appeared to be in a healthy state.

In looking over the registers of gunshot injuries of the head, two general facts are noticed : First, that in the after-treatment of scalp wounds, a multitude of surgeons did not consider spare diet, perfect rest, and antiphlogistic measures as of essential importance; and, secondly, that in the treatment of cranial fractures, the general tendency was to the practice recommended by Guthrie in regard to operative proce- dures, rather than the more expectant plan insisted upon by the majority of modern European writers on military surgery. The interest of the material and the import- ance of the subject alike invite extended comment; but in this brief and cursory review, the motto of Montaigne, je raconte, je ne juge pas, must be rigorously adhered to. A few more cases of gunshot injuries of the head are appended, to illustrate the form of the register of wounds now in use in the army.

3

18

ON SFECIAL WOUNDS AND INJURIES.

Hospital.	NAME.	Rank.	Co.	Regiment.	Age.	When admitted.	From what General Hos- pital Trans- ferred.	From what other source ad- mitted. From Field, from Field Hos- pital, etc.	DIAGNOSIS. In Surgical Cases, state Seat and Character of Wound or Injury.	On what occasion Wounded. Date.
Hygeia Hospi- tal, Old Point Comfort, Va.	Burd, Charles W.	Lieutenant.	F	4th Maine	26	Feb. 20,		Prison in	Gunshot fracture of both tables of os frontis at left frontal eminence. Penetration of the substance of the brain by a portion of the ball.	Bull Run, July 21,1861.
	Volunteers.	1862.		Richmond
National Hos-	Stallman, John	Private.	A	4th Penn.	21	Sept. 8, 1864.	Sandy Hook, Maryland.		Missile entered at the right temple, and emerged at the opposite side of the head.	Winchester, Va., July 24, 1864.
pital, Balti- moro, Mary- land.				Cavalry.
Cnvl'T Hospi- tal, Philadel- phia, Penn.	Stallman, John H.	Private.	A	4th Penn. Cavalry.	21	Dec. 11, 1864.	National, Baltimore.		Missile entered the right side of the frontal bone near its superior margin. Evidently passed through the brain, and emerged on the opposite side.	Winchester, July24,lS64.
Mower Hospi-	Stallman, J. H.	Private.	A	4th Penn.	21	May 10, 1865.	Cuyler, Phila., Penn.		Ball passed through brain, carrying away anterior portion.	Winchester, July 24,1864.
tal, Philadel- 1 phia, Penn.				Cavalry.
Armory	Kennedy, Charles	Lieutenant.	I	28th Penn.	25	May 7, 1863.		Hospital Transport.	Missile removed tho superior angle of the occipital bone and the dura mater beneath. •	Chancellors- ville, Va., May 2, 1863.
Square Hospi- tal, Washing- ton, D. C.				Volunteers.
1st Division Hospital, An- napolis, Md. 18,254.	Kennedy, Charles	Lieutenant.	I	28th Penn.	25	Nov. 14,	Armory Square.	From
			Volunteers.		1863.	furlough.
D. S. A. Gene- ral Hospital, Frederick, Md.	W , Charles	Private.	E	14th Virginia		Sept. 17, 1864.		Field.	Missile entered the left temporal bone one inch from the meatus auditorius externus, and penetrated the cavity of the skull, lodging on the side of the sella turcica.	Berryville, Sept. 3, 1864.
			Infantry.
Grafton Hospi- tal, West Vir- ginia. 788.	W , Charles	Private.	E	14th Virginia	22	Nov. 2, 1864.	Frederick, Maryland.
			Infantry.

GUNSHOT INJURIES OF THE HEAD.

19

IN SURGICAL CASES ONLY.	RESULT.	REMARKS. Here state cause of death, of discharge, or of transfer to Veteran Reserve Corps.
Nature of Mi--il Weapon. Round or Conical Bullet, Solid Shot ISayonct, Sword.	Treatment. Amputation. ..Date of Other opera- Simple dress- ings " '•	Returned to duty. Date.	Trans- ferred to Veteran Reserve Corps. DaU.	To other General Hospital. State or City. Date.	Fur- loughed. Date.	Deserted. Date.	Dis- charged from Ser- vice. Date.	Death. Date.	Readmit- ted from Furlough or Deser- tion. Date.
Musket Ball. Musket Ball.	A portion of the ball was removed from under the integu- ment, on the field. Seven months after- wards the fistulous orifice of the wound was dilated, depres- sed bone was re- moved, and a por- tion of the ball from within the cavity of the cranium. Simple dressings.	March, 1863.								During his imprisonment he suffered from pain in the head, but had no delirium, coma, or paralysis. Was perfectly well when he rejoined his regiment. (Vide Special Report from Surgeon R. B. ISon- tecou, U.S.V. General Index A, No. 50.) When admitted, his bowels were consti- pated, and nausea was almost constant. His pulse was slow and feeble. His pupils were constantly dilated. When discharged his mental operations seemed slow and uncertain, but there was no aberration of mind, and his memory was unimpaired. (See Report of Assistant Surgeon Schell, U.S.A.)
	Dec. W, 1864, to Cuyler Hospital. May 10, 1865, to Mower Hospital, Phila., Pa.
						May 23, 1865.
Probably a piece of shell.	May 7th. Hair shav- en, water-dressings, cathartics, injec- tions and anodynes, leeches to temples and behind the ears. May 13th. A splinter of bone removed.				June 20, 1863.				On admission, substance of brain protruded about one inch and a half; wound was about two inches long and one inch wide; pulsation was distinct; total loss of vision; pulse 60; inclined to sleep but could not ; mind dull; partial paraplegia. May 11th. Rests quietly but cannot sleep; has not slept from date of injury; no alvine evac- uation. May 12th. Not so much pain. May 13th. Had four dejections. May 15th. Fungus retracted somewhat, with a healthy granulating surface; vision partially restored. June 10th. Sitting about ward, talking and laughing; fun- gus retracted entirely, but pulsation dis- tinct; vision restored; pulse and bowels regular; sleeps well; intellect perfect; no pain. The wound is represented in Nos. 20 and 27 Surgical Series of Drawings, S. G. 0.
Jan'y 12, 1804.
Com lidftl Musket Ball.	Part of ball extracted from under the scalp in the frontal region, by forceps. This fragment was about one-third of the ball.		To Graf- ton, Nov. 2, 1864. 1						When admitted, patient had paralysis of 2d, 3d, 4th, 5th, 0th, and 7th nerves of the leftside. No pain in the head. General health of patient was good. His pulse, skin, and bowels were natural. His con- sciousness perfect. His articulation was thick, but improved, and after the extrac- tion of the ball became almost natural. There was a free evacuation of pus after the operation, the pupil of the left eye diminished in size, and vision partially returned. Oct. 10th, 1864. Was so far re- covered as to walk about and assist in nursing in the ward. If, however, he exerted himself too much he suffered from headache. While heiDg transferred to Grafton, Va., he drank a large quantity of whiskey. The day after his arrival he had a violent chill, followed the next morning by convulsion, and strabismus of right eye; these continued during the day, and coma succeeded on the following morning and he died without reaction. Post-mortem showed the larger portion of a conoidal musket-ball resting against the sella turcica. The encephalon was extensively disorganized; the ventricles, and nearly the whole base of the brain, bathed in pus. (Med. Des List, from J. EC. Bartholf, A. A. Surg U.S.A.)
			1		Nov. 6, 1864.

20

ON SPECIAL WOUNDS AND INJURIES.

GUNSHOT WOUNDS OF THE FACE.

Of 4167 gunshot wounds of the face transcribed from the reports from the begin- ning of the war to October, 1864, there were 1579 fractures of the facial bones, and 2588 flesh wounds. Of the former 891 recovered, 107 died, and the terminations are still to be ascertained in 581 cases.

Secondary haemorrhage has been the principal source of fatality in these injuries. It is a frequent complication in gunshot fractures of the facial bones; and the difficulties in securing bleeding vessels in this region are very great. Recourse has often been had to ligations of the carotid, with the result of postponing for a time the fatal event.

Owing to the great vascularity and vitality of the tissues in this region, gunshot wounds of the face have commonly healed rapidly, and many creditable plastic oper- ations for the relief of deformities following such injuries have been accomplished. Such operations are illustrated at the Army Medical Museum by numerous casts and photographs. An interesting example is the case of Private Rowland Ward, Co. E, 4th New York Heavy Artillery. A fragment of shell removed the anterior portion of the lower jaw within one inch of the ramus on both sides, destroyed the genio-hyoglossus and genio-hyoid muscles, and afforded the occasion for a very successful cheiloplastic operation by Surgeon J. C. McKee, U. S. A. (See Photographs of Surgical Cases, S. G. 0., vol. iii. p. 1, et seq.)

GUNSHOT WOUNDS OF THE NECK.

Of the 1329 cases of this category that have been entered on the records, the ulti- mate results have been ascertained in 546 cases only. Time has not been found to trace the histories of many of the remaining cases. In the terminated cases, the mor- tality is 14 per cent.

Several instances are recorded in which large grapeshot, on striking the hyoid bone, were deflected, and buried themselves in the supra-spinous fossa of the scapula, or among the muscles of the back. These patients died from laryngitis or oedema of the glottis, and might have been saved, perhaps, by tracheotomy; but they died sud- denly, when surgical assistance could not be immediately procured.

Wounds of the neck, with lesions of the vertebras, are classified with fractures of the spine.

There are eight examples of gunshot perforations of the larynx or trachea among the specimens at the Army Medical Museum. The series of surgical drawings includes several curious illustrations of the escape of the great blood-vessels of the neck from injury, when balls have traversed the neck directly in their course.

Cases in which the great vessels were injured are classified with wounds of the arteries.

GUNSHOT WOUNDS OF THE BACK AND SPINE.

In this class have been included the fractures of the vertebral column which were not complicated by penetrating wounds of the chest or abdominal cavity, and flesh wounds of the region covered by the trapezius, latissimus dorsi, and gluteal muscles.

GUNSHOT WOUNDS OF THE CHEST.

21

Of 187 recorded cases of gunshot fracture of the vertebrae, all but 7 proved fatal. Six of these were fractures of the transverse or spinous apophyses. The seventh case is that of a soldier wounded at Chickamauga, September 20th, 1863, by a musket-ball, which fractured the spinous process of the fourth lumbar vertebra, and penetrated to the vertebral canal. The ball and fragments of bone were extracted at a Nashville hospital. The patient was transferred to Louisville, thence to Jefferson Barracks, Mis- souri, thence to Madison, Indiana, and finally, on July 26th, 1804, to Quincy, Illinois. The last report states that he was likely to recover.

Gunshot lesions of the vertebrae and spinal cord are illustrated at the Army Medical Museum by 66 specimens.

An engraving of one of these is subjoined.

Private Frederick L , Co. H, 8th New York Vols., aged twenty-six years,

was wounded at Cold Harbor June 3d, 18G4, and admitted into Carver Hospital, at Washington, D. C, June 11th, 1864. A conoidal musket-ball had entered the right side of his back and penetrated the vertebral canal, shattering the transverse and articular processes of the eighth and ninth dorsal vertebrae. The patient stated that, immediately upon the reception of his injury, he lost all sensation and power of mo- tion below the wound. On admission, he was in a very feeble state; his pulse was slow, his respiration labored, his skin cool, clammy, and cyanosed, his excretions in- voluntary. In this wretched condition he lingered till the 27th of June, when symp- toms of extreme gastric irritability supervened, and every form of nourishment was

promptly rejected by the stomach. He died July 2d, 1864. At the autopsy, the 1 1 J J J J ' i J' Fio.26^Eighth, ninth, and tenth doi>

spinal cord appeared to have been completely severed at the seat of injury, and was sal vertebrae, with a conoidal ban

in the vertebral canal. Spec. 2939,

disorganized above and below. a. m. m.

Five thousand one hundred and ninety-five gunshot flesh wounds of the back have been recorded, of which a large proportion are injuries from shell. Troops being often ordered to lie down under a shell fire, this region becomes particularly exposed.

GUNSHOT WOUNDS OF THE CHEST.

Of 7062 gunshot wounds of the chest that have been examined and transcribed from the reports belonging to the period prior to July, 1864, there were 2303 that either penetrated the thoracic cavity or were accompanied by lesions of the thoracic? viscera. The results have been ascertained in 1272 of these, and were fatal in 930, or 73 per cent. The 4759 flesh wounds presented a very small ratio of mortality. It was observed, however, that they were commonly long in healing, in consequence, no doubt, of the mobility of the thoracic parietes.

The cases of wounds of the lung by the sharp edges of the fractured ribs, or of contusion of the lung by non-penetrating gunshot injuries, have been recorded with the penetrating wounds.

In the treatment of penetrating wounds of the chest, venesection appears to have been abandoned altogether. Haemorrhage was treated by the application of cold, per- fect rest, and the administration of opium. These measures seem to have proved adequate generally, and no instances are reported of the performance of paracentesis or of the enlargement of wounds for the evacuation of effused blood. Haemorrhage from the vessels of the costal parietes has been exceedingly rare, and, in the few instances recorded, was a secondary accident. Hence the management of bleeding from wounded intercostal arteries has presented theoretical rather than practical difficulties.

22

ON SPECIAL WOUNDS AND INJURIES.

It has been the common practice to remove splintered portions of fractured ribs, and to round off sharp edges that were likely to wound the pleura or lung. After this, with the exception of extracting foreign bodies whenever practicable, and performing paracentesis when empyema was developed, it has been usual to leave these cases to the natural process of cure.

The records of the results of the so-called method of "hermetically sealing" gun- shot penetrating wounds of the chest are sufficiently ample to warrant an unqualified condemnation of the practice. The histories of the cases in which this plan was adopted have been traced, in most instances, to their rapidly fatal conclusion. The following case is the only recorded exception :

Corporal Peter Wclker, Co. A, 1st U. S. Sharpshooters, was admitted July 30th, 18G3, into Mount Pleasant Hos- pital, at Washington, having received, at Manassas Gap, July 23d, 1863, a gunshot wound of the chest. The missile entered near the nipple, between the fourth and fifth ribs, traversed the lung, and emerged at the inferior border of the scapula, fracturing the sixth rib. Treatment: Opiates and stimulants, the wound being hermetically sealed. When admitted, the patient had much pain in the chest, and dyspnoea. The latter increased almost to suffocation, and was accompanied by fever. On July 31st, the posterior wound gave way, and a profuse discharge of clotted blood and purulent matter escaped. The next day the anterior wound was opened, and a pint of matter of similar character escaped, after which the patient became much better. He continued to improve until furloughed. On December 13th, 1863, when readmitted, he had entirely recovered.

Few examples of recovery are recorded where the track of the ball passed near the root of the lung. The cases in which there was a fracture of the rib at the wound of entry were very dangerous. The established opinion, that penetrating wounds with lodgement of the ball are more fatal than perforating wounds, was amply illustrated. But very few recoveries with balls lodged in the lung are recorded, and the histories of such cases are less explicit and complete than could be desired.

Private John H. Prouty, Co. G, 27th Illinois Vols., was admitted into the Sherman U. S. General Hospital, at Nashville, Tennessee, from the Field Hospital at Chattanooga, Tennessee, with gunshot wound of the thorax. He was struck in the left chest at Dallas, Georgia, May 25th, 1864, by a musket-ball, which lodged in the substance of the left lung, and was not extracted. The case progressed favorably, and on July 14th, 1864, the patient was fur- loughed and went to his home.

Private Isaac Miller, Co. B, 139th Pennsylvania Vols., was admitted into the Haddington General Hospital, at Philadelph ia, on the 3d of August, 1864, from Fort Schuyler Hospital, New York Harbor. He was wounded at the battle of the Wilderness, May 5th, 1864, by a musket-ball, which entered at the left shoulder, and passed downwards and inwards, and lodged in the left lung. He was fairly convalescent when admitted to Haddington Hospital, and ultimately regained his usual health almost, and on May 3d, 1865, was transferred to the Veteran Reserve Corps.

In the following case the ball was believed to have lodged in the body of one of the upper dorsal vertebrae :

Private Daniel Rich, Co. B, 55th Pennsylvania Vols., aged twenty-one, was wounded at the battle of Pocotaligo, October 22d, 1862, and was admitted to Hospital No. 1, at Beaufort, South Carolina, on October 24th. The ball had entered at the left sterno-clavicular articnlation, traversed the apex of the left lung, and lodged in the vertebral column. Immediately after his injury, he had haemoptysis. He was able to walk from the field of battle to the hospital steamer, six miles distant. He stated that the wound bled very freely. When admitted to the hospital his face was dusky, his pulse accelerated, and crepitant rales were audible in the left chest. There was partial paralysis of the arms. He was ordered |th of a grain of tartarized antimony every two hours, low diet, and perfect quiet. On October 25th, there was less vascular excitement and less dyspnoea. The medicine had nauseated and purged the patient There was great tenderness of the spine in the upper dorsal region, and the vertebral column was perfectly rigid. The patient would allow no one to touch him anywhere but on the head. He was lifted by his head into an upright position, like a stick. The antimony was continued till October 31st. At this date au abscess pointed over the sternum, and was evacuated by a free incision. The wounds were poulticed. On November 13th, he was allowed to sit up a portion of the time, and was much less troubled by a cough in this position. On November 20th, he b'-iran to walk aboul the ward, and (he wounds discharged but little. On December 1st, a necrosed bit of the sternum was removed. Cerate dressings were applied to the wounds. On December 20th, erysipelas attacked the wounds

GUNSHOT WOUNDS OF THE CHEST.

