Several reports and cases having reached me from various medical
officers in the Crimea, too late for publication in their proper
places, I have thought it best to notice some generally as to results,
others particularly. Chloroform has been freely administered in all the
Divisions of the army save the Second, and has been generally approved;
one death only, as far as is known, having occurred directly from its
administration, of which Staff-Surgeon Gordon, P.M.O. of the Second
Division, has favored me with the following report:--
Martin Kennedy, 62d Regiment, aged 32 years, a healthy soldier, having
accidentally wounded one of his fingers by his musket going off, and
the medical officer in charge considering it necessary to remove it,
was brought under the influence of chloroform, but, according to his
(the surgeon’s) statement, only about ʒij could have been inhaled. He
had commenced the operation, when the patient suddenly expired. On the
post-mortem examination, beyond a little fatty deposit on the external
surface of the left ventricle, together with a degree of hypertrophy
of the same, no morbid appearance existed. The usual restoratives were
resorted to, but ineffectually.
The following case, furnished by Assistant-Surgeon Hannan, 49th
Regiment, is given as an illustration of the success of amputation
without chloroform in the Second Division:--
Patrick Kenny, 49th Regiment, aged 22. This soldier, while on duty
in the trenches on the 21st of July, received a compound comminuted
fracture of the right humerus, extending from its middle third to the
head of the bone. The integuments of the outer and upper part of the
shoulder were carried away. There was also a contused and lacerated
wound of the left knee, opening into the joint, with comminuted
fracture of the patella, these injuries being caused by pieces of
shell. He was seen a quarter of an hour after admission by Dr. Gordon,
P.M.O., who removed the arm at the shoulder-joint, making a sufficient
flap from the integuments of the axilla. The thigh was then amputated
in its lower third. These operations were performed in immediate
succession without the administration of chloroform. The thigh healed
nearly by the first intention--all the ligatures having come away by
the fourteenth day. The shoulder healed by granulation--the ligature
of the axillary artery coming away on the twenty-first day. During the
progress of treatment he had not any constitutional disturbance further
than three slight attacks of diarrhœa. He is now up and about, and goes
to England by the next opportunity.
In the worst cases of amputation at the hip-joint, or at the upper
third of the thigh, chloroform has appeared to cause insensibility
to pain without diminishing the powers of the sufferer, when given
with due caution or not carried so far as to affect the pulse or
respiration. (See _Aphor._ 51.) The evidence on this point is
sufficient to authorize surgeons to administer it in all such cases,
with the expectation that it will always prove advantageous, an
accidental death, such as has been observed from its use, being
independent of the nature of the injury. The amputations performed
at the hip-joint, at least six in number, have not been successful
as to the result, although the sufferers bore them well in the first
instance, offering every prospect of recovery for days and even for
weeks.
Deputy Inspector-General Taylor informs me, and his opinion is
corroborated by all the medical officers, that the labors the
troops had to perform, the privations they suffered, the frequent
insufficiency of their food, the want of proper clothing, with other
depressing causes, had so deprived them of that power British soldiers
generally possess, that all the operations of importance performed on
the lower extremities were more or less unsuccessful, while those on
the upper were as remarkable for their success. This deprivation of
power, it is said, was even more observable in the French army; and
he informs me that most of their surgeons had declined performing any
of the great operations usually done on the upper third of the thigh,
in consequence of their almost certain failure, preferring to let
the injuries take their course, even unto the death of the sufferers,
rather than hasten their dissolution by any operation usually
considered and often found to be conservative; a lamentable state of
things from which governments may draw an inference of the utmost
importance, viz., that to guard against the effects of disease as well
as of injuries, the utmost pains should be taken to preserve the health
and maintain the vigor of their soldiers. A matter of expense as well
as of arrangement.
This statement is corroborated by Deputy Inspector-General Alexander,
who informed me, on the 3d of August, 1855, that “during the whole of
this campaign, where we have had ample opportunities of testing the
use of chloroform, both after the battles of the Alma and Inkerman, as
well as throughout the whole siege operations before Sebastopol, up to
the present period, no operations whatever of any consequence (save
with one or two exceptions, and then at the patients’ own request,)
have been performed in the Light Division, without first placing the
patient under the influence of chloroform, and in no single instance
have either the medical officers of the Division, or myself, seen any
bad results follow, or had to reject its use, but quite the contrary.
