_Surgeon, 68th Light Infantry_.
Camp, 4th Division, Crimea, Sept. 14, 1855.
The bones removed are in the museum of the Royal College of Surgeons.
The fourth case is given at length by Staff-Surgeon Crerar, as
follows:--
Private William Smith, First Battalion First Royals, was brought to
hospital from the Greenhill trenches, in front of Sebastopol, about
twelve P.M., on the 6th of August. On questioning him, I ascertained
that an hour or so before he was struck by a fragment of an exploded
grenade, which first broke into small pieces a water canteen which
was suspended over the left hip, and then made an opening or wound
about the size of a shilling nearly a quarter of an inch posterior
to the great trochanter. Crepitus was quite distinct on moving the
limb; and I easily ascertained, on exploring the wound with my
finger, that a fracture through the trochanter had taken place, but
was quite unable to ascertain to what extent upward and downward the
fracture extended. I accordingly solicited a consultation with Deputy
Inspector-General Taylor and Staff-Surgeon Paynter. After a careful
examination, (the patient being under the influence of chloroform,)
the femur was discovered to be comminuted. Excision at the hip-joint
being recommended by these officers, in which opinion I concurred, I
proceeded to perform the operation by commencing an incision, nine
inches in length, in a line with and two inches posterior to the
anterior superior spinous process of the ilium, and carrying it down in
a straight line directly over the trochanter major; a second incision
about two and a half inches in length was made, commencing immediately
below the trochanter backward through the gluteus maximus; by a little
easy dissection the seat of fracture was exposed, the trochanter was
found broken into several portions, detached and imbedded in the
contused muscles around, from which they were at once removed. The
fracture was found to extend obliquely inward about an inch and a
half along the shaft of the bone. The femur was now protruded through
the wound, and I sawed off the whole of the fractured bone, leaving a
smooth, clean surface; I then proceeded to disarticulate the head of
the femur, which was effected without difficulty. Scarcely three ounces
of blood were lost, and little or no shock was induced; only one small
bleeding point was secured near the tail of the wound, and the divided
parts were brought together by two sutures and bands of adhesive
plaster.
At twelve A.M., two hours after the operation on the 7th instant, his
pulse being rather feeble, he was ordered some wine and water.
7th, vespere.--Countenance cheerful, voice strong; says he intends
keeping up his pluck, and is sure he will get well; has no inclination
to take the beef-tea ordered for him, but has had some arrow-root and
wine. To have a morphia draught at bedtime.
8th.--Passed a good night; limb in a good position; retracted about two
inches; wound looks healthy; pulse 100, soft; has made urine freely;
skin moist; bowels were opened freely in the night.
9th.--Slept well at night; says that he feels very comfortable; skin
moist; pulse 120; sutures were removed, and the wound allowed to gape;
it has a remarkably healthy appearance. To go on with the simple water
dressing, chicken-broth, arrow-root, and wine.
Vespere.--Has been very cheerful all day; limb has retracted about
another half inch; pulse 112.
10th.--Passed a more restless night, in consequence of not having the
morphia draught as early as the previous night; has had several hours’
sleep this morning, and is more refreshed; pulse, on waking, from 114
to 120, skin comfortable; no sign of distress in his aspect; wound
suppurating healthily; bowels were opened again once last night.
10th, vespere.--Has been very easy all day; skin cool; tongue normal;
pulse 120, soft and regular; has had to-day two eggs, one ounce of
arrow-root, two gills of wine, and two pints of chicken-broth, all
of which he relished much. To have a grain of acetate of morphia in
solution at bedtime.
11th.--Slept soundly all night; when I visited him, at six A.M., he had
just awoke; pulse 115, soft; appears contented and comfortable.
Vespere.--Doing well; wound continues to look healthy; position of
limb good; has consumed a fair quantity of chicken-broth, beef-tea,
arrow-root, and three gills of sherry to-day; pulse 113 at eight P.M.
12th.--Bowels were opened in the night; the introduction of the bed-pan
gave him a good deal of annoyance; the air of the hut was rather
stagnant last night, and he did not sleep as well as usual; pulse 120,
soft; tongue continues clean and moist; there is more discharge from
the wound to-day.