23

Fro. 27.— Portions of the eleventh and twelfth ribs of the right side, exhibit- ing gunshot fractures of the shafts with attempts at reparation. Spec. 845, A M. M.

and spread over the chest. On December 28th, the patient had recovered from the erysipelas, the wounds were nearly healed, but the immobility of the spine continued. He was this day sent to a Northern hospital, on the steamer " Star of the South." He ultimately recovered, and was transferred to the First Battalion of the Veteran Reserve Corps. A photograph of the recent wound is preserved. (See Photographs of Surgical Oases, S. G. 0., vol. i. No. 47.)

In the next case the ball was extracted. Nature made an effort to repair the fractured ribs, but the wound of the lung was followed by fatal suppuration.

Private S B , Co. A, 83d New York Vols., was wounded at the battle

of Fredericksburg, and was admitted into the Lincoln Hospital, at Washington, December 23d, 1862. He had been struck by a conoidal musket-ball in the back of the right chest, the ball entering over the attachment of the eleventh rib, and passing forwards. The ball was extracted and simple dressings were applied. Pleuro-pneu- monia ensued, and resulted in empyema. On January 3d, 1863, a pint of pus was evacuated from the pleural cavity. The case termiuated fatally on January 21st, 1863. The specimen was contributed by Surgeon H. Bryant, U. S. Vols., and the particulars of the case were furnished by Surgeon J. Cooper McKee, U. S. A. At the point of fracture, necrosed splinters are seen, attached by large irregular formations of callus.

A remarkable recovery is recorded, in a case in which the anterior mediastinum was opened.

Private Charles P. Betts, Co. I, 26th New Jersey Vols., aged twenty-two, was struck by a three-ounce grape- shot, on the morning of May 3d, 1863, in a charge upon the heights of Fredericksburg. The ball comminuted the sternum, at the level of the third rib, on the left side, and tore through the costal pleura. It remained in the wound and was removed by the patient. On the following day, Betts entered the hospital of the Second Division of the Sixth Corps. Through the wound the arch of the aorta was distinctly visible, and its pulsations could be counted. The left lung was collapsed. When sitting up there was but slight dyspnoea. Several fragments of the sternum were re- moved, and the wound soon granulated kindly. On May 10th, a colored drawing of the wound was made. (No. 19, Surgical Series of Drawings, S. G. 0.) On July 5th, the patient was transferred to Washington, convalescent. He ultimately recovered perfectly.

The result was less favorable in the next case.

Private Patrick H. B , Co. C, 147th Pennsylvania Vols., was wounded at

Chancellorsville, May 2d, 1863, by a conoidal musket-ball, which entered between the second and third ribs, on the right side, two inches from the median line, frac- tured the sternum, and lodged beneath it. The wound bled profusely, but the ha;morrhage was arrested by pressure. The patient was conveyed to Douglas Hos- pital, at Washington, on May 8th, and died the following day. He had hemoptysis and the symptoms of traumatic pneumonia.

Only four cases are recorded of gunshot wounds of the heart that came under treatment. The specimens from these four cases are preserved in the Army Medical Museum. The patient that lived longest after a gunshot wound of the heart survived twelve hours (Spec. 837, A. M. M.). In this case a small pistol-shot entered the left ventricle and passed out through the right auricle.

Not a few cases are recorded of gunshot wounds involving both the thoracic and abdominal cavities. Among them occur the following remarkable instances of recovery from this formidable kind of injury :

Lieutenant Daniel B , 63d New York Vols., was wounded at Gettysburg, July 2d, 1863, by a conoidal

musket- ball, which passed through the belly of the biceps of the right arm, entered the chest, traversed the base of the right lung and diaphragm, wounded the intestines, and passed out above the anterior superior spinous process of the left ilium. When admitted to the field hospital, he had dyspnoea and bloody sputa, and there was a faecal discharge from the wound of exit. He was treated by large doses of opium, and, at the end of three weeks, convalescence was fairly established. In the course of a few months his wounds had entirely closed, and he rejoined his regiment for duty.

Flu. 28. — Sternum, showing a gunshot fracture by a musket-ball. The mis- shapen, battered ball is attached. Spec. 1073, A. M. M.

24

ON SPECIAL WOUNDS AND INJURIES.

Captain Robert S , Co. A, 29th New York Vols., was wounded at Chancellorsville, on the 2d of May, 1863.

A round musket-ball, fired from a distance of about one hundred and fifty yards, entered the eighth intercostal space of the left side, at a point nine and a half inches to the left of the extremity of the ensiform cartilage, and fractured the ninth rib. Without wounding the lung apparently, the ball passed through the diaphragm, and entered some

portion of the alimentary canal. Captain S walked a mile and a half to the rear, and entered a field hospital. On

examining his wound, the surgeons found a protrusion of the lung of the size of a small orange, which they unavail- ingly attempted to reduce. The wound was enlarged, and still it was impracticable to replace the protruded lung.

On May 3d. the field hospital where Captain S lay was exposed to the enemy's fire. He walked half a mile

further to the rear, and was there placed in an ambulance, and taken across the Rappahannock, at United States Ford, to one of the base hospitals. Here fruitless efforts were again made to reduce the hernial tumor, after which a ligature was thrown around its base and tightened. A day or two subsequently the patient passed into the hands of Surgeon Tomaine, who removed the ligature from the base of the tumor. A small portion of gangrenous lung sepa- rated and left a clean granulating surface beneath. On May 7th, the ball was voided at stool. On May 8th, the patient was visited by Surgeon John H. Brinton, U. S. Vols., who found him walking about the ward, smoking a cigar. There was an entire absence of general constitutional symptoms ; no cough, no dyspnoea, no abdominal pain ; the bowels were regular and appetite good. The protruding portion of the lung was carnified, and there was a dulluess on percussion and absence of the respiratory murmur in a zone an inch and a half in width around the circumfer- ence of the base of the tumor. Surgeon Tomaine stated that the hernia had been gradually diminishing in volume. It was at this date half the size of an egg, and covered with florid granulations. On May 10th, a drawing of the parts

was executed by Mr. Stauch, artist of the Army Medical Museum. On June 2d, Captain S was transferred to

Washington. There was an elastic partly reducible tumor, over which' was an oval granulating surface, an inch and a half by three-quarters of an inch. The vesicular murmur was perfect throughout the lung, except in the immediate

vicinity of the tumor. Compression of the tumor was advised. After a furlough of sixty days, Captain S was

again examined. The wound had entirely healed ; the respiratory sounds were normal ; there was still a slight hernia of the lung. The general health of the patient was excellent. At this date a second drawing was executed.

Private B. S. Sheridan, Co. A, 9th Massachusetts Vols., was wounded at Malvern Hill, July 1st, 1862, by a musket-ball, which entered the right side between the ninth and tenth ribs, and passed out a little to the right of the xyphoid cartilage. Soon after the reception of the injury, a portion of the lung protruded from the anterior wound, and from the posterior wound there was a constant dripping of bile. On July 4th, Sheridan walked from the ambu- lance station to James River, a distance of a mile and a half, with the hope of getting on board of a gunboat. He was disappointed, and was taken prisoner and conveyed to Richmond. No dressings were applied to the hernia of the lung. It was uncovered, and the patient occasionally washed it. He suffered little pain or dyspncua, and there was an amazing absence of shock or prostration. On July 25th, the bile had ceased to dribble from the posterior wound, and the hernia of the lung had greatly receded. The imperfect field notes state that the patient ultimately recovered, and was exchanged.

Private Latimer Whipple, Co. H, 73d New York Vols., was wounded at Bristoe Station, Virginia, August 27th, 1862, and admitted to the First Division Hospital, at Alexandria, on August 31st. A musket-ball struck him on the right side, four inches above the crest of the ilium, and six inches from the spine, passed upwards and inwards, and lodged. On admission, the patient had cough, with bloody expectoration, and crepitant rales in the lower lobe of the left lung. There was a profuse discharge of bile from the wound. There was acute pain and tenderness in the hepatic region, but no evidence of peritonitis. At the end of a week the symptoms of acute inflammation of the lung sub- sided, but a cough, with purulent expectoration, persisted for months. Early in October the discharge of pus and bile from the wound began to diminish, and in November the pain ceased in the hepatic region, and was referred to the immediate vicinity of the orifice of the wound. The patient now began to walk about the ward. Throughout the treatment there was great tendency to constipation, which was obviated by enemata. In the middle of December the cough had nearly disappeared, and there was but a scanty discharge from the wound. On January 12th; 1863, the wound was entirely healed, and the patient was discharged from service.

GUNSHOT WOUNDS OF THE ABDOMEN.

Of 2707 gunshot wounds of the abdomen reported from the beginning of the war to July 1st, 1864, there were 2164 flesh wounds, and 543 cases in which the peritoneal cavity was penetrated or the abdominal viscera injured. Among the flesh wounds, 114 fatal cases are recorded, which were, in most instances, cases of sloughing from injuries of the abdominal parietes by shells. Of the 543 penetrating wounds, the results have been ascertained in 414, and were fatal in 308, or 74 per cent. The number of re-

GUNSHOT WOUNDS OF TIIE ABDOMEN.

25

coveries is unexpectedly large, but includes only cases in which the reports showed,

beyond question, that the abdominal cavity had been involved. Abstracts of several

such cases are subjoined:

Private John Barr, Co. E, 76th New York Vols., aged forty- five years, was admitted into Douglas Hospital, at "Washington, May 18th, 18G4, with a penetrating gunshot wound of the abdomen, received on May 9th, at the battle of the Wilderness. A conoidal musket-ball had entered at the junction of the left twelfth rib with its cartilage, and, passing downwards, backwards, and outwards through the ilium, lodged in the gluteal muscles, whence it was removed by incision. On admission, the wound copiously discharged a thin translucent fluid, resembling diluted bile, which evidently came from the small intestine, for, among other reasons, it had no faecal odor. Were further proof of the origin of the discharge required, it would be furnished by the fact that three ascarides lumbricoides escaped from the wound during the second and third weeks of the treatment. The discharge, for nine days prior to admission, was, according to the patient, similar to that above noted. The patient was kept perfectly quiet in a recumbent posture. The discharge from the wound was facilitated by large masses of charpie being used to absorb it. For several weeks the patient was nourished solely by milk, milk-punch, and beef tea. His appetite was poor, his sleep much disturbed by cough. But there was no abdominal pain or tenderness, and at no time, throughout the treatment, was there any symptom of peritoneal inflammation. On May 22d, a soap and water enema was administered without result. Nothing more was attempted in this direction, as the patient was doing well, and nature seemed competent to meet every indication. On June 3d, the discharge had entirely ceased, and the patient was much improved. On June 6th, he had a large alvine evacuation, the first since May 9th. Ou June 11th, with the aid of an enema, he had another large dejection. From this time he improved rapidly. On August 16th, a fragment of necrosed bone, that could be recognized as a portion of the ilium, was removed from the wound in the gluteal region. About the same period bits of necrosed cartilage were taken from the fistulous orifices opening near the wound of entrance. The bowels were disposed to costiveness, and flatulence was troublesome. Early in October there was an attack of dysentery, which lasted one week. On May 5th, 1865, a needle-shaped bit of bone escaped from the wound of entrance. On May 8th, both wounds were entirely healed. On July 16th, the patient was photographed at the Army Medical Museum. He was then in good health.

Private George H. Bowers, 8th Illinois Cavalry, was wounded in a skirmish near Frederick, Maryland, Septem- ber 13th, 1862, by a musket-ball, which entered two inches above the umbilicus, an inch to the left of the linea alba, and made its exit beneath the tenth rib, three inches to the left of the spinous process of the tenth dorsal vertebra. Immediately after he was shot, he vomited blood copiously until syncope supervened. Hcematemesis recurred fre- quently for seven days, and blood was passed at stool. Acute peritonitis ensued. The medical attendants had no doubt that the stomach was perforated. Liquids taken into the stomach passed freely through the anterior wound. The case was treated by opium in large doses. In May, 1863, the patient was transferred to the hospital at Stewart's Mansion, in Baltimore. The wound had healed, and the digestive organs had resumed their normal action. But the body was bent forward by intra-abdominal adhesions. The patient was subsequently discharged from service.

In many instances faecal fistulas were produced. They commonly closed after a time, without operative interference, reopening at intervals, and then healing per- manently.

Sergeant Lewis E. Morley, Co. F, 61st New York Vols., was wounded at Gettysburg, July 1st, 1863, by a conoidal musket-ball, which entered a little below the umbilicus and to the left of the linea alba, and passed directly through the body, dividing the intestine in its passage. When brought to the field hospital he was in a state of collapse. Faces escaped from the wound. There was excessive tenderness and pain. Opiates were freely administered, and the symptoms of peritonitis gradually abated. On July 10th, the patient was in a condition to be removed to Balti- more. The discharge of fa;ces from the wounds continued until September 28th, when there was an evacuation by the rectum. The wounds soon afterwards closed, and on October 27th, the patient was sent home on furlough.

Private A. J. Marker, Co. I, 4th Maine Vols., aged eighteen years, was wouuded at Centreville, September 1st,

1862, by a conoidal musket-ball, which entered the left hypochondriac region, between the eighth and ninth ribs, and lodged under the skin a little to the left of the spinous process of the second lumbar vertebra. He entered Epiphany Hospital, at Washington, ou the following day, and the ball was removed by an incision. There was immediately a copious fsecal discharge through the incision. It was ascertained that the ninth rib was fractured, and fragments of it were removed. On September 5th, a portion of gangrenous omentum presented at the posterior wound and was excised. A sphacelated portion of the descending colon was also removed. The faecal fistula persisted until May,

1863, when the discharge from the anterior wound became sero-purulent. A month afterwards both wounds healed up soundly, and the patient was sent to his home in Belfast, Maine. In November, 1863, while the wounds were still discharging stercoraceous matter, a colored drawing was made, which is No. 15 of the Surgical Series of Drawings, S. G. 0.

Private John Harm, Co. I, 20th Indiana Vols., was wounded at the battle of Fair Oaks, May 31st, 1862, by a

4

26

ON SPECIAL WOUNDS AND INJURIES.

musket-ball, which entered three inches to the right of the spine and one inch above the crest of the ilium, and, pass- ing upwards across the abdominal cavity, made its exit in the left hypochondriac region. He was admitted to Broad and Cherry Streets Hospital, in Philadelphia, on July 29th, 18G2. He stated that there was free haemorrhage from the wounds at first, and subsequently a discharge of faeces. At the date of his admission, the wound of exit had closed; but faeces and flatus still escaped by the posterior wound. At the end of October, 1862, this wound also closed; but it reopened a few weeks subsequently, and a fragment of flannel was extracted from it. After this it healed soundly, and the patient was discharged from service.

Private Franklin Harsh, Co. G, 7th Ohio Vols., was wounded at Chancellorsville, May 3d, 1863, by a conoidal musket-ball, which entered the abdomen six inches to the right of the umbilicus, and passed out posteriorly, having wounded the ascending colon and the crest of the right ilium. He was admitted to Armory Square Hospital, at Washington, and remained there for a long time with a faecal fistula. On September 13th, 1863, the anterior wound had closed, and the discharge from the posterior wound was much diminished. Ultimately the fistula closed, and the patient was discharged from service. Early in the history of the case, a colored drawing of the patient was made. (Nos. 21 and 22, Surgical Series of Drawings, S. G. 0.)

Sergeant Joseph E. Fletcher, Co. D, 8th Connecticut Vols., aged twenty, was struck at the battle of Antietam, September 17th, 1862, by a musket-ball, which entered six inches to the left of the umbilicus, and, passing somewhat downwards, emerged an ''roll and a half to the left of the spine. The ball opened the descending colon, and when the patient was examined 1 _t Surgeon T. H. Squire, 89th New York Vols , there was a profuse faecal discharge from the wound of exit. The ens, ing peritonitis was circumscribed, and the patient was transferred to Frederick, a few weeks subsequently, in a satisfactory condition. The faecal fistula finally closed and the patient recovered.