Of course, in such a campaign, many operations of the most serious
character, both on the upper and lower extremities, have been performed
in the Division by the different medical officers as well as by myself.
At the Alma, I operated upon three patients at the hip-joint, two
being our own men and the third a Russian. All the three patients were
first placed under chloroform, with the results above stated. In the
case of a soldier of the 90th Regiment, whose right arm I removed at
the shoulder-joint on the 10th of July, for great destruction of the
soft parts and extensive injury to the humerus, the patient was so
low when placed on the table that brandy and water was given to him,
and he was then immediately afterward placed under chloroform. When
I had finished, it was found that his pulse was stronger than before
commencing the operation. In Sir T. Trowbridge’s case, in which I had
to remove both feet, one at the ankle-joint and the other above it, he
was placed under chloroform for both operations, a few minutes having
been allowed to elapse before giving it to him again for the second
operation, and with the best results. Both feet were much injured
by round shot, the bones of both being completely smashed with great
destruction of the soft parts, so much so, that in the case at the
ankle-joint I had to form the flap from the cushion of the heel. I,
however, did not remove the articular surface of the lower end of the
tibia, as recommended by Mr. Syme, and the wound healed well. Of the
three cases mentioned at the hip-joint, two were performed on the 21st,
and the Russian on the 22d of September. At one of the former I was
assisted by the late Dr. Mackenzie, from Edinburgh. All three were
carried down on the 22d, to be placed on board ships for conveyance
to Scutari. It has been reported to me that one of the two operated
on, on the 21st, Peter Sullivan, 33d Regiment, died at Scutari General
Hospital on the 11th of October, three weeks from the date of the
operation, ‘from excessive debility.’ Nothing could be ascertained
about Peter Cleary, 23d Fusiliers; it is therefore most likely that he
died on the passage.
“The Russian died on the 22d of October, ‘from great debility and
extensive sloughing.’
“A shoulder-joint case in the 90th Regiment never had a bad symptom,
and the wound is all but healed. The flap in this case was made from
the axillary portion of the arm, the deltoid having been all but
destroyed.
“The flap operation has been invariably performed in the Light
Division, with but two exceptions, viz., one of the arm and the other
of the thigh.”
Excision of the head, neck, and trochanter of the femur, with portions
of the shaft, has been performed at least six times before Sebastopol.
The result has been unfavorable in five, although in all there were
well-grounded expectations of success for weeks. In one case by Mr.
Blenkins, of the Grenadier Guards, he informs me, it was for the first
three or four weeks very favorable. The man, however, sank at the end
of the fifth week from deposition of matter in the knee-joint. (See p.
42 et seq.) Of the second case, which occurred in the general hospital
in the camp and ended fatally, I have no further notice. The third, in
the 68th Regiment, in charge of Mr. O’Leary, the operation performed on
the 19th of August, was going on most favorably on the 5th of October.
Private Thomas M’Kenena, aged twenty-five, was struck by a fragment of
shell, on the 19th of August, over the great trochanter of the left
femur. The wound, nearly an inch in length, extended down to the bone,
which was distinctly fractured. Some loose scales could be felt at
the bottom of the wound. On examination, the injury appeared to be a
transverse fracture of the neck of the thigh-bone, apparently involving
the joint.
After a consultation with superior medical officers, it was decided
that excision should be performed, which was done without difficulty.
No vessels required ligature, although the man lost a considerable
quantity of blood.
The excised parts, which are herewith forwarded, show that the nature
of the injury was different from what it was supposed to be, and that
the head of the bone was intact.
After the wound, about five inches long, had been sewn up, the limb was
placed in a sling made of strong canvas, and was swung from a beam over
the man’s cot, the bed being raised.
This method of treatment was adopted with a view to encourage
approximation of the upper end of the bone to the pelvis, and by
pressure on the sides of the limb to prevent the accumulation of matter
among the tissues. The man progresses favorably.
Diet was very generous.