Vespere.--The progress of the case is most satisfactory; had a fresh
egg, tea, and toast for breakfast, his own selection, which he appeared
to relish greatly; at twelve he had two mutton-chops and a glass of
wine, and at five P.M., a pint of chicken-broth, with bread, and a
second glass of wine. The morphia draught as usual.
13th.--Continues to look happy and contented. Healthy-looking
granulations are evident over two-thirds of the wound; swelling of limb
subsiding; discharge from wound healthy; pulse 114, regular and soft;
all the symptoms are so very favorable that I have every reason to
expect a successful issue.
14th.--A small slough at the lower part of the wound, remainder healthy
and clean; tongue a little too dry this morning, and he has more thirst
than usual; pulse 118. To have effervescing draughts of bicarbonate
of potassa and citric acid three times a day; to continue simple water
dressing.
Vespere.--Thirst not so urgent; tongue cleaner and moister; has a
feeling of fullness in the abdomen. To have his usual morphia draught
and an ounce of castor-oil at bedtime.
15th.--Passed three large stools in the night, with great relief;
aspect resigned, and his spirits continue good; slough has come away;
pulse 118, soft and regular; skin tolerably cool.
Vespere.--Felt a good deal exhausted to-day from the heat, which was
very great--ninety-two degrees.
16th.--Looks heavy and out of spirits this morning; discharge has
increased, but is of a better quality since the slough separated;
tongue dry, inclined to brown; pulse the same, skin rather hot;
continue effervescing draughts every third hour.
Vespere.--Tongue more moist, less thirst. When asked how he felt, he
replied, with a great deal of life in his countenance, “I am very well,
and I feel very comfortable;” asked for a mutton-chop early in the day,
which he got, and appeared to like; he had at different times in the
day arrow-root, chicken-broth, and wine.
17th.--Wound looks very healthy, and the general symptoms very
favorable to-day; tongue clean and moist; less thirst; skin cooler; had
him removed to a fresh bed without a great deal of pain or trouble;
limb retracted less than three inches; position now good since he was
shifted.
18th.--Very much worse this morning; had a rigor about ten A.M.
yesterday; features now sharpened and pinched; tongue dry and brown;
pulse thready, about 125.
Vespere.--Continues in a very low state; wound has a very healthy
appearance; discharge healthy, but not as abundant as it was; has had
besides wine, a pint and a half of porter, mutton-broth, and a chop
to-day; zinc lotion to the wound.
19th.--When I visited him at six A.M. to-day, I was much pleased
to find him looking quite cheerful; pulse soft, 112; skin cool and
moist, paler than usual; wound doing well. Continue zinc lotion to
the sore, and to have his choice to-day of mutton-broth, beef-tea, or
chicken-broth; arrow-root to be given twice, four gills of sherry or
port as usual.
Vespere.--No change to report.
20th.--Looking rather pale, and features pinched; pulse better, about
100, soft; skin cool; tongue more coated than usual, inclined to be
dry. I fear this case is a bad one, not likely to terminate as we so
much desire.
Vespere.--Has been very uneasy all day; skin hot; tongue dry.
21st, six A.M.--Has just awoke, having been asleep since nine last
night; says that he feels stronger; aspect certainly improved since the
last visit; coating on the tongue thicker, brown; the pulse has more
strength than it had yesterday; no feeling of uneasiness; wound looking
remarkably well, and discharging laudable pus; asks for cold drinks;
to have his choice of iced soda, tamarind, toast or rice water; diet
the same as yesterday.--Eleven A.M.: has fallen off very much since
the morning, features pinched and blue; pulse irregular, small, and
wiry.--Twelve nocte: continues to sink; died at half-past twelve P.M.
Examination of the limb six hours after death.--Cut surfaces of femur
perfectly smooth; bone easily denuded of its periosteum; acetabulum
smooth; muscles infiltrated with pus; nature had not made the slightest
attempt to repair the loss.
What would the result have been if amputation at the hip-joint had
been performed? The same. The vis medicatrix naturæ is not sufficient
to carry our sick through such formidable operations; it is no fault
of the surgeons. A better and a more liberal allowance of animal and
vegetable food during health is required, if England expects her
soldiers to survive severe operations, disease and wounds. An attempt
to save the limb, for the very same reason, would, most undoubtedly,
have been a failure. Our Minié rifle-ball fractures of the femur all
sink under conservative surgery. Our amputations above the middle of
the thigh have a like issue; it is truly disheartening.