Lieutenant G. F. Deichler, Co. I. 69th Pennsylvania Vols., aged twenty-two years, was wounded by a conoidal musket-ball, at Hatcher's Run, Virginia, in March, 1865. The ball entered the right iliac region, and, passing through the ascending colon, made its exit a little to the left of the last dorsal vertebra. The patient was taken to a field hospital, and from thence to Armory Square Hospital, at Washington, where he was admitted on April 1st, in an exhausted condition, with grave symptoms of peritonitis. There was a copious faecal discharge from both * wounds. Appropriate dressings were applied, a fourth of a grain of sulphate of morphia was ordered to be given every second hour, and stimulants were directed. On April 7th, sloughs separated from both wounds, and left a clean granulating surface. A large piece of sphacelated omentum was removed from the anterior wound. The opiate treatment was continued till April 27th, when there was a faecal evacuation by the anus, for the first time since the injury. On June 12th, the discharge from the wounds was very slight. The edges of the wounds were now refreshed and approximated by adhesive strips. On August 10th, the anterior wound was firmly healed. There was a small fistulous sinus at the posterior wound, discharging pus scantily. On this day, a photograph was taken at the Army Medical Museum, from which the plate opposite is copied, and the patient left the hospital for his home in excellent general health.

Private Robert Brierly, Co. A, 1st Delaware Vols., aged twenty-two, was wounded at the battle of Antietam, by a conoidal musket-ball, which entered a little to the left of the umbilicus, and lodged under the muscles near the anterior superior spinous process of the right ilium. There was great prostration, with nausea and vomiting, which were treated at the field hospital by the administration of opiates. Three weeks subsequently, the patient was trans- ferred to Frederick, Maryland. On October 25th, faeces escaped through the lower wound* which had been for several days in a sloughing state. The artificial anus continued open until November 15th. On November 25th and December 11th, there were attacks of colic, followed by reopening of the faecal fistula. By the end of December, the wounds appeared sound and permanently healed, and the patient was transferred to Baltimore, and subsequently was discharged from service.

Private James T. Dowdy, 28th Virginia (Rebel) Regiment, aged twenty-three years, was wounded at the battle of Gettysburg, July 3d, 1863, by a conoidal musket-ball, which entered at the tip of the ensiform cartilage, and remained in the body. He was removed to one of the Gettysburg field hospitals. On July 4th, fourteen hours after he was shot, he passed the ball at stool. There was no general peritonitis, and the wound healed promptly, and the patient was transferred to Baltimore, and thence sent to City Point, Virginia, for exchange.

Recoveries after wounds of the large intestines have been much more numerous than after wounds of the ileum or jejunum.

No case has been reported in which it was thought expedient to apply a suture to the intestines alter gunshot wounds.

Gunshot wounds of the liver were usually followed by extravasation into the abdominal cavity and rapidly fatal peritonitis. Of 32 cases in which the diagnosis was unquestionable, all but 4 terminated fatally. Abstracts of two of the fortunate cases are appended :

Private Fritz Siebel, Co. D, 139th New York Vols., aged twenty-three years, was wounded at Cold Harbor,

PERFORATING GUNSHOT WOUND OF THE ABDOMEN

CASE Or LIEUTENANT DElCHLER

•

If

«■

GUNSHOT WOUNDS OF THE ABDOMEN.

27

Virginia, June 3d, 1863, by a musket-ball, which entered the right hypochondriac region, below the tenth rib, and passed out posteriorly an inch and a half to the right of the spine. He was admitted to Harewood Hospital, at Washington, on June 18th, in a very feeble state. There was a fa;cal discharge from the wound, mixed with bile. The ball had passed through the colon and the liver. There was great abdominal pain, aa anxious countenance, nausea, and the other symptoms of traumatic peritonitis. A cold water-dressing was applied, and opium was admin- istered in full doses. On July 1st, the pain on pressure was circumscribed, and the general symptoms were less threatening. The discharge from the wound was unaltered. On September 1st, the wound of exit had healed, and the anterior wound discharged only a thin serum. On September 14th, the wound of entrance closed. The patient was furloughed on October 8th, 1863, and on the expiration of his furlough was returned to duty.

Corporal W. A. C. Biles, Co. K, 25th North Carolina (Rebel) Regiment, was wounded at Gettysburg, July 3d, 1863, by a conoidal musket-ball, which passed through the lower portion of the right lobe of the liver. He was treated at one of the field hospitals at Gettysburg, and his case was carefully observed by Surgeon EL Janes, U. S. Vols. There was a free discharge of bile from both the wound of entry and of exit. There was circumscribed pain and tenderness on pressure, but apparently no extra-abdominal extravasation. The wounds continued to discharge bile until August 27th. On November 1st, the patient was transferred to West's Buildings Hospital, at Baltimore, and on November 1.2th, 1863, he was sent to City Point, Virginia, for exchange, his wound being entirely healed.

All the cases of gunshot wounds of the spleen that have been reported, were fatal. No symptoms are mentioned that particularly distinguished these from other gunshot injuries involving the abdominal cavity, and it is quite possible that the list of re- coveries may include cases in which this viscus was injured, though the diagnosis was not made out

A case is recorded of a lacerated wound of the abdominal walls, with lesion and protrusion of the pancreas, a portion of which is reported to have been excised. It appears probable that it was rather a portion of the omentum that was removed. Several cases are reported in which it was believed that recovery took place after gun- shot wounds of the kidney :

Private Groff, Co. D, 61st Pennsylvania Vols., was admitted on June 8th, 1862, to Fifth Street Hospital, in Philadelphia, for wounds received at the battle of Fair Oaks, June 1st, 1862. He had a flesh wound of the left hip, another of the right thigh, and a wound in the left lumbar region, which was considered to be a penetrating wound of the abdomen. Immediately after he was struck, blood passed freely by the urethra. When he entered the hospital, he had hajmaturia. His wounds healed, however, kindly, and he left the hospital entirely well

Sergeant Galloway, Co. H, 8th Pennsylvania Reserves, was wounded at South Mountain, September 14th, 1862, by a musket-ball, which passed through the abdomen. He was treated at Satterlee Hospital, in Philadelphia. He had hematuria, and pain and tenderness in the region of the left kidney. He ultimately recovered.

It can hardly be considered that the evidence of gunshot wound of the kidney was, in these cases, unequivocal.

Gunshot wounds ot the bladder, when the projectile entered above the pubes or through the pelvic bones, have proved fatal, so far as the records have been examined. There are many examples of recovery, however, from injuries of the parts of the blad- der uncovered by the peritoneum.

Several examples of recovery, after protrusions of the abdominal viscera through gunshot wounds, have been reported. In two cases in which loops of small intestine issued, they were immediately returned and retained by means of adhesive strips and bandages, and the patients recovered with ventral hernia. The escape of omentum, through wounds, would not appear to be a very serious complication, for in many cases portions of protruding omentum have been excised, and the patients have, nevertheless, recovered promptly.

In relation to gunshot wounds of the great vessels of the abdomen, a few words will be said in treating of ligations.

Penetrating wounds of the abdomen, complicated with fractures of the vertebrae,

28

ON SPECIAL WOUNDS AND INJURIES.

uniformly proved fatal such cases.

A single extract will suffice to show the usual progress of

-L 9

Fig. 29.— Gunshot fracture of the second and third lumbar verte- bra;. Sjjec.3583,A.M.M.

Corporal John E , Co. M, 14th New York Heavy Artillery, was wounded before

Petersburg, in July, 18G4. He was sent to Washington, and admitted to Douglas Hospital, with peritonitis and complete paraplegia. A musket-ball had entered at the right hypo- chondriac region, passed downwards through the right lobe of the liver and the abdominal cavity, and fractured the second and third lumbar vertebra;. He died on August 3d, 1864.

At the Army Medical Museum are specimens of 18 gunshot wounds of the stomach or intestines, 10 of the liver, 8 of the spleen, 10 of the kidneys, 4 of the bladder, and G of the genito- urinary organs.

GUNSHOT FRACTURES OF THE PELVIS.

The records under this head include only the cases in which the abdominal cavity was not penetrated. From the beginning of the war to October 1st, 1864, 359 such cases have been reported. Recovery took place in 97, death in 77, and the result is still to be ascertained in 185. In 256 cases the ilium alone was injured, the ischium alone in 19, the pubes in 12, the sacrum in 32, and in 40 cases the lesions extended to two or more portions of the innominata.

The gravity of these cases depended upon the location and extent of the fracture. The majority of recoveries were from fracture of the ilium by musket-balls, in which the crest was grooved, or comparatively slight injury was inflicted. Yet there were many examples of perforation of the body of the ilium with ultimate recovery. The following is an abstract of such a case:

Major H. A. Barnum, 12th New York Vols., was wounded at Malvern Hill, July 1st, 1862, by a conoidal musket- ball, which entered midway between the umbilicus and the anterior superior spinous process of the left ilium, passed through the middle of the ilium, and emerged posteriorly. On July 2d, he was captured and taken to Libby Prison, a distance of eighteen miles, in an express wagon. On July 17th, he was taken to Aikens' Landing in an ambulance, a distance of seventeen miles, and exchanged. He was conveyed by water to Albany, and thence by rail to Syracuse, New York. At no time were any symptoms of peritonitis manifested. On October 1st, Major Barnum went to Albany, where Dr. March dilated the anterior wound by an incision and extracted several fragments of the ilium, and directed that a tent should be worn. Promoted to the command of the 149th New York Vols., Colonel Barnum took the field in January, 1863. He wore the tent about a month, when the anterior wound healed. About the middle of March, a large abscess formed, and evacuated itself at the site of the anterior wound. In April, Dr. March again cut down to the ilium, and introduced a tent. No loose fragments of bone were found. The Colonel resumed his duties, and commanded his regiment at Gettysburg. In January, 1864, another large abscess formed, and discharged pos- teriorly. The orifice was enlarged by Dr. L. A. Sayre, of New York, and a seton of oakum was passed from before backwards through the entire track of the ball. This was worn for several weeks, when Surgeon M. K. Hogan, U. S. Vols., substituted a seton of candle-wick, which was gradually reduced in size, and finally replaced by a single linen thread. A photograph of the patient was taken at the Army Medical Museum in August, 18G5. The wound still discharged slightly, and the thread seton was still worn. Promoted to be a brigade commander, General Barnum has Keen almost continually in the field for the past two years. He participated in the campaigns of Atlanta, Georgia, and Carolina, was shot through the right forearm at Kenesaw Mountain, and received a shell wound of the side at Peach Tree Creek.

In most cases of injury of the pelvic bones, very tedious suppuration ensued, and surgery could do but little, except to facilitate the escape of pus, and to remove dead bone as it became separated. The returns corroborate the observation of Stromeyer, that there is a great liability to pyaemia in gunshot fractures of the pelvis.

GUNSHOT WOUNDS OF THE UPPER EXTREMITIES.

29

GUNSHOT WOUNDS OF THE GENITO-URINARY ORGANS.

In this category are included gunshot wounds of the genitals or urinary organs that are not complicated with fractures of the pelvis, or with penetration of the ab- dominal cavity. To October 1st, 1864, the reports furnish 457 such wounds, of which 37 had a fatal result.

Surgeon S. W. Gross, U. S. Vols., reports the singular history of a soldier of the 16th U. S. Infantry, struck at Shiloh, on the right side of the penis, by a conoidal musket-ball, which buried itself in the corpus cavernosum, and became encysted. It gave no pain, and the patient refused to have it extracted.

The following is an interesting case of gunshot wound ot the bladder :

Private Conrad L , Co. A, 23d Indiana Vols., aged thirty-two years, was wounded at Vicksburg, Miss.,

June 23d, 1863, by a fragment of a hand-grenade, which entered the right nates two inches outside of the end of the coccyx, and passed into the bladder, where it lodged. Urine passed by the wound immediately after its reception. The patient was admitted into the General Hospital at Jefferson Barracks, Missouri, August 5th, 1863. His general health was much impaired. The urine passed mainly by the wound, and was largely mixed with pus and blood. The treatment directed comprised warm fomentations, mild diuretics, stimulants, and nu- tritious diet. On February 20th, 1864, a catheter was with much difficulty

passed by the urethra, and the presence of a foreign body was ascertained. Fl,°- so.— Fragment of p-enade incnisted with caicu- 1 1 Ions matter, extracted from the bladder by lithotomy .

On March 19th, the general condition was improved, the wound was so far SpecSS, a. M. m.

closed as to admit only a large- sized probe. Attempts to pass a catheter or to probe the wound caused chills and febrile irritation. On April 2d, 1864, the lateral operation of lithotomy was performed by Surgeon John F. Randolph, U. S. A., the patient being anaesthetized by equal parts by bulk of chloroform and ether. A rectangular fragment of shell, largely incrusted with earthy phosphates, was extracted. It was two inches in length, seven-eighths of an inch in width, and three-eighths of an inch in thickness. It weighed two ounces and five grains troy. On April 12th, the urine passed by the wound. On April 27th, the wound had healed, and the patient was soon afterwards restored to his ordinary condition of health. The incrusted fragment of shell is preserved in the collection of the Army Medical Museum (Spec. 88). It weighs 898 grains, portions of the phosphatic deposit having crumbled away.

GUNSHOT WOUNDS OF THE UPPER EXTREMITIES.

When unaccompanied by lesions of the vessels and nerves, the gunshot flesh wounds of the upper extremity are not very serious injuries. All foreign bodies hav- ing been extracted, they commonly heal, under the use of water-dressings and the lightest bandaging, in a few weeks. The 21,248 cases entered on the registers are all copied from the reports for the last quarter of 1863 and the first two quarters of 1864.

The gunshot fractures of the upper extremity are recorded in four classes: those of the scapula and clavicle, which are not, at the same time, penetrating wounds of the chest; those of the shaft of the humerus and either of its articular extremities; those of the ulna and radius; and those of the carpus and metacarpus. It is only with the second class that much progress has been made. This comprises 2408 cases of gunshot fractures of the humerus that have been examined and recorded. Recovery followed in 1253 cases, death in 436, and the result is as yet undetermined in 719 cases. In the 1689 completed cases, amputation or excision were practised in 996, and con- servative treatment was adopted in 693, with a ratio of mortality of 21 per cent, in the former and 30 per cent, in the latter. But it is premature to make deductions from statistics which are daily augmenting and tending towards completion.

30

ON SPECIAL WOUNDS AND INJURIES.

Gunshot lesions of the upper extremity are illustrated at the Army Medical Mu- seum by 978 specimens, including examples of almost every variety of contusion and fracture, of the repair of fractures, of consecutive diseases of bones, and of excisions, amputations, and their secondary lesions. A few specimens are copied here.

Private William F , Co. F, 18th Massachusetts Vols., aged

thirty years, was wounded at the second battle of Bull Run, August '^'^Hlk 30th, 1862, by a conoidal musket-ball, which entered to S -V Wtm the left of the spinal column, and, passing outwards, trav- wBfe. . JS ersed the body of the scapula and the muscles of the 1 upper part of the arm. The patient was conveyed to *V \ Union Chapel Hospital, at Alexandria. On the 3d, and V"/ J| again on the f>th of September, misshapen pieces of ball and a few fragments of bone were extracted through an KgW incision on tlie outer e(3ge of the scapula. On Septem- "^■^■a^^^ESiS Sto ber 19th, symptoms of purulent infection were manifested.

fn^m.nt* of a conoidal ,n»sket-baii. Spec. 809, A. An active treatme„t by stimulants, quinia, iron, and am- monia, was instituted, but unavailingly, and on September 25th, 1862, the case terminated fatally. At the autopsy, a large collection of extravasated blood was found beneath the scapula, and between the muscles of the shoulder. There was extensive serous effusion in the left pleural cavity, and numer- ous metastatic foci in both lungs.

A soldier of the 2d Division of the 12th Army Corps had his left arm shattered by an elongated musket-ball, in the attack on the stone wall on the heights at Fredericksburg, December 14th, 1862. Primary amputation at the shoulder-joint was performed, and the patient recovered. The specimen illustrates the ordinary longitudinal splitting produced by a conoidal ball in the shaft of a long bone.

Private B W , Co. I, 37th New York Vols., aged twenty-two years, was wounded at

Williamsburg, Virginia, May 5th, 1862 in the right elbow, by a conoidal musket-ball. A simple

dressing was applied, and he was re- moved to Yorktown, and thence to Phil- adelphia, where he was admitted to Race Street Hospital. No report could be ob- tained of the progress of the case until fig March 13th, 1863, when the patient was transferred to the McClellan General Hospital, at Nicetown, with extensive necrosis of the shaft of the humerus and caries of the elbow-joint. About the joint and arm there were numerous sinuses, through which a profuse purulent discharge escaped, and, occasionally, small fragments of detached bone. Under a supporting treatment, the general condition improved. About the middle of July, it was first noticed that the patient's legs were oedematous. General anasarca ensued, and an examination of the urine showed that it was highly albuminous. The patient became rapidly worse, and on August 12th, an uncontrollable diarrhoea set in, accompanied by vomiting. The case terminated fatally, August 22d, 1863. The characteristic lesions of Bright's disease were revealed by the autopsy.

GUNSHOT WOUNDS OF THE LOWER EXTREMITIES.

Of these, 30,014 cases have been recorded, of which 4862 were fractures, and 25,152 were flesh wounds. The latter were transcribed from the reports from October 1st, 18G3, to October 1st, 1864. It has not been practicable as yet to tabulate the flesh wounds of the lower extremities that occurred in the earlier part of the war.

For gunshot fractures of the femur, two registers have been kept. On one, all cases were entered. On the other, only those in which the histories of the cases had been carefully scrutinized, and in which the locality and extent of the injury were clearly designated in the reports. In the latter register 1823 cases had been entered on September 1st, 1865, or about one-third of the total number that have been reported.

Fig. 33.-

-Necrosis of the shaft of the humerus, following a gunshot wound tin- elbow. Spec. 2749, A. M. M.

Left hu- oniniinu- conoidal musket-ball. Spec. 1082, A. M. M.

meru ted by

GUNSHOT WOUNDS OF THE LOAVER EXTREMITIES.

31

Gunshot wounds of the knee-joint, with or without fracture of the patella, or of the epiphyses of the femur or tibia, have been recorded in like manner, to the number, thus far, of 1183.

Of the 1823 cases of gunshot fracture of the femur that have been entered on the permanent records, the results have been ascertained in 1233. Of the 1183 cases of gunshot wounds of the knee-joint, the results are known in 740.

While it is deemed premature to discuss these results when it may be reasonably hoped that the completed statistics will definitely settle the important questions that are here involved, it is yet thought expedient to report them, chiefly that the magni- tude of the subject may be put in evidence, and that the absolute necessity for long and patient investigation may be acknowledged.

The following table exhibits at a glance the results of 2003 cases of gunshot fracture of the femur, or of gunshot wounds of the knee-joint, out of a total of 3106 cases hitherto recorded. The fractures of the femur are separated according to regions. The left hand column gives the number of cases belonging to each region of which the ultimate results have been satisfactorily determined. The right hand column gives the total number of cases of injuries of each region that have been recorded. The inter- mediate columns give the comparative results of treatment by amputation, excision, or attempt at conservation of the limb, the number of recoveries and deaths and unfinished cases in each category being mentioned, and the rate of mortality calculated for the finished cases alone.

Table, exhibiting the Results of 2003 Terminated Cases of Gunshot Fracture of the Femur, or of Gunshot Wounds of the Knee- Joint, out of 3106 Cases that liave been entered on the Eecords.

			Amputation.	Excision.	Conservative Measures.
		Total				£ 1				o S s %				te of	Aggre-
		TERMIN-			C				.5	u t3			a	CO w 1- T3	gate.
		ATED.	•a U		1	&J	■a u		3 u	.t?.S	-a		|	£?§
			Recove	■6 3	Undete	"rt 3 ^ o *j	Recove	■a 5	Undete	Mortal determ	Recove	■a 3	*d a P	i n +■> il o **
Gunshot Fractures of Femur, impli-
cating Hip-Joint		82	0	2	0	100-	2	10	1	83-33	0	68	14	100-	97
Gunshot Fractures of upper	third of														603
		387	8	24	11	75-	7	18	6	72-	93	237	199	71 81
Gunshot Fractures of middle	third of
		346	42	51	47	54-83	2	13	10	86-66	106	132	148	55 46	551
Gunshot Fractures of lower	third of
		418	131	112	117	46 09	1	1	0	50-	72	101	137	57-79	672
Gunshot Wounds of the Knee-Joint,														1183
with or without Fracture		770	121	331	206	73-23	1	9	1	90-	50	258	146	83-76
		2003	302	520	441	63-26	13	51	18	79-68	321	796	644	71-26	3106

In examining the above table in detail, it is seen that the results are ascertained in 822 of the 1263 cases treated by amputation, or 65 per cent,; in 64 of the 82 cases treated by excision, or 78 per cent.; and in 1117 of the 1761 cases treated by conser- vative measures, or 63 per cent.

32

ON SPECIAL WOUNDS AND INJURIES.

The only recorded recoveries after gunshot fracture of the femur involving the hip-joint are those in which excision was practised. In fractures of the upper third, the mortality rate is greatest for the cases treated by amputation. There were 43 of these cases, and in 19 of them the amputation was done at the hip-joint. Excision gives 7 recoveries after fractures of the upper third ; 2 of these were excisions of the head and a portion of the shaft of the femur, 4 were formal excisions of the continuity, and 1 was a removal of fragments and rounding off of sharp edges of bone, which was admitted among the excisions with some hesitation. Under conservative measures 93 cases of fracture of the upper third had survived the injury a year or more, and are reported as recovered. The mortality rate of the completed cases of amputation for gunshot wounds of the knee-joint is large, and will probably be modified when the results of the numerous unfinished cases are recorded. It depends partly, however, upon the excessive mortality of intermediate amputations of knee-joint injuries. With six or eight exceptions, the 50 recoveries without amputation classified with gunshot wounds of the knee-joint were examples of fractures of the patella, in which the evidence that the joint was opened was not unequivocal.

Comparing in gross the 822 finished cases treated by amputation, with the 1117 treated by conservation, the mortality rate of the former has the advantage by 8 per cent.; an advantage that is maintained in the different regions, except in the upper third. It must be remembered that the amputations include most of the bad cases, and those in which preservation of the limb was attempted and abandoned.

But little progress has been made in the examination and registration of the frac- tures of the tibia and fibula. Only 1056 have been recorded, of which 696 are term- inated cases, chiefly belonging to the earlier periods of the war. Of these, 169, or 24 per cent., were fatal.

A similar remark applies to the fractures of the tarsus and metatarsus. But 629 cases have as yet been recorded.

For gunshot fractures of the phalanges, it has been thought superfluous to keep a separate register, as the majority of such cases will appear on the register of amputa- tions of the toes.

At the Army Medical Museum, the gunshot injuries of the lower extremity are illustrated by 1984 specimens, comprising examples of almost every conceivable form of contu sion or fracture, illustrations of secondary lesions, and of reparative attempts m all stages, wet preparations showing the appearances of wounds of entrance and exit, the ravages of hospital gangrene, wounds or consecutive lesions of the great vessels, numerous drawings, casts, and photographs, and, among the latter, representations of over seventy patients, who had so far recovered after gunshot fracture of the femur as to be able to move about.

The specimens of fractured or diseased bones at the Museum are arranged accord- ing to the regions involved, the primary being separated from the secondary lesions, and the illustrations of operations being classified apart. Representations of a few specimens will be introduced here.

In Stromeyer's classification of the action of bullets on bone, the fifth division is that in which the ball pierces the bone and forms a canal without causing further splintering. Examples are common in the upper portion of the tibia, but very rare in the upper extremity of the femur. The following is such an instance :

ON SPECIAL WOUNDS AND INJURIES.

33

Fir,. 34. — Upper extremity of left femur perforated by a conoida! ball. Spec. 505, A. M. M.

\1

Captain James M. L , Co. I, 20th Indiana Vols., was admitted into Colum- bia College Hospital, at Washington, June 29th, 18G2, with two gunshot wounds, received a day or two previously in one of the battles before Richmond. The first wound was through the left lumbar muscles. After receiving it the officer fell, and while lying on the field he was again struck by an elongated musket-ball, which entered on the outer side of the left thigh, a little below the great trochanters, and, passing upwards and inwards, lodged. A finger could be readily passed into the per- foration in the femur, but the ball could not be reached. Three formal attempts to ascertain its position and accomplish its removal were made unsuccessfully. The patient died from exhaustion on August 19th, 1862. The near proximity of the ball had not induced any disease of the hip-joint. The specimen and the facts relating to it were contributed by Assistant Surgeon W. M. Notson, U. S. A.

An illustration of a comminuted gunshot fracture in the

trochanteric region is given in the section on excisions of the

head of the femur. Of comminuted fractures of the shaft of

the femur by the conoidal musket-ball, the following is a fair example :

Private John Draker, Co. I, 57th Pennsylvania Vols., aged twenty-five years, was wounded while on picket duty on the Rapidan, November 27th, 18G3. A conoidal musket-ball passed through the muscles of the right thigh, and, entering the middle of the left thigh at its inner side, flattened itself against the femur, and shattered the bone. The patient was transferred to Alexan- dria by rail, and admitted, December 4th, 18G3, to the Second Division U. S. A. General Hospital. He died December 13th, 1863.

Just above the condyles, where the cancellated structure of bone

predominates, musket-balls often make a clean perforation. But the

wedge-like action of the elongated musket-ball almost invariably involves

longitudinal splintering. The following is a good illustration :

Private Samuel S. Kopp, Co. E, 10th Pennsylvania Reserves, was shot through the lower third of the right thigh, by a musket-ball, at the second battle of Bull Run, August 28th, 1862. The ball entered just above the patella, and made its exit in the popliteal space. The patient was taken, after a few days, to Alexandria. On Septem- ber 20th, 1862, his thigh was amputated at the middle. He survived the operation two days.

The later writers on military surgery have duly insisted upon the different effect upon bones of the impact of round musket-balls and of the cylindro- conical projectiles. The degree of difference in the injuries inflicted has, perhaps, been exaggerated. It is unquestionably true, however, that the round ball usually produces much less longitudinal splintering than the conoidal ball, with its greater weight and immense force of propulsion and wedge-like action. In the case which furnished Specimen 3228, A. M. M., where a round ball entering the outer condyle behind, passed upwards, forwards, and inwards through the bone, it was practicable to amputate successfully much nearer the track of the ball than would have been admissible in the case quoted just before.

One curious effect, occasionally produced by the heavy conoidal ball in striking the femur, has not been very generally noticed. The bone is fissured and comminuted, though less than is common, 5

Fig. 35. — Fracture of the shaft of the left femur by a musket- ball. Spec. 1907, A. M. M.

Fio. 30.— Perforation of the right femur by a musket-ball. Spec. 70, A. M. M.

Fio. 37.— Condyle of left fe- mur nearly perforated by a round musket-ball. Spec. S228, A. M. M.

84

GUNSHOT WOUNDS OF THE LOWER EXTREMITIES.

Fio. 38. — Fracture of the

musket-ball. Spec. 1118, A. M. M.

long bones,

at the point at which the ball impinges, while at two or three inches above or below this point, according as the point of impact is below or above the middle of the shaft, a nearly transverse fracture of the shaft is produced. The accompanying figure is an example; but the Museum contains a dozen better illustrations The best are of cases in which a ball has struck the condyles anteriorly, and the shaft is snapped across two inches above. In several of these specimens, the transverse fracture is not connected by fissures with the comminuted fracture produced by the ball. It appears that these injuries were produced by balls fired at short range.

When the femur is simply contused by a ball, a limited necrosis commonly ensues from the destruction of the periosteum, and inflam- S"rtbydafcto1noiIdIi matioii of the medullary cavity often results, and death from pyaemic infection. The records would indicate that gunshot contusions of the a subject ably discussed* of late by Surgeon J. A. Lidell, U. S. Vols., are more dangerous accidents than comminuted gunshot fractures even. Of gunshot contusions of the femur, there are seventeen specimens at the Army Medical Museum. Several of these bones were sawn through the long axis, immediately after the death of the patient, and colored drawings were prepared, exhibiting the appearances of the inflamed or suppurating or gangrenous medulla.

Cases in which a portion of the shaft of the femur is gouged out, or a part of its cylinder crushed without entire division of the continuity, are also very fatal. The following is an example:

Private Orson B. Norwood, Co. K, 3d Michigan Cavalry, was wounded July 15th, 1863, in a skirmish near Jackson, Tennessee. He was acting as a vidette at the time, and was stationed on a bridge. The ball, fired from below, produced a long fissure in the lower third of the inner aspect of the femur, and was it- self split by the compact lamina of the bone. This patient was removed to the General Hospital, at La Grange, Tennessee, July 22d, 1863. The thigh was then erysipelatous, and amputation was deemed inadvisable. Septem- ber 27th, 1863, he was removed to the Washington Hospital, at Memphis, where he died of pyaemia, October 2d, 1863. The fragment of the inner sur- face of the femur, though but slightly separated from the diaphysis, was found to be necrosed.

The series at the Army Medical Museum, illustrating the reparative efforts of nature after gunshot fractures of the femur, consists of 190 specimens, and is of exceeding interest. A lew cases arc selected. The first shows the extent of repair ten weeks subsequent to the injury.

Private E. W. A , Co. G, 5th Florida (Rebel) Regiment, aged eighteen

years, was wounded July 3d, 1863, at the battle of Gettysburg, by a conoidal musket-ball, which shattered the upper third of the left femur. He was first treated at a field hospital, but on August 5th, 1863, was admitted to Camp Letterman General Hospital. At that date, the patient was reduced by profuse suppuration ; he was greatly emaciated, and large l.cd-sores had formed on his back. On August 12th, a troublesome diarrhoea set in. He lingered

Fig. 39.— Lower end of right fe- mur, split by a conoidal mus- ket-ball. Spec. 1788, A. M. M.

Fid. 40. — Left femur, exhibiting attempts at repair after a gunshot fracture of the upper third. The patient survived ten weeks. Spec. 1938, A. M. M.

* American Journal of Medical Sciences, vol. xlix. p. 17, el seq

ON SPECIAL WOUNDS AND INJURIES.

till September 15th, 1863, when he died from exhaustion. The large foliaceous masses of callus uniting the fragments were extremely delicate and brittle.

In the next case, the patient likewise survived ten weeks after a comminuted gunshot fracture of the middle third.

Corporal H. Burns, Co. H, 31st New York Vols., was struck by a conoidal ball, at the battle of Chancellorsville, May 3d, 18G3. The missile fractured the shaft of the left femur, with the usual longitudinal splintering. On May 8th, the patient was admitted to Douglas Hospital, at Washington, and it was decided to attempt to save the limb. This was first suspended by Smith's anterior splint. Afterwards Hodgen's apparatus was ap- plied, and apparently answered a better purpose; but large abscesses having formed in the thigh, and free incisions becoming requisite, a long fracture-box, filled with bran, was substituted. On June 16th, 1863, the ball and several fragments of detached bone were removed. The patient died on July 11th, 1863, from exhaustive suppuration. Several days before his death gangrenous patches appeared on the left leg. (Figure 41.)

In the next case, the patient survived more than four months.

Sergeant Sewell T. Douglas, Co. G, 1st Regiment Maine Heavy Artillery, aged twenty-eight years, was wounded at the battle of Spott- sylvania, and was admitted to Emory Hospital, at Washington, May 22d, 1864. A nmsket-ball entering posteriorly, had fractured the lower third of the left femur, and lodged in the medullary cavity. The injured limb was placed on a double iuclined plane, and moderate extension was used. Internally, stimulants and tonics were employed. In August, 1864, the patient suffered from severe diarrhoea. There was a copious ill-conditioned discharge from the wound. The patient died September 26th, 1864, from exhaustion, and, at the autopsy, a deposition of callus was found at the seat of injury, enclosing several necrosed splinters and a battered musket-ball.

Partially consoli- dated gunshot fracture of the middle third (if the left femur. Spec. 1643, A. M. M.

42 — Partially con- solidated gunshot frac- ture of the left fernur. Spec. 32C7, A. M. M.

In the following case the process of repair had gone on for nine months, and union was nearly com- plete, when the patient was carried off by an intercurrent disease.

Private Christian Ilolzworth, Co. B, 20th Indiana Vols., was wounded at the second battle of Manassas, August 20th, 1862, by a conoidal musket-ball, which entered on the anterior aspect of the upper third of the left thigh, and lodged against the femur, which was fractured with extensive longitudinal splitting. He was conveyed to Armory Square Hospital, at Washington. No particulars of the treatment employed can be ascertained, but it is reported that in March, 1863, he was able to go about on crutches, and that he was "doing well" until the latter part of May, when an attack of cerebro-spinal meningitis supervened, and terminated fatally on May 25th, 1863. Upon examination of the in- jured limb, the fractured extremities of the femur were found to be united, with great angular deformity, by irregular arches of callus. A fragment of the ball was enclosed between the arches. The specimen was contributed by Assistant Surgeon Byrne, U. S. A. (Figure 43.)

The next figure represents a specimen in which consolida- tion is quite firm. The patient succumbed to phthisis seven months after the injury.