J. CRERAR, _Surgeon_, _68th Regiment_.
Camp before Sebastopol, 24th August.
Dr. Crerar was greatly distressed by the loss of this man, and the
manner in which he expresses his grief is declaratory of his feelings.
The excised bones are in the museum of the Royal College of Surgeons.
The fifth, by Dr. Hyde, ended fatally on the sixth day.
Corporal Benjamin Shehan, 41st Regiment, advanced with his corps, about
twelve o’clock, on the 8th of September, to storm the Redan. Having
succeeded in getting into the work, the regiment was afterward obliged
to retire; in the retreat to our trenches he was wounded, and lay on
the field till the following day, when he was brought to the hospital
of the Royal Sappers and Miners. On examining the wound, it was found
that a grape-shot had entered at the great trochanter, and, passing
inward and a little forward, had passed out at the groin of the same
side, about an inch below Poupart’s ligament, externally to, and a
little in front of, the femoral vessels. The lower fragment of the
fracture protruded through the external wound, and the introduction of
the finger discovered a comminuted state of the neck of the bone.
Excision of the joint having been decided on, the operation was
performed in the presence of Deputy Inspector-General Taylor,
Staff-Surgeon Dr. Paynter, and Surgeon Elliot, Ordnance Department.
Operation performed about one P.M. 9th of September.--An incision,
about four inches in length, commencing a little above the trochanter,
was carried downward along the outer side of the femur. The lower
fragment, for about an inch of its extent, was cleared of its
attachments. An assistant holding the thigh below, and pushing the bone
upward and outward, so as to bring the fragment through the incision,
about an inch of the bone was then sawed off. The head of the bone
was next dissected from the socket; this part of the operation was
considerably facilitated by an assistant catching a firm hold of the
neck by means of a pair of tooth forceps, then rotating the head,
and using slight force to dislodge it from the cavity, the operator
dividing the capsular and round ligaments, the latter of which is
more easily and safely divided at the lower and outer side of the
articulation. The upper part of the trochanter was next dissected out,
and several small spiculæ of bone removed. The edges of the incision
were then brought together by sutures, and a bandage applied. It was
not found necessary to tie any vessel, and there was very little
hemorrhage. The man bore the operation well, and was returned to his
bed in good spirits, and with a good pulse.
10th.--Passed a good night; slept pretty well; pulse 106, soft; skin
cool; in good spirits.
11th.--Slept some hours; pulse 106, soft; bowels open; tongue furred,
but moist. Wound dressed and looking well; some healthy discharge.
13th.--Going on apparently very well; pulse still 106; countenance
good. Vespere: Complains of an increase of pain in the hip, but
otherwise says he feels much as usual; pulse small and rapid. Ordered
wine and arrow-root.
14th.--Died at six this morning.
The autopsy showed a considerable cavity filled with sanies in the
situation of the operation, but no other fractured bone was discovered.
The articulating surface of the acetabulum was coated by a fetid, pasty
substance.
GEO. HYDE, M.D., _Staff-Surgeon_.
The sixth, by Staff-Surgeon Coombe, also ended fatally.
Private James Nadauld, aged twenty-one, First Battalion Rifle Brigade,
was admitted into the Castle Hospital, Balaklava, upon the 16th of
July, 1855, five days after the receipt of a gunshot injury of the
right shoulder. Upon the 19th of July the head of the humerus was
excised, and the ball was found impacted in it. The healing process
went on most favorably, and the man was discharged upon the 26th of
August, quite well, for the purpose of proceeding to England. The
excised bone is in the museum of the Royal College of Surgeons.
W. H. McANDREW, M.D.,
_Surgeon, 57th Regiment_.
Camp, Sebastopol, Sept. 14th, 1855.
Private John Purcell, 57th Regiment, aged twenty-one, was wounded
upon the 18th of June, in the unsuccessful assault upon the Redan,
by a Minié rifle-ball, which passed directly through the head of the
humerus, but did not touch the glenoid cavity. Upon the 22d of June,
the head of the bone was excised; and upon the 26th of August, the man
was discharged from hospital, quite well, for the purpose of proceeding
to England. The excised bone is in the museum of the Royal College of
Surgeons.
W. H. McANDREW, M. D.,
Surgeon, 57th Regiment.
Camp, Sebastopol, Sept. 14th, 1855.