Private Luman M. Millius, Co. K, 6th Pennsylvania Reserves, was wounded at Antietam, September L7th, 1862, by a conoidal musket-ball, which entered a little below the great trochanter of the right thigh, shattered the upper third of the femur, and lodged beneath the skin on the inner part of the right thigh, whence it was extracted through an incision. The patient was treated in a field hospital until the middle of October, when he was transferred to the General Hospital, at Smoketown. Although a slender man, with a narrow chest and feeble organization, his condition on admission was not unpromising. During the autumn of 1862, the suppuration was copious, and fragments of necrosed bone were occasionally discharged. Under a nourishing diet, the patient's strength was supported remarkably. On January 21st, 1863, the fracture was firmly consolidated. The

Fig. 43.— Partially consolidated pun- shot fracture of the left femur. Spec. 11(31, A. M. M.

36

GUNSHOT WOUNDS OF THE LOWER EXTREMITIES.

limb was shortened four inches. The wound on the inner side of the thigh had closed. There was a slight fistula,

with trifling discharge at the wound of entrance. The patient passed several hours daily in the open air, on crutches. About this time, cough and night-sweats, and other indications of tuberculosis of the lungs, appeared, and confirmed phthisis was soon established. The patient died March 9th, 1863. (Figure 44.)

355

Fia.44 — Upper half of right fe- mur, exhibiting a consolida- ted gunsliot fracture. Spec. 1042, A. M. M.

Fio. 45.— Outer condyle of right femur, grooved by a musket-ball. Spec. 2134, A. M. M.

Of gunshot injuries of the knee-joint, the Museum possesses specimens. A number of illustrations will be given. The case that furnished Specimen No. 2134 (Private Baldwin, Co. K, 42d Indiana Vols.) was treated by laying open the knee- joint, by free incisions, as soon as suppuration was established. The patient was wounded September 20th, at Murfreesboro', and died December 12th, 1863. The injury to the outer condyle was very slight. The specimen was contributed by Surgeon Israel Moses, U. S. Vols.

Dr. Bellanger has recorded* five fatal cases of gunshot injuries of the knee-joint treated by free incisions into the articulation, and Surgeon Lidell, U. S. Vols., has published three such cases.-}- The records contain a score of similar examples. Yet amputations for gunshot injuries of the knee that have reached the secondary period are scarcely less disastrous.

The next case well illustrates the obscurity of symptoms and difficulty of diagnosis of a serious gunshot injury of an articulation so accessible for examination as the knee. The fracture of the internal condyle was not discovered until after death. The speci- men was contributed by Surgeon J. A. Lidell, U. S. Vols.

Private Kisner, aged twenty-nine, Co. E, 7th Michigan Cavalry, was wounded June 19th, 1863, while on picket at Chantilly, Virginia, by an elongated carbine-ball, which entered in front at the middle of the left thigh. He was admitted to hospital, in Wash- ington, on June 26th, and the ball was cut out from beneath the integument on the inner aspect of the knee. On the next day, there was pain and tender- ness of the joint. Death took place July 18th, 1863.

In the next case a conoidal ball, fired from a great distance, has crushed the anterior part of the femur just above the condyles, and produced fissures that extend to the joint. The patient that furnished this specimen was wounded at Petersburg, March 31st, was amputated at Emory Hospital, April 7th, and died on June 24th, 1865. The specimen was contributed by Surgeon N. B. Mosely, U. S. Vols.

The two following figures exhibit the common appearances of fractures of the bones composing the knee-joint by round musket- balls.

Private Richard Williams, 28th Pennsylvania Vols., was wounded September 16th, 1862, at the battle of South Mountain, by a musket-ball, which entered near the outer hamstring, and lodged between the condyles of the right femur. He was conveyed to Washington, D. C,

FlO. 46. — Gunshot fracture of tin' internal condyle of the left kuee. Spec, V6<M, A M. M.

Via. 47.— Partial fracture of the left femur by a conoi- dal ball, which lias lodged in the cancellated structure. Spec. 4071, A. M. M.

American Journal of Medical Sciences, vol. xlvi. p. 42.

t Ibid., vol. xlix. p. 295.

GUNSHOT WOUNDS OF THE LOWER EXTREMITIES.

37

Fin. 4S. — Lower extremity 01 right femur, the outer con- dyle split off Ijy a round musket-ball. Spec 59, A. M. M.

Fig. 49.— Amputated end of right femur and head of tibia, with a round musket-hall impacted in the latter. Spec. 1481, A. M. M.

and admitted into Mount Pleasant General Hospital, September 22d, 18G2. On September 30th, his right thigh was amputated by flap incisions. At this date the limb was excessively swollen; the discharge of pus was profuse; abscesses had burrowed in the soft parts, and irritative fever existed to an alarming degree. The case terminated fatally on October 2d, 1862.

Private , a soldier of the 3d Division of the 1st

Army Corps, was wounded at Gettysburg, Pennsylvania, on July 1st, 1863, by a musket-ball, which entered through the right popliteal space, fissured the internal condyle of the fe- mur, and lodged in the head of the tibia. He underwent amputation at the lower third of the thigh on July 15th, and died July 17th, 1863. The specimen was contributed by Sur- geon Quinan, in charge of the Division Hospital. (Figure 49.)

Three patients have been photographed at the Army Medical Museum who had recov- ered without amputation after gunshot injuries of the knee-joint. (Photographs Nos. 63, 64, and 78.) Four or five additional cases appear upon the records. In scarcely any of these cases could it be asserted that the danger of consecutive disease of the knee-joint was passed. The "curious fact," adverted toby Surgeon I. Moses, U.S. Vols.,* "that more men had been discharged the service at that post [Louisville, Kentucky] who had received gunshot wounds of the knee-joint with recovery than when ampu- tation of the thigh had been performed," is directly contradicted by the official reports from that post.

The following is the most carefully compiled of the abstracts of cases of recovery after gunshot wounds involving the knee. Photograph 63, A. M. M., represents the patient.

Private Peter Stuck, Co. E, 116th Pennsylvania Vols., was wounded on May 12th, 1864, at the battle of Spottsylvania, and was admitted, on May 18th, to Douglas Hos- pital, in Washington. The projectile, which was probably a conoidal musket-ball, had entered at the inner edge of the right patella, passed directly through the articulation, and made its exit near the centre of the popliteal space. The inner condyle was slightly grooved, but the ball passed mainly through the intercondyloid notch. There was an abundant thin discharge of mingled pus and synovia. The joint was somewhat swollen, but the inflammatory symptoms and constitutional disturbance were moderate. The patient was of a delicate organization. The treatment was limited to rest and water-dressings. On June 9th, there was swelling and pain in the joint, and a febrile reaction. Poultices were applied to the wound of exit, the anterior wound having healed. In a few days the bad symptoms abated. In the latter part of August, 1864, the patient began to walk about on crutches, the leg being flexed at an angle of 135° with the thigh. In October, the limb was bandaged to a movable angular splint, and the flexion was gradually reduced. Almost complete extension was obtained without exciting inflammation in the joint. The patient kept his bed during this period of the treatment. For the following eight months nothing of special interest transpired. There were several attacks of inflammation of the joint; but they were moderate in degree, and were readily subdued by poulticing. On such occasions abscesses some- times formed in the thigh. For the greater part of the time the patient's appetite was fair, his bowels regular, his sleep refreshing. When inflammatory mischief was threatened, poultices, hot fomentations with flannel covered with oiled silk, and appli- cations of tincture of iodine were employed. At other times, cold water-dressings, with charpie to absorb the discharge, were used. Ice was never applied. A photo- graph was taken July 9th, and the patient was discharged from service and the hos- pital July 14th, 1865. The posterior wound was still open, and a probe could be

-Destruction of the left knee hy explosion. Spec. 709, A. M. M.

* American Journal of Medical Sciences, vol. xlvii. p. 341.

38

ON SPECIAL WOUNDS AND INJURIES.

Fm. 51. — Upper portion of

introduced through it for three inches. There was a large deposit of new bone. The patella was firmly anchylosed to the femur. The facts of the case were forwarded by Assistant Surgeon Wm. F. Norris, U. S. A.

Two more illustrations of gunshot injuries of the knee-joint are here introduced :

The patient who furnished the first (Private B. M , Co. A, 28th Massachusetts Vols.)

was brought to Washington on December 26th, 1862, his left knee having been shattered by a shell at the battle of Fredericksburg, on December 14th. He died on December 29th. Evidently primary amputation could alone have saved this man, and this was probably impracticable on that disastrous day. (See Figure 50 on the preceding page.)

In the nest case of shell wound involving the knee-joint (Private C. H. M , Co. F,

1st Maine Heavy Artillery), primary amputation was performed on October 2d, by Surgeon Jamieson, 86th New York Vols. The patient died of exhaustive suppuration on October 27th, 1864. (Figure 51.)

Of gunshot injuries of the tibia and fibula, two examples are given, by^'fragmenTorthe one of fracture by a musket-ball, the other of comminution by solid

base of a shell, which ••

is attached. Spec. 4121, SUOt :

A. M. M.

A general officer was wounded at the assault on Port Hudson, May 27th, 1863, by a conoidal musket-ball, which passed from the inner to the outer aspect of the right leg, and shattered the upper thirds of the tibia and fibula. A staff surgeon extracted a number of detached fragments of bone, and dressed the limb, and, on June 2d, the patient was removed to New Orleans. The wounds were opened, and decomposed coagula, pus, and bone splinters in large quantities were evacuated. The constitutional symptoms were of the most aggravated character. About the middle of June, amputa- tion was performed at the lower third of the thigh by Professor Warren Stone, with the very slightest hope of success. The patient, however, struggled through, and ultimately wore an artificial limb with comfort. The specimen and the particulars of the case were contributed by Prof. F. Bacon, of Yale College, formerly Surgeon U. S. Vols. (Figure 52.)

Major General D. E. Sickles, U. S. Vols., was wounded on the evening of the second day of the battle of Gettysburg, by a twelve-pounder solid shot, which shattered his right leg. General Sickles was on horseback at the time and unattended. He succeeded in quieting his affrighted horse and in dismounting unassisted. Aid arriving promptly, he was removed a short distance to the rear, to a sheltered ravine, and amputation was performed low down in the thigh by Surgeon Thomas Sim, U. S. Vols. The patient was then sent to the rear, and the following day was transferred to Wash- ington. The stump healed with great rapidity. On July 16th, the patient was able to ride about in a carriage. Early in September, 1863, the stump 1 1 ... 52.— Right tibia was completely cicatrized, and the general was able again to mount his horse. turcdbyamu8ket- Tne specimen was contributed to the Army Medical Museum by General am J?'"' Mm' tickles, aiu' tne *"acts of the case by his stall' surgeon, Dr. Sim. (Figure 53.)

Fin. 53.— Right tibia and fib- ula shattered by'acaunon- shot. Spec. 1335, A. M. M.

GUNSHOT WOUNDS OF THE ARTERIES.

The number of cases reported under this head is extremely small. In the cam- paign of the Army of the Potomac from the Rapidan to the James, in May, June, and July, 18G4, of a total of 36,508 gunshot wounds, only 27 belonged to this category. The cases of compound fracture complicated with injuries of the large vessels, the cases in which limbs arc carried away by solid shot or shell, and the cases in which all the tissues of a limb are disorganized by contusion from a large projectile and the vitality of the arteries is destroyed, are all returned under other heads. Those only are included in which the canal of a large vessel is primarily opened, and in which this

SABRE AND BAYONET WOUNDS.

39

is the principal accident. Such cases are to be sought for among the dead on the bat- tle-field rather than in the field hospitals. Surgeon J. A. Lidefl, U. S. Vols., reports that on the morning of March 25th, 1865, he examined 43 bodies of soldiers killed in the combat near Fort Steadman, in the lines before Petersburg; 23 were shot in the head, 15 in the chest, and 5 in the abdomen. " The bodies of all those wounded in the abdomen were very much blanched, as if they had died of haemorrhage, and the same remark held true in regard to all but two or three of those wounded in the chest." In the few cases of primary gunshot lesions of the arteries that came under treatment, it was usually found that only a portion of the calibre of the vessel had been carried away, and that retraction had been thus prevented. But 44 cases are entered on the records. In most of them, ligatures were placed above and below the seat of injury; but, in a few instances, the main trunk was tied at a distance, and amputation was practised when the bleeding recurred. Twenty of the 44 cases term- inated fatally.

A number of drawings at the Army Medical Museum, exhibiting the course of balls directly in the track of the great vessels of the neck or of the limbs, illustrate the fact so well known to military surgeons of the great resiliency of the large arteries. The dread of primary haemorrhage on the battle-field is confined to the inexperienced. It was so exaggerated at the beginning of the war, that it was seriously proposed by several benevolent associations that every soldier should carry a field tourniquet with his equipments.

GUNSHOT WOUNDS OF VEINS.

No cases have been reported in which the bleeding could not be controlled by pressure.

GUNSHOT WOUNDS OF NERVES.

Only those cases are recorded as yet upon the register that were reported in the last quarter of 1863 and the first quarter of 1864. Numerous and careful observations on this class of injuries have been received from the Christian Street Hospital, in Phil- adelphia, in which wards were especially assigned, in 1863, for the treatment of such cases.

SABRE AND BAYONET WOUNDS.

The number of sabre and bayonet wounds that have come under treatment has been comparatively small ; 105 cases of the former, and 143 of the latter comprise nearly all that have been reported for the first three years of the war. Of these wounds, two-thirds were received in action, and the remainder were inflicted by senti- nels or patrols. There are 11 deaths from sword wounds recorded, and 6 from bayonet wounds. At the Army Medical Museum there are 9 specimens of sabre cuts of the cranium,* a specimen of punctured fracture of the skull by a bayonet, and a prepara- tion exhibiting a bayonet thrust through the stomach.f From General Sheridan's

* Specimens 235, 970, 971, 974, 1672, 2623, 3307, 3684,4206.

t Specimen 2258, A. M. M.

40 ON SPECIAL WOUNDS AND INJURIES.

V

FiG. 54.— Three sabre ruts on the left parietal. Spec. 3307, A.M. M.

campaign in the Shenandoah Valley, 25 sabre wounds are reported; and from the battle of Jonesborough, in Georgia, 30 bayonet wounds. After the first battle of Bull Run, several of the wounded left upon the field were bayoneted by the insurgents.* A patient, brought afterwards to Georgetown, received no less than fourteen stabs. A

similar instance occurred after the battle of Fair Oaks.f Later in the war such atrocities were very infrequent. A few abstracts are subjoined of cases of sword and bayo- net wounds :

Private R H , Co. C, 7th Colored Regiment, U. S. Artillery,

was wounded at Fort Pillow, Tennessee, April 12th, 1864, by three sabre cuts on the left side of the head, one of the wounds penetrating the skull. The symptoms are not recorded, but it is stated that the patient died on April 21st, 18G4, and that the post-mortem examination revealed a large extravasation of blood upon the brain, and a splinter an inch and a half long from the inner table driven through the dura mater.

Private J. T. B , Co. F, 7th Michigan Cavalry, was captured on July 3d, 1863, at Gettysburg, his horse

being shot under him. He was hurried to the rear with other prisoners. In the subsequent retreat he was

unable to keep up with the column, and all efforts to goad him on being unavailing, a confederate lieutenant, in command of the provost guard, cut him down, and left him for dead by the roadside. He was brought in by a scouting party, and admitted to the Cavalry Corps Hospital. On the 25th of July, he was sufficiently rational to give the above account to Surgeon Rulison, 9th New York Cavalry. He was in a very depressed state at this time. His pulse was weak, and beat from 40 to 45 per minute. He was indisposed to mental exertion ; but when aroused and interested was quite rational. He lingered until August 15th, 1863, the tendency to stupor becoming greater and greater towards the close. The autopsy revealed a sabre cut six inches long, which had raised an osseous flap, adherent at its base, from the left parietal, and cloven the right parietal, with great splin- tering of the vitreous plate. The sabre had penetrated the dura mater on the left side, and on the right side the meninges were injured by the de- pressed inner table. The posterior lobes of both hemispheres of the brain were extensively disorganized. The speci- men, with the above history, was contributed by Surgeon W. H. Rulison, 9th New York Cavalry, since killed in battle.

aged twenty-five, of the guard of Lovell General Hospital, Portsmouth Grove, Rhode Island, was confined on February 28th, 1863, in a strong box, as a punishment for bringing liquor into camp. When released, he rushed upon the sergeant of the guard and struck him, whereupon the sergeant drew his sword and put himself en garde. In this position the prisoner made a second assault, but the ground being uneven he slipped, and fell heavily upon the point of the sword, and to the ground. When raised, his face was bleeding, and he was insensible. He was examined by the medical officer of the day, who found a slight cut on the ala of the nose, and ascribed the insensibility to intoxication, and to the fall on the head. The prisoner was removed to the guard-house and there spent the night. In the morning, he was still unconscious and breathed stertorously, and had a slow pulse and dilated pupils. He was removed to a ward in the hospital, and the remedies commonly employed in cases of apoplexy were prescribed. There was no return of consciousness, and the case terminated fatally on March 2d, thirty-one hours after the injury. At the autopsy, it was found that the sword had entered at the right nostril, pierced the right superior turbinated bone and the body of the sphenoid, and caused a transverse fracture at the base of the posterior clinoid process. There was much extravasated blood in the cranial cavity, especially on the surface of the right hemisphere.

Fig. 55. — Section of the posterior portion of a cranium, showing a sabre cut of both parietals parallel to the lambdoidal suture. Spec. 1072, A. M. M.

Private John H

Fig. 56.— Portion of a spl transfixed by a sword. A. M. M.

;noid bono Spec. 1012,

Surgeon Joseph R. Smith's Report, t Report of Assistant Surgeon H. E. Brown, 70th New York Vols.

TETANUS.

41

Private Thomas B , Co. B, 90th Ohio Vols., was admitted into Hospital No. 1, Nashville,

on November 27th, 1863, with a bayonet wound behind the left parietal protuberance, inflicted by whom the patient, being intoxicated, had refused to obey. For several days after admission he was somnolent and obstinately constipated. Under the use of powerful purgatives this condition was removed, and the wound nearly cicatrized. But, on December 8th, the patient complained of headache, and a probe passed through the small orifice of the wound revealed the presence of denuded and detached bone. A crucial incision was made and the frag- ments of dead bone were removed. On December 11th, there was more headache, and a tendency to stupor; the pulse was at 48; there was intoler- ance of light and sound ; the scalp was tumid ; the wound gaping, and filled with fungous granulations. The incisions in the scalp were extended, an ice-bladder was applied to the head, and purgatives and purgative enemata were employed. A day or two subsequently cerebral hernia took place; then extended suppuration in the left hemisphere; then delirium and coma, and death on December 23d, 1863. The description and specimen were con- tributed by Assistant Surgeon C. J. Kipp, U. S. Vols.

Tennessee, a sentinel,

0

Fig. 57. — Skull-cap, exhibiting parietal boue by a bayonet.

J '

a fracture of the left Spec. 2179, A.M. M.

SIMPLE FRACTURES AND MISCELLANEOUS WOUNDS.

The number of cases reported is quite large, and the record is still very incom- plete. For the first two years of the war, the monthly reports give of simple fractures alone 28G4 cases with 92 deaths.

The Army Medical Museum possesses comparatively few illustrations of this class of injuries, and it is to be desired that this department of the collection may be augmented.

Specimen No. 6 presents a good example of a united simple fracture of the femur through the trochanters. It was taken from a man of forty, who died of pneumonia two years after recovery from the local injury.

The number of incised and fractured wounds received in broils and altercations is quite numerous. The following is an interesting example of this class of cases:

Private George S , Co. B, 15th New

York Engineers, was stabbed in the back by a dirk, April 20th, 1863, at Falmouth, Virginia, in an altercation with a comrade. The blade passed between the transverse processes of the fourth and- fifth vertebrae, and severed the spinal cord. The man fell instantly, completely paraplegic. He was admitted to Armory Square Hospital, at Washington, April 22d. On April 27th, he began to pass his faices and urine involuntarily, and bed-sores appeared on the portions of the low,er part of the body exposed to pressure. He sank dfrk gradually, and died from exhaustion on May 27th, 1863. The specimen was contributed by Assist- ant Surgeon C. C. Byrne, U. S. A.

Fig. 59.— Fourth, fifth, and a portion of the sixth dorsal vertebra;, sawn asunder to exhibit a which traversed the spinal canal. Spec. 11(30, A. M. M.

'IG. 58.— Firmly Bimple fracture

consolidated f the left fe-

mur. Spec. No. 6, A. M. M.

TETANUS.

The 363 cases of traumatic tetanus recorded in the register for that subject are all that have been reported during the war. The proportion to the total number of wounds is not large. In the Schleswick Holstein war, Stromeyer had 6 cases among 2000 wounded. In Napoleon's campaign in Egypt, in the Peninsular campaign, and

6

42

ON SPECIAL WOUNDS AND INJURIES.

in the revolt in India, the ratio appears to have been larger than this. Among 12,094 wounded, the British in the Crimea had 19 cases only.

The histories of the 363 reported cases of tetanus are generally satisfactory in their details of symptoms, progress, and treatment: 336 cases terminated fatally. Of the 27 recoveries reported, the disease was of a chronic form in 23. In the 4 remaining cases, the svmptoms were very grave. In 2, recovery took place under the use of opiates and stimulants; in 2, after amputation of the wounded part.

The great majority of the cases were treated by the free use of opium, conjoined with stimulants and concentrated nourishment. Chloroform inhalations were very generally employed during the paroxysms of spasmodic contraction. Subcutaneous injections of the salts of morphia and atropia were frequently used. Cathartics, quinia, camphor, cannabis indica, bromide of potassium, strychnia, belladonna, and aconite are mentioned among the remedies employed. Cups, blisters, turpentine stupes, and ice were among the applications made to the spine; and fomentations with opium or to- bacco were, in some cases, applied to the wound. Amputation, the division of nerves, and the extirpation of neuromata in stumps were the surgical measures sometimes employed. The results have not modified the conclusion of Romberg, that "wherever tetanus puts on the acute form, no curative proceeding will avail, while in the milder and more tardy form, the most various remedies have been followed by cure." The value of nicotine, of the Calabar bean, and of curare* as curative agents in tetanus was not tested.

Autopsies were made in many cases; but with almost negative results. There were no microscopic examinations to corroborate or disprove the assertions of Roki- tansky and Demme,f that tetanus has a constant anatomical lesion, consisting in a proliferation of the connective tissue of the white medullary substance of the medulla oblongata, of the inferior peduncles of the cerebellum, of the crura cerebri, and of the spinal cord, producing a viscous mass, abounding in nuclei, and never progressing to the formation of fibres. It is frequently mentioned, however, that great congestion of the brain and spinal cord was observed, a condition on which the lesions of the con- nective tissue above described are believed to depend.

The records abound with illustrations of the influence of sudden vicissitudes of temperature in producing this fatal affection, and of the effect which unextracted balls and other foreign bodies and matter confined under fasciae appear to exercise upon its development. It seems probable also that the disease occurred in a larger proportion of cases among the troops serving in the more Southern States; but this and other generalizations must be deferred until the records are more minutely examined.

SECONDARY HEMORRHAGE.

On this important subject the records are still very incomplete. There are 1450 special reports relating to it yet to be examined, which will furnish a large number of cases to be transcribed upon the register. The cases have been reported in three

\ •riling li> II. I K'liuno, of 22 cases of traumatic tetanus treated by the latter agent, 8 recovered. See Schweiz. Zeitschrift fur Eeilkunde, ii. 356.

t Schmidt's Jahrbucher, vol. cxii.

SECONDARY HAEMORRHAGE. — PYAEMIA .

43

classes : bleeding proceeding from a stump, from a gunshot wound, or from an artery previously ligated in its continuity. Cases of the latter series have not been placed on the registers of secondary haemorrhage, but the repetition of the bleeding has been noted in the history of the case in the volume of the registers of surgical operations devoted to ligations.*

Of the two other classes, 1037 cases have been examined and recorded on the registers of secondary haemorrhage. Of these, 387 were cases of secondary bleeding from a stump, and 650 were cases of secondary haemorrhage from gunshot wounds. Of the first class, 233, or 60 per cent., ended fatally; of the second, the termination was fatal in 330 cases, or 51 per cent.

In the 1037 recorded cases, the femoral artery was ligated 93 times for bleeding from stumps, and 45 times for bleeding from wounds; the subclavian was tied 5 times for bleeding after amputation at the shoulder-joint, and 6 times for haemorrhage from gunshot wounds of the axilla. The common carotid was ligated 15 times for haemor- rhage from the deep branches of the internal carotid. Amputation was practised 78 times for secondary bleeding from gunshot wounds, and reamputation was performed 14 times when other means of arresting haemorrhage from stumps had failed.

The 387 cases of secondary haemorrhage from stumps were chiefly examples of arterial bleeding. In 95 cases, the haemorrhage was, perhaps, mainly venous, and was checked by elevating the stump, or applying cold water, ice, pressure, or the solution of the persulphate of iron. When the haemorrhage was arterial, the most common practice was to tie the main vessel, at the second bleeding, as near as was prudent to the end of the stump. In a few cases, the artery was successfully tied on the face of the stump. The results of tying the vessel above, according to Anel's method, were very unfortunate.

In reviewing the 650 recorded cases of secondary haemorrhage from gunshot wounds, it appears that, during the earlier part of the war, there were many surgeons who were not sufficiently impressed by the precepts of Bell and Guthrie, and who fre- quently treated secondary haemorrhage from gunshot wounds by tying the main trunk at a distance from the wound, even when the bleeding occurred at a comparatively early period. Later in the war, however, it was the universal practice to endeavor to secure both ends of the bleeding vessel at the seat of injury, and some brilliant ex- amples are recorded in which this was accomplished in wounds of the posterior tibial or popliteal, when limbs had become infiltrated and swollen, and the difficulties of the operations were immense.

PYAEMIA.

On this subject 281 reports have been examined, and the individual cases detailed in them have been transcribed upon the registers : 251 special reports on the subject remain to be examined. The histories of 754 cases are recorded in the register, the post-mortem observations accompanying a large proportion of the fatal cases. These number 719, or 95*35 per cent. Pyaemia supervened in 377 cases of gunshot injury in which no operation had been performed, and after 295 cases of amputation, of which

* See page 85 of this Report.

44

SURGICAL OPERATIONS.

155 were cases of amputation in the continuity of the femur. The purulent infection was subsequent to excision of the shafts of long bones in 27 cases, and to excisions of joints in 28 cases.

These figures by no means represent the frequency with which pyemic poisoning has occurred. It has been one of the great sources of mortality after amputations, and its victims are to be counted by thousands. The small number of cases on the register are taken from special reports. Several valuable papers have been contributed on the pathology of this affection, and a number of statistical reports on its treatment. The conclusions of the latter are adverse to the therapeutical utility of the sulphites and hyposulphites in this disease.

A series of colored drawings, illustrating the embolic phenomena attendant on pyaemia, the metastatic depots, etc., have been prepared at the Army Medical Museum.

SURGICAL OPERATIONS.

All surgical operations are recorded on the registers of the office, according to the form which will be presented on a subsequent page, in treating of excisions of the head of the femur. The name and military description of the patient are given, the nature and date of his injury, an account of the operation, a notice of the local lesions which made it necessary, and of the constitutional condition of the patient at the period it was performed. A summary of the progress and after-treatment follows, and the result, if ascertained, the name of the operator, and the post-mortem appearances, when known, if the case terminated fatally. If the case furnished a pathological preparation to the Army Medical Museum, a reference is made to the number of the specimen on the catalogue.

While this plan involves much labor, it effectually precludes the duplication of cases, and ensures, probably, the highest attainable degree of statistical accuracy. The name and military designation of the patient being known in all cases, the ultimate results of operations can be traced, hereafter, and errors may be corrected.

Operations have been reported in this form from all general hospitals since Oc- tober, 1863. But nearly half of the sixteen thousand operations now recorded were taken from special reports and field returns belonging to an earlier period of the war, and it was necessary that these should first be transcribed on the proper forms, a task that has been accomplished by clerks who were students of medicine, their work being revised by a medical officer.

AMPUTATIONS.

45

AMPUTATIONS.

The histories of 13,397 amputations for gunshot injury have been examined and recorded, and the final results have been ascertained in 9705 cases. The following table exhibits the number belonging to each region, and includes both primary and secondary cases. It shows the regular increase in the rate of mortality as the trunk is approached.

Amputations of the, Superior Extremities

Fingers and Parts of the Hand

Wrist

Elbow

Forearm

Arm

Shoulder-Joint

Total of Upper Extremity

Amputations of the Inferior Extremities,

Toes

Partial Amputations of the Foot

Ankle-joint

Leg .

Knee-Joint

Thigh

Hip-Joint

Total of Lower Extremity

Aggregate

Recovered.

1778 34 10 500 1535 144

4010

Died.

29 2 0

99 414

93

G37

1807 30 19 599 1949 237

4647

Per cent, of Mortality.

1-60 5-55

16-52 21-24 39-24

13-70

784	6	790	•75
108	11	119	9-24
58	9	67	13-43
1737	611	2348	26-112
52	64	116	55-17
508	1029	1597	64-43
3	18	21	85-71
3310	1748	5058	34-55
7320	2385	9705	24-57

Amputations of the Fingers and Portions of the Hand. — The cases that have been transcribed on the records form but a small proportion of the total number in- cluded in the reports. In the 1807 terminated cases, the mortality has been compara- tively large. The causes of death in the 29 fatal cases is stated to have been: in 4, pyaemia; in 4, erysipelas; in 2, gangrene; in 1, tetanus; in 18, different intercurrent diseases, as typhoid and malarial fevers, pleurisy, etc.

Amputations at the Wrist. — The disarticulation at the wrist has been performed in preference to the amputation of the forearm, when the hand was totally disorganized. When practised by the circular method it is a good operation. The results of the cases examined are satisfactory, the mortality being ten per cent, less than in amputation of the forearm.

Amputations of the Forearm. — Except in those cases in which the wrist or lower extremity of the radius have been shattered by large projectiles, this amputation has commonly been practised secondarily. It has been impracticable to examine all the cases that have been reported. Of the terminated cases that have been transcribed upon the records, 99 died and 500 recovered. Of the latter, 397 have been supplied

46

SURGICAL OPERATIONS.

with artificial limbs. In the forearm, the amputation by the double flap method has been generally preferred.

Amputations at the Elbow. — The returns corroborate the conclusions of Dupuy- tren, Malgaigne, and Legouest, who combat the disfavor into which this operation has fallen. It was done infrequently in the late war, but 19 cases having been reported. But in all of these the ultimate results have been ascertained, and were favorable in every instance. The success of Salleron and other French surgeons with this operation in the Crimea is well known. Whenever, then, it is impracticable to amputate the forearm, disarticulation at the elbow should be preferred to amputation of the arm. The oval method answers the purpose best in this locality.

Amputations of the Arm. — Of 2774 cases of amputation of the arm that have been entered on the registers, the results are ascertained in 1949 cases: 1535 recov- ered, and 1014 of these patients have been furnished with artificial arms.

Amputations at the Shoulder-Joint. — It is creditable to the surgery of the war that the number of cases of amputation at the shoulder-joint reported is less than the number of cases of excisions of the head of the humerus, and that the latter operation appears to have been adopted in nearly all the cases in which it was admissible. The reported cases of amputation at the shoulder-joint, for the entire period, number 458; of excisions of the head of the humerus, there were 575. Of the 237 terminated cases of amputation, 93 died, a ratio of mortality of 39-2, which is G-7 per cent, greater than the mortality in excisions. The amputations of the upper extremity for gunshot injuries are illustrated at the Army Medical Museum by 89 examples of diseases of stumps, and by a large number of plaster casts and photographs, exhibiting the suc- cessful results of operations.

Amputations of the Toes. — Of 784 cases that have been examined, 6 were fatal. Tetanus supervened in one case, and phlegmonous erysipelas invaded the leg in another. In the four remaining cases, the fatal termination was due to causes foreign to the operation.

Partial Amputations of the Foot. — Of the 160 recorded cases, 119 were termin- ated, with a mortality of 9 24 per cent. The tarso-metatarsal operation of Hey or Lisfranc was performed 25 times; the medio-tarsal operation of Chopart 45 times. The remaining cases were ablations of toes with one or more of the metatarsals. There are several casts of stumps, made by Chopart's method, at the Army Medical Museum, which exhibit the drawing up of the heel which so frequently occurs after this operation.

Amputations at the Ankle-Joint. — The record is far from complete. In the terminated cases, Syme's method was employed in 25 cases, Roux's method in 2 cases, and Pirogoff's in 9 cases. Several casts and photographs of well-rounded stumps, obtained by the latter procedure, are deposited in the Army Medical Museum. But the operation appears to be regarded with but little favor. Baron von Horronitz, Surgeon- iu-Chief of the Russian Marine, in his recent visit to this office, mentioned that Pirogoff had himself abandoned it, finding the segment of the os calcis likely to become necrosed. An abstract of a favorable case, with an illustration, is subjoined :

AMPUTATIONS.

47

Lieutenant W. C. W , Co. 1, 5th Michigan Cavalry, was wounded

April 1st, 1865, at the battle of Five Forks, by a conoidal musket-ball, which passed through his left ankle-joint. He was immediately carried to the hospital at City Point, and amputation at the ankle was per- formed on the same day by Surgeon St. Clair, 5th Michigan Cavalry. The articulating surfaces of the tibia and calcaneum were removed, and the cut surfaces were brought into apposition. On April 16th, 1865, the patient was transferred to Armory Square Hospital, at Washing- ton. On admission, he was in a feeble condition. An erysipelatous blush extended above the knee on the injured side; an abscess had formed in the lower part of the leg; and no union of the flap had taken place. With the employment of stimulants and nutritious diet with emollient applications to the limb, there was a gradual improvement, until April 28th, 1865, when symptoms of pyaemic infection super- vened. Eapidly recurring chills, an icteroid coloration of the skin and conjunctiva, anorexia, and a frequent feeble pulse, suggested the gravest prognosis. Energetic treatment was adopted. An ounce of brandy was given every two hours, and quinia, sesquichloride of iron, and beef tea were freely administered. On May 6th, the grave symptoms began to subside, and, by the end of the month, the patient was fairly convalescent. On June 26th, he was pronounced well. The os calcis had firmly united to the tibia, and there was a good solid stump. A cast in plaster was taken from it (Spec. 2298, A. M. M.), and a few days subsequently a photograph, which is numbered 75 in the Photographic Series of the Army Medical Museum.

Amputations of the Leg. — Of the 3302 amputations of the leg that have been recorded, the results have been ascertained in 2348. The ratio of mortality was 26-02, which will doubtless be augmented by further examination of the returns. The oper- ation just above the malleoli, sometimes called Lenoir's operation, has not been very largely practised, but it has given some excellent results, and its mortality rate is sur- prisingly small. The majority of the cases were amputations at the middle of the leg and at the place of election. The circular method has been most commonly employed. Larrey's operation through the head of the tibia has been done but little, though an examination of the specimens at the Army Medical Museum leads to the conviction that this procedure might have been substituted, in some instances, for disarticulation at the knee-joint, or amputations at the lower third of the thigh. Of the 1737 patients that recovered after amputation of the leg, 1057 have been furnished with artificial limbs.

Amputations at the Knee-Joint. — This operation has found numerous advocates during the war, and has been frequently performed. The returns to October, 1864, give 132 cases, of which 52 recovered and 64 died. In 6 cases, amputation of the thigh was subsequently performed, with 3 recoveries and 3 deaths. In 10 cases, the result is undetermined. These figures are encouraging, and if we look at the primary operations alone, the result is still more gratifying. Of 49 cases of primary amputation at the knee-joint, 31 recovered and 16 died; while 2 underwent reamputation, of whom 1 recovered, and 1, a tuberculous subject, died. This gives a percentage of mortality in primary amputations at the knee-joint of 34'9. The mortality in primary amputation at the lower third of the thigh is much larger than this : indeed, it has been already indisputably proved by the Crimean statistics, and by M. Malgaigne, that the mortality in amputation augments in exact proportion as the incisions approach the trunk.

At the Army Medical Museum there is a photograph, accompanying Specimen 2778, of the fine, well-rounded stump of Private Nevelling, Co. A, 71st Pennsylvania

Fig. 60. — Stump after a Pirogoff amputation.

48 SURGICAL OPERATIONS.

Vols., who was wounded at White Oak Swamp, and amputated, at Philadelphia, by Acting Assistant Surgeon T. G. Morton. The objection to amputations at the knee-joint, that the resulting stump is ill adapted to the use of an artificial limb, is set at rest by the results obtained by Hudson and other manufacturers, who distinctly declare that the stumps from the operation at the knee-joint give a base of support far better than any possibly to be gained in thigh-stumps.

It is well known that M. Legouest emphatically pronounces the disarticulation at the knee "une mauvaise operation, plus grave que 1' amputation de la cuisse dans la continuity et qui doit etre rejetee de la pratique," basing this assertion on the Crimean returns ; but it is probable that the more extended experience of the late war will lead surgeons to share the convictions of Macleod, Baudens, and Malgaigne, that this oper- ation is altogether preferable to the amputation at the lower third of the thigh.

Amputations of the Thigh. — In 1597 terminated cases, 568 recovered and 1029 died, or 64*43 per cent., which is within a fraction of the mortality after amputations of the thigh in the English army in the Crimea during the latter part of the campaign. In the French army in the Crimea, the whole number of amputations of the thigh for gunshot injuries was 1666, of which 1531, or 91-89 per cent., terminated fatally.

Of these 1597 amputations, the date of operation is ascertained with precision in 1061. Of these, 423 were primary and 638 were intermediate or secondary. The ratio of mortality was 54*13 in the former, and 74*76 in the latter.

In the 568 recoveries after amputation of the thigh above mentioned, the patients have been supplied with artificial limbs in 254 cases, and reports are on file of 439 other cases of recovery after this operation in which artificial limbs have been provided. These cases are not entered on the registers, because the returns exhibiting the deaths for the corresponding periods have not yet been reached.

Amputations at the Hip-Joint. — At the commencement of the war, the uniform fatality of amputation at the hip-joint in the Crimean war was impressed upon the minds of surgeons, and many believed that the operation should be discarded alto- gether. Still, it has been occasionally performed, and several lives have unquestion- ably been saved by it. A noted case is that of Kelly, whose appearance, after recovery, is represented in the plate opposite. The following is an abstract of the case :

Private James E. Kelly, Co. B, 5Gth Pennsylvania Vols., aged twenty-eight years, was wounded at about 9 o'clock of the morning of April 29th, 1863, in a skirmish of the First Division, First Corps, on the Rappahannock, nearly opposite the " Pratt House," below Fredericksburg. A conoidal musket-ball, fired from a distance of about three hundred yards, shattered his left femur. A consultation of the senior surgeons of brigades decided that exarticula- tion of the femur was expedient, and the operation was performed, at four in the afternoon, at the "Fitzhugh House," by Surgeon Edward Shippen, U. S. Vols., Surgeon-in-Chief of the First Division. The single flap method was adopted, and the amputation was accomplished with slight loss of blood. The patient was at first placed in a hospital tent, and was transferred, May 22d, to the Corps Hospital, progressing favorably. By May 28th, all the liga- tures had been removed. On June 15th, 1863, the patient was captured by the enemy, and was removed to the Libby Prison, in Richmond. Up to this date there had been no bad symptoms. On July 14th, Kelly was exchanged, and was sent to the Annapolis U. S. A. General Hospital. On his admission, he was much exhausted by profuse diar- rhoea. The internal portion of the wound had united, but the external portion was gangrenous. Applications of bromine were made to the sloughing surface without amelioration. A chlorinated soda lotion was substituted, and in the latter part of July, there was a healthy granulating surface. On December 23d, 1863, the wound had entirely healed, and Kelly visited Washington and obtained an honorable discharge from service, and a pension. Kelly then went to his home, near Black Lick P. 0., Indiana County, Pennsylvania. A letter dated January 12th, 1865, was received from him at this office, and represented him as in excellent health and spirits at that time. A year after the operation, a photograph of the stump was obtained. The accompanying plate is copied from it.

AMPUTATIONS.

49

A successful primary case, operated upon at Memphis, by Dr. Fenner, is reported by a student of Dr. F. H. Hamilton, late Medical Inspector U. S. A., who saw the sub- ject of it after his complete recovery.

A successful secondary case, reported by Assistant Surgeon C. Wagner, U. S. A., was a reamputation of a diseased stump. Necrosis of the femur was induced by osteo- myelitis, and the disarticulation was effected at a period when the traumatic phe- nomena had entirely disappeared. The particulars of this case are subjoined :

Private Eben. E. Smith, Go. A, 11th Maine Vols., aged nineteen years, was wounded at the engagement at Deep Bottom, near Drury's Bluff, Virginia, on August 16th, 1864, by a musket-ball, which fractured the head of the right tibia. He was admitted at the U. S. General Hospital, at Beverly, New Jer- sey, on August 22d, 1864. On admis- sion, the injured knee-joint was swollen and painful, and there was irritative fever of a moderate grade. On Sep- tember 12th, secondary haemorrhage oc- curred, and the thigh was amputated by circular incisions at the lower third, by Acting Assistant Surgeon T. M. Mor- ton, U. S. A., the patient being under chloroform. The case progressed favor- ably until October 17th, when secondary haemorrhage recurred, and was arrested by ligating the femoral artery in Scarpa's triangle. The stump remained swollen and painful, and furnished a profuse foetid suppuration. Osteo- myelitis supervened ; the end of the femur protruded, and was removed by the chain-saw. Necrosis finally extended as high as the trochanters, and numerous abscesses formed. On January 19th, 18G5, amputation at the hip-joint was performed, under chloroform, by Acting Assistant Surgeon J. H. Packard, U. S. A., the antero-posterior flap operation being adopted. On January 27th, there was haemorrhage from the stump, and the external iliac artery was tied. The ligature separated on February 17th, and two days afterwards there was profuse bleeding from the divided artery, which was controlled by pressure for fourteen days. After this the patient rapidly improved. In April he was reported well, and Hospital Steward Baumgras, one of the artists of the Army Medical Museum, was sent to Beverly, and made the drawing from which the engraving was taken. It is numbered 67 in the Surgical Series of Drawings of the Surgeon General's Office. On April 12th, 1865. Smith was transferred to White Hall Hospital, near Bristol, Pennsylvania. Assistant Surgeon W. H. Forwood, U. S. A., reports that, on May 27th, 1865, he was discharged from service quite well and strong, the wounds being entirely healed. The necrosed lower portion of the femur is Specimen 3709; the upper portion is Specimen 81, A. M. M.

Another successful secondary disarticulation of the femur is reported, which was also a case of reamputation, necessitated by disease of the femur. The first amputa- tion was performed at the lower third of the thigh on account of a bayonet wound of the knee-joint. The case is consequently excluded from the tabular statement of am- putations for gunshot injury. The patient is represented in Photograph 113, A. M. M.

Private Lewis Francis, Co. I, 14th New York Vols., aged forty-three years, was admitted to Ladies' Home U. S. A. General Hospital, New York City, on October 28th, 1863. He had been wounded by a bayonet in the right knee, at the battle of Bull Bun, July 21st, 1861, and was taken prisoner, and suffered amputation of the thigh in Richmond, Virginia, May 28th, 1862. The femur becoming diseased subsequently, its protruding extremity had been sawn off. What remained of the femur was necrosed, when the patient arrived in New York, and, on May 21st, 1864, the flaps were laid open, and the necrosed femur was removed by Surgeon Alexander B. Mott, U. S. Vols. No untoward symptoms followed, and the patient recovered, and was discharged from the service, August 12th, 1864.

A memorandum is subjoined of all amputations at the hip-joint for gunshot injury that have been reported. Nine were primary, and twelve were secondary operations. This is followed by a table exhibiting the results of this operation in previous wars.

7

Fig. 61. — Appearance of stump three months after secondary amputation at hip joint.

50

SURGICAL OPERATIONS.

AMPUTATIONS AT

No.	Name of Operator.	Name and Rank of Patient.	Nature and Date of Injury.
1	David P. Smith, Surgeon U.S. Vols.	Private on Hospital Steamer Crescent City.	Comminution of the upper half of the femur by canister, April 6th, 1862.
2	Prof. Geo. E. Blaekman, Act. Asst. Surgeon U. S. A.	Private on Hospital Transport.	Gunshot fracture of upper extremity of femur, April 6th, 1862.
3	E. S. Fenner, Surgeon P. A. C. S.	A private of the Confederate Army.	Gunshot fracture of the left femur, March, 1862.
4	Edward Sbippen, Surgeon U. S. Vols.	Private James E. Kelly, aged 28, Co. B, 56th Penn. Vols.	Conoidal ball comminuted upper extremity of left femur, April 29th, 1863.
5	P>. Howard, Asst. Surgeon U.S.A.	Private J. Martin, aged 20, Co. I, 14Gth N. Y. Vols.	Conoidal ball fractured the upper part of left femur, July 13th, 1863.
G	Unknown.	Private William Waters, Co. K, 123d N. Y. Vols.	Gunshot fracture of left femur, May 15th, 1864.
7	Prof. J. M. Carnochan, Act. Asst. Surgeon U. S. A.	Private of 9th Corps, aged 28.	Left femur shattered by a shell, May 18th, 1864.
8	Edward Shippen, Surgeon U. S. Vols.	Private J. M. Brown, Co. K, 63d Indiana Vols.	Fracture of upper third of right femur by a conoidal musket-ball, June 16th, 1864.
9	Edward Shippen, Surgeon U.S. Vols.	Private of 23d Corps.	Conoidal ball shattered head and neck of femur, and involved the hip-joint.
10	Peter Pineo, Medical Inspector U. S. A.	Private P. Johnson, Co. C, 2d Delaware Vols.	Fracture of the upper third of the right femur, and wound of the femoral artery, by a co- noidal musket-ball, Dec. 14th, 1862.
11	Alexander Ingram, Asst. Sur- geon U. S. A.	Private Charles Lackey, aged 19, Co. E, 7th Wisconsin Vols.	Upper third of right femur fractured by a musket-ball, May 12th, 1864.
12	H. C. Roberts, Asst. Surgeon U. S. Vols.	Private Levi Eckley, aged 33, Co. I, 67th Ohio Vols.	Gunshot fracture of left thigh, May 20th, 1864.
13	Albert C. Gorgas, Surgeon U. S. Navy.	Seaman George Cook, aged 21.	Rifle-ball passed through both testicles, and entered left thigh, comminuting the femur and passing out, Feb. 1st, 1864.
14	Edwin Bently, Surgeon U. S. Vols.	Private Michael O'Neil, aged 19, Co. E, 58th Mass. Vols.	Gunshot comminuted fracture of right femur, by a conoidal musket-ball, June 3d, 1864.
15	J. C. McKec, Asst. Surgeon U. S.A.	Private Daniel II. Bowman, aged 24, Co. C, 110th Penn. Vols.	Gunshot comminuted fracture of upper third of right femur, July 27th, 1864.
10	F. Hassenburg, Act. Asst. Sur- geon U.S.A.	Private Lewis Larry, aged 23, Co. A, 1st New Orleans Vols.	Amputation of thigh on account of gunshot fracture. Subsequent necrosis of femur. First injury July 17th, 1864.
17	Dr. Gurdon Buck, New York City.	Lieutenant Charles II. Hawkins, Co. C, 4th N. Y. Cavalry.	Amputation of right thigh, on account of gunshot fracture of femur received June 8th, 1862.
18	Edwin Bently, Surgeon U. S. Vols.	Sergeant Lewis Carroll, aged 33, Co. A 1st Delaware Vols.	Gunshot fracture of right femur just below lesser trochanter, by a musket-ball, Oct. 22d, 1864.
19	J. H. Packard, Act, Asst. Sur- geon U. S. A.	Private Eben. E. Smith, aged 19, Co. A, 11th Maine Vols.	Amputation of right thigh on account of gun- shot fracture. Subsequent necrosis of femur. First injury Aug. 16th, 1864.
20	C. Wagner, Asst. Surgeon U.S.A.	Private John Williams, aged 44, Co. F, 13th Ohio Cavalry.	Gunshot fracture of left femur, Sept. 30th, 1864.
21	E. Griswold, Surgeon U. S. Vols.	Private Geo. M. Spencer, aged 17, Co. B, 2d N. Y. Mounted Rifles.	Gunshot fracture of right femur, March 31st, 1865.

AMPUTATIONS.

51

THE HIP-JOINT.

Date of Operation.	Result.	Authority.	Remarks.
April 8, 1862.	Died in five days.	Smith's Report, Surgical Records, A, No. 11. J. H. Brinton's Report.	Was transferred to a hospital at St. Louis.
April 8, 1862.	Died in twenty minutes.	Surgeon J. H. Brinton's Report.	A patient wounded at Shiloh.
March, 1862.	Recovered.	Report from Memphis U. S. A. General Hos- pital.	Operation performed twenty-four hours after reception of wound.
April 29, 1863.	Recovered.	Shippen's Report. Vanderkieft's Report. Letters from Kelly.	Was quite well in the summer of 1865. Spec. 1148, A. M. M. Draw- ir>!rs31 inclT'1 Snvo- Sprip« S (1 O
July 14, 1863.	Died in forty-eight hours.	Report of Surgeon Flandrin, N. Y. Vols. His- i nvir nf* Slnon i m nil 1 Arm v TVTpfl TVTll^Plini LUl V Ul O U L 1 ill v 11 lO i Cj XI. I 111 V 1TJ. CUi 1»± UoC Hill.	See Specimen 1379, Army Medical lVTn qpii m
May 15, 1864.	Died May 15th, 1864.	Report of Army of Cumberland, Book ix. p. 355, S. G. 0.
May 18, 1864.	Died in ten hours.	Letter of Prof. Carnochan of Nov. 7th, 1864.	Done at 9th Corps Hospital, at battle of Spottsylvania.
June 16, 1864.	Died in one hour.	Special Report of Surgeon Shippen, U. S. Vols.	A primary operation.
1864.	Died in less than one hour.	Special Report of Surgeon Shippen, U. S. Vols.	A primary operation.
Dec. 27, 1862.	Died in a few hours.	Letter from Medical Inspector Pineo.	See Specimen 710, Army Medical Museum, and Photographic Series A. M.M., No. 14.
May 21, 1864.	Died in twenty-four hours.	Quarterly Report of Surgical Operations from Judiciary Square Hospital.
May 24, 1864.	Died in four days.	Quarterly Report of Chesapeake Hospital.
1864.	Died in less than two hours.	Report from U. S. Naval Hospital, Norfolk, Va.	See Specimen 2773, Army Medical Museum.
August 10, 1864.	Died in nineteen days.	Quarterly Report from Third Division Gen- eral Hospital, Alexandria, Va.	Ligation of external iliac artery. See Spec. 3098, Army Med. Museum.
Sept. 15, 1864.	Died in one day.	Quarterly Report from Lincoln General Hos- pital, Washington, D. C.
Sept, 21, 1864.	Died in nine days.	Quarterly Report from University General Hospital, New Orleans, La.	Reamputation.
Sept. 21, 1864.	Died in one day.	Report from St. Luke's Civil Hospital, New York City, and letter from Professor Buck.	Reamputation.
Nov. 11, 1864.	Died in eight days.	Report from Alexandria Hospital.	See Specimen 1020, Army Medical Museum.
January 9, 1865.	Recovered.	Quarterly Report from U. S. A. General Hos- pital, Beverly, New Jersey.	Reamputation. See Specimen 81, Army Medical Museum, and Pho- tographic Series A. M. M., No. 29.
Feb. 17, 1865.	Died in one day.	Quarterly Report from U. S. A. General Hos- pital, Beverly, N. J.	See Specimen 84, Army Medical Museum.
April 12, 1865.	Died before removal to the ward.	Quarterly Report from Judiciary Square General Hospital, Washington, D. C.	An excision of the head of the femur was first practised.

52

SURGICAL OPERATIONS.

Table, showing the Mortality of Amputations at the Hip-Joint for Gunshot Injury, including Primary,

Intermediate, and Secondary Cases.

Hate)

Larrey's primary cases

Larrey's intermediate cases

Guthrie's Ciudad Rodrigo case (interme

Guthrie's Waterloo case (primary)

S. Cooper's case ,

Blandin's cases (in 1794)

Hutin (Mem. de Med. Mil., t. xliv.)

Brownrigg (Elvas, 1811)

Wedemeyer (Bull, de Ferusac, t. iii. p. 101)

Letulle (Siege d'Anvers)

Clot Bey (Legouest's table)

Jubiot (Legouest's table)

Guyon (Algeria, 1840)

Sedillot (Annales de la Chir , t. ii. p. 279)

Richet (Journdes de Juin, 1848)

Robert (Idem)

Guersant (Idem)

Vidal (Idem)

Baudens (Trait*; des Plaies d'Armes a Feu)

Schleswick Holstein cases

Langenbeck's case (Schleswick Holstein)

Two operations in the English Army in the Crimea by the Director General

A soldier of the 33d English Regiment

Two other cases prior to April, 18")f>, in the English Army in the Crimea

Seven enlisted men and two officers ( Med. and Surg. Hist, of Brit. Army in the Crimea)

Twelve primary cases in the French Army in the Crimea

Mounier's case at Dolma Batchi

Legouest's case (really recovered, and died of cholera)

Four other secondary cases in the French Crimean hospitals

Bertherand's case after the engagement at Novara (Campagne d'ltaliede 1859, p. 37).

Jules Roux's cases at Toulon (all secondary)

Primary cases in the late war

Secondary cases in the late war

Recovered.

11

2 1 2 9 12 3 1 4 1 2

7 11

92

1 1

3 1 5 1 1 1 1 1 6 1 2 1 2 9

12 3 1 4 1 6 9

12

103

There seem to be but three conditions under which early amputation at the hip-joint is admissible in military surgery, viz., when nearly the entire thigh is carried away by a large projectile, when the totality of the femur is destroyed by osteomyelitis, and, possibly, when, with comminution of the upper extremity of the femur, the femoral vessels are wounded.

The experience of M. Jules Roux, in the Italian war, seems to prove conclusively that secondary amputations at the hip-joint are less dangerous than primary ones.

As to the method of operating, it may be observed that the anterior single flap procedure has of late been generally preferred.*

Amputations of the lower extremity are illustrated at the Army Medical Museum by numerous casts, drawings, and photographs, by 9 specimens of shattered femurs removed by amputation at the hip-joint, and by 211 specimens of the diseases of the

* Since t his report was put in print, two additional cases of amputation at the hip-joint have been reported. In the case of Private F. Kelb, Co. H, 7th New York Vols., whose right femur was fractured at Fredericksburg, by a musket-ball, in December, 1862, Dr. R. F. Weir amputated at the hip joint, at St. Luke's Hospital, New York, on June 7th, 1865, on account of necrosis of the entire femur. The stump nearly healed; but the patient died October 4th, 1865, of pulmonary tuberculosis. On October 12th, 1865, Surgeon E. Bently, U. S. Vols., amputated at the hip- joint, in the case of Private Lemon, 6th Maryland Vols., on account of necrosis of the left femur, resulting from a gunshot fracture of the upper third, received at the battle of the Wilderness, May 5th, 1864. The patient was in a satisfactory condition on November 24th, 1865. (Specimen 4386, A. M. M.)

AMPUTATIONS.

53

FlO. 02. — Necrosis of right tibia and fibula after amputa- tion of the leg. Spec. 422a, A. If. M.

Fid. 63. — Hyperostosis of the extremities of the right tibia and fibula after amputation. Spec. 2778, A. M. M.

bone after amputation. Wood-cuts of a few of the latter are subjoined. In regard to Specimen 4225, the following particulars are recorded:

Private Daniel S. Crawford, Co. A, 47th Pennsylvania Vols., aged twenty-seven, was wounded at Cedar Creek, October 19th, 1864, his right leg being fractured at the middle third. Amputation at the middle of the leg was performed the same day. On October 26th, he was trans- ferred to the Natioual Hospital, at Baltimore, and thence to the Jarvis Hospital, where it was found that the amputated extremities of the tibia and fibula were necrosed. On March 25th, 1865, lateral flaps were reflected and five inches of the diseased bones were resected by Acting Assistant Surgeon W. G. Small, U. S. A. After this the stump

healed promptly, and the patient was discharged from service May 31st, 1865. (See Surg. Rec. S. G. 0., Amputations, vol. vi. part ii. p. 141.)

Specimen 2778 presents a remarkable example of the exaggeration of the natural process by which the amputated ends of bones are rounded off. The redundant osseous formation presents the histological characters of ordi- nary callus. In the case which furnished this speci- men, a successful secondary amputation was performed through the knee-joint.

Cases of myelitis after amputation of the thigh have furnished the Museum with a large number of sequestra comprehending the entire circumference of the bone. The accompanying example is remarkable for the unusual length of the sequestrum, and from the fact that the patient recovered after its removal. It was contributed, with the following narrative, by Assistant Sur- geon W. Thomson, U. S. A.:

Corporal H. H. Ellis, Co. I, 16th New York Vols., was wounded at Chancellorsville, May 3d, 1863, and admitted into Douglas Hospital, at Washington, May 8th, 1863. A conoidal ball had comminuted the left patella (Spec. 1852, A. M. M.), and the knee-joint was involved. On the 13th of May, the thigh was amputated at the lower third by the circular method. This patient's health was

much impaired by chronic diarrhoea, and after l^S>^^^^S^^-^gg^^^^-r?-yr^g^!5g£?^^gL. A the operation, his condition was unpromis- ing. Secondary haemorrhage occurred on May 20th, and recurred on the 21st, when the fem- oral artery was tied in Scarpa's triangle. For many weeks this man clung to life by the slen- derest thread. The thigh stump was greatly

swollen and very tender on pressure. The line of incision, however, was not unhealthy in appearance, and the dis- charge was moderate. From the inner angle of the stump the necrosed extremity of the femur protruded. August 9th, 1863, the sequestrum was found to be loose, and was removed. After its extraction there was considerable haemorrhage ; nevertheless, convalescence now proceeded rapidly. A formation of new bone, replacing the original femur, could be readily felt. The stump was not shorter than at first. It soon closed entirely, was firm, and in every respect satisfactory. The man was discharged from the hospital, and from the service of the United States, October 26th, 1863. In December, 1864, he reported himself in good health.

The next specimen illustrates the numerous class of cases in which pyaemia accom- panies osteomyelitis, and proves fatal before the dead bone is sufficiently detached to be extracted. The involucrum is thin and eroded. The specimen, with the following facts relating to it, was forwarded by Sur- geon E. Bently, U. S. Vols.:

91 inches

Fio. 64. — Cylindrical sequestrum from the left femur after amputation at the lower third of the thigh. Spec. 1853, A. M. M.

Fig. 65. — Necrosis of the amputated end of the left femur.

A. M. M.

Spec. 3343

54

SURGICAL OPERATIONS.

Private Andrew H , Co. B, 6th New Jersey Vols., was wounded May 6th, 1864, at the battle of the Wilder- ness, by a musket-ball, which entered the left knee-joint, at the upper outer margin of the patella. He was admitted to the 3d Division General Hospital, at Alexandria, Virginia, on May 26th. On July 9th, a large abscess near the elbow was laid open. Others formed along the thigh, and were likewise opened. On July 16th, the thigh was ampu- tated in the lower part of the middle third. The case terminated fatally on July 26th. The autopsy revealed numerous metastatic foci in the lungs ; the liver was fatty ; the spleen much enlarged. There were bed-sores on the back, and the body was much emaciated.

EXCISIONS.

The number of excisions after gunshot injuries that have been transcribed from the reports is given on page 6 of this report, and indicates that this branch of conserva- tive surgery was largely practised in the late war. It is proposed here to review very briefly the records of the individual excisions.

Excisions of the Wrist. — The 35 cases included in this category were all examples of partial excision. In 27, the ends of the radius or ulna, or of both, were removed, and, in some instances, shattered fragments of the upper row of carpal bones. In 8, the greater part of the carpus was excised. Death took place once from pyaemia, and twice from exhaustion from protracted suppuration and irritative fever: 26 cases are reported as recovered. In 2 cases, amputation of the forearm became necessary. The reports are unsatisfactory in relation to the amount of mobility left in the hand, and the cases are now under investigation with reference to this point.

As the literature of this subject is meagre, a few illustrative cases are appended:

Private Joseph Hoover, Co. A, 62d Pennsylvania Vols., aged twenty-six years, was wounded at Spottsylvania, May 12th, 1864, by a musket-ball, which passed through both wrists. He entered Judiciary Square Hospital, at Washington, on May 26th. His right forearm had been amputated on the field. On May 30th, Assistant Surgeon A. Ingram, U. S. A., removed nearly all the left carpus, the styloid process of the ulna, and the carpal end of the first metacarpal bone, and made free incisions over the ulna and the dorsum of the hand for the evacuation of pus. The patient recovered, and was discharged from service. The condition of the hand is not reported.

Surgeon H. Culbertson, U. S. Vols., removed the cuneiform and pisiform, and a portion of the os magnum, and extracted fragments of the unciform and semilunare in the case of Private Neal, Co. D, 3d Wisconsin, who was shot through the carpus, at Dallas, Georgia. The patient recovered with some use of his hand, and entered the Veteran Reserve Corps, April 1st, 1865.

Assistant Surgeon C. Bacon, U. S. A., excised the lower portion of the right radius, the trapezoid, scaphoid, os magnum, and the second, third, and fourth metacarpals, in the case of Private Bard, Co. I, 1st Pennsylvania Vols., who was wounded at Antietam. The result is stated to have been favorable.

Photograph 59 of the Army Medical Museum represents the forearm and hand of Major C. W. Hobbs, 7th New York Heavy Artillery, who was wounded at Cold Harbor, Virginia, June 3d, 1863, by three musket-balls. One inflicted a flesh wound of the left thigh, passing across the popliteal space, close to the hamstring tendons. A second fractured the third and fourth metacarpal bones of the left hand, and made its exit near the wrist. The third entered the left hand between the distal extremities of the first and second metacarpals, comminuting the second and third metacarpals, the unciform and cuneiform bones, and the lower extremity of the ulna, and made its exit on the outer side of the forearm. Primary excision was performed by Surgeon J. E. Pomfret, 7th New York Heavy Artillery. Two inches of the distal extremity of the ulna were removed, with the fractured bones of the carpus and metacarpus, and three outer fingers. The case progressed without any untoward complication, and recovery was complete in two months. The remaining portion of the radio-carpal articulation was not anchylosed, and the movements of the thumb and forefinger were unimpaired.

Professor J oseph Lister's recent paper,* in which are narrated the successes ob- t ;n nod by his method of excising the entire wrist-joint for caries, encourages the hope that the same operation may be hereafter successfully adopted in cases of gunshot wounds of the wrist.

* Lancet, American edition, July, 1865, p. 306.

EXCISIONS.

55

Excisions of the Elbow. — The returns for three-fourths of the entire period give 315 cases of excision of the elbow, and the results are ascertained in 286 cases. In 16 cases, amputation of the arm became necessary: 62 cases terminated fatally, or 21*67 per cent., which is a mortality a fraction greater than that resulting from amputations of the arm. This result is altogether opposed to the Schleswick Holstein and Crimean experience, and will doubtless be modified when the statistics are completed. It may be ascribed j)artly to the fact that the returns for the earlier part of the war include quite a large proportion of partial excisions, which 'are far more hazardous than com- plete removal of the articular surfaces.

The Army Medical Museum possesses 98 specimens of the injured epiphyses re- moved in excisions of the elbow, and a goodly number of photographs of patients in whom the operation has been performed.

The happy results of this well established operation are so fully known, that it is unnecessary to give more than a single illustrative case :

Private William D. Riley, Co. D, 86th New York Vols., aged twenty-one years, was accidentally wounded at Brandy Station, Virginia, November 26th, 1803, by a musket-ball, which shattered the inner condyle of the right humerus and the olecranon process of the ulna. He was admitted to Mansion House Hospital, at Alexandria, the same day, having bled quite largely on the way. On December 19th, 1863, Surgeon Charles Page, U. S. A., excised the elbow-joint, employing the H-shaped incision. Two and a half inches of the lower extremity of the humerus, an inch of the upper extremity of the ulna, and a small portion of the head of the radius were removed. The case progressed most favorably, and in May, 1864, Riley went to his home, on furlough, with a useful arm. He was subsequently discharged from service. In 1865, he re-enlisted in Co. K, 5th Regiment, First Army Corps, with the approval of Lieutenant Colonel Dougherty, Medical Director of the Corps. "The man went through the manual before me," Surgeon Dougherty writes, "and stated his readiness to do all the duties of a soldier. He wished it recorded that he was competent and prepared, in order that, during the term of his service, he might be held to full duty. The degree of motion was, perhaps, one-third of the normal amount." A photograph of the patient (No. 54, A. M. M.) was taken in June, 1865, at the Army Medical Museum.

Excisions of the Shoulder-Joint. — Nearly all of the cases that have been reported during the war have been recorded. The results are given in the following table:

Table, exhibiting the Results of Cases of Excisions of the Shoulder- Joint for Gunshot Injuries.

	Primary	Secondary
	Operations.	Operations.
Died	50	115
Recovered.	100	183
	42	25
	252	323
	575

The percentage of mortality is 23'3 in primary cases, 38-59 in secondary cases, or a mean ratio of 32-48. The ratio in amputations at the shoulder-joint is 39*24, a per- centage of 6-76 in favor of excision. Of 36 cases of gunshot fracture of the head of the humerus, selected as favorable cases for the expectant plan and treated without exci- sion or amputation, 16 died, or 44-4 per cent., a ratio in favor of excision of 1T96 per cent. But it is superfluous to offer further proofs in behalf of this admirable operation.

56

SURGICAL OPERATIONS.

Fio.66.— liall impact- ed in the head of the humerus. A typical case for ex- cision. Spec. 1206, A. M. M.

Esmarch* makes the curious observation, that resection of the left shoulder gives less favorable results than the operation on the right side. This statement is not con- firmed by the returns. Of 442 terminated cases in which mention is made of the side injured, the right shoulder was involved in 200 and the left in 242. The oper- ation resulted fatally in 72 of the former, or 36 per cent., and in 71 of the latter, or 29-3 per cent. The greater frequency of injuries requiring the operation on the left side is doubtless due to the exposed position of the left shoulder in firing.

Generally the