Six amputations at the hip-joint (if not more) have been performed in
the Crimea, and all the sufferers have died, a loss which has not been
experienced in civil life under any circumstances, many persons having
survived the operation for years. It has been fairly attributed to
the depressing causes from which the army suffered, and for which the
government has been blamed; although the great functionaries appear
to me to have less to account for than their subordinates, as far as
regards deficiencies in the treatment of the sick and wounded.
The operation for removing the head of the femur from its connection
with the hip, leaving the limb for future use, was first recommended by
me as a substitute for amputation at the hip-joint, and has been done
in at least six instances, one only surviving. I limited the operation
to injuries of the head and neck of the bone, or with little extension
beyond these two parts, being cases which hitherto invariably died
unless amputation at the hip-joint were performed, and which it was
and is hoped the operation of excision might render unnecessary; but
it must be done under happier circumstances, and perhaps with greater
restriction. The success which has followed the removal of the head of
the humerus from the shoulder-joint even with as much as one-third of
the shaft, as low as the insertion of the deltoid muscle, has led to
the belief that as much may be done in the thigh; and in the hope that
it might be so, a considerable portion of the shaft of the femur has
been removed with the head and neck in the cases alluded to, so that an
approximation of the remainder of the shaft to the cavity of the joint
has not been possible. If the operation performed by Surgeon O’Leary,
68th Regiment, (page 564,) which at the end of seven weeks is reported
as doing well, although the pulse remained between 80 and 100, should
succeed, it is doubtful whether the limb will be of any use or better
than an artificial leg, from the extent of the bone removed, which will
prevent the formation of a firm joint or union. The sling used in this
case has been considered very advantageous by all who have seen the
man, and proves how much may be done in all cases of compound fractures
by similar appliances, but which has not yet been done. A correct
judgment cannot, however, be formed as to the value of this operation
until it has been performed on one of those cases in which a ball shall
simply lodge in the head or neck of the femur without injuring the
shaft of the bone--an accident which has been so frequently observed in
the head of the humerus, and of which I have sent two preparations to
the museum of the College of Surgeons. (See page 127.)
It has been already stated that the loss of life after amputations
performed for gunshot fractures of the upper part of the thigh has been
so great, both in the French and English armies, that such operations
have been nearly abandoned.
The Russians, at the commencement of the siege of Sebastopol, made use
of a conical rifle bullet, flat at the base, weighing nearly one ounce
and three-quarters. Latterly they have used a larger conical one, with
three grooves around the circumference of the base of the cone, which
is hollowed out to receive a cup, and shows a projection on the inside
of the hollow. This ball is near two inches long, and weighs somewhat
more than one ounce and three-quarters.
The balls formerly used by the French army were twenty to the pound,
and by the English, sixteen. The balls alluded to are nine to the
pound. When this Russian ball strikes soft parts only, such as the
thigh, it merely makes a larger hole than the common bullet, into which
the finger passes easily, and the wound heals as readily. Whenever it
strikes a bone, it would appear to break it more extensively, and to
require more certainly the amputation of the limb; although the smaller
French ball used in former days, when it struck a bone, disabled the
sufferer as effectually for all future service, yet it might not as
certainly lead to his death.
Dr. Lyons not only transmitted to me the case, related page 579, of
John Shehan, but has since sent me the broken bones, which confirm
everything I have said on this subject, page 321. The sound bone above
the fracture has become more solid; the splinters not having been
removed are lying across, and prevent the approximation or union of
the ends of the old bone, while the effort made by nature to effect
this object by the deposition of new ossific matter, adds to the evil
by fixing these splinters in so solid a manner that they cannot escape
or be removed by any other means than that of forcible abstraction,
after painful and perhaps dangerous operations, each splinter possibly
requiring a separate one. Shehan’s case was one for amputation from
the first, if he had been in a state to undergo it with a prospect of
success.
The treatment of gunshot fractures of the leg ought to have been more
successful than it has been, even when both bones were broken; the
want of success may be in part attributed to the remissness which has
taken place in supplying the necessary, nay, the essential appliances,
by means of which much suffering might have been alleviated, perhaps
prevented, even if cures could not have been effected.
In performing the operation for the excision of portions of the
extremities of bones, a chain saw is a most desirable aid on many
occasions. There was not one with the British army in the Crimea, and
when wanted, they were borrowed from the French ambulances. It was only
on the 30th of September last some were ordered to be sent out, and
they cannot yet have arrived. In a lecture I delivered on the 14th of
April last in the Theater of the College of Surgeons, as its President,
by permission of the Council, the proceeding being unusual, I drew
attention, for the express purpose, to the necessity which existed
for the Crimean army being supplied with a machine capable of being
moved from bed to bed, by means of which the unfortunate soldier could
be raised in the extended state, and after being washed, his wounds
dressed, and his bedclothes changed, he might be again laid down with
comparatively little uneasiness. Fifty of them would not cost £300, but
there are none in the Crimea, except two, one sent to the Coldstream
Guards, by Lord Strafford at his own expense, and one which the makers
placed at my disposal. I hear that _three_ have been ordered lately,
like the chain saw, when too late, for many are now no more who stood
in the greatest need of them, and without which machine they had little
chance of being saved.
On the 14th of April, 1855, I published a lecture, in which I gave a
sketch of an apparatus for slinging a broken leg, which instrument
I declared to be a _sine qua non_ in the successful treatment of a
gunshot fracture of the leg. By permission of the Duke of Newcastle,
I sent out forty-six sets complete for every part of the body, the
year preceding. They were, I am told, left at Varna; and four medical
officers, of character and knowledge, who have lately returned
from the East, assure me within the last week that no such, or any
similarly useful, apparatus was ever seen in the hospitals in front of
Sebastopol. Other instances of remissness of equal importance might
be adduced, if it were not useless to advert to them; for we delight,
I believe, in being admitted by foreigners to be a wonderful people
in the mismanagement of our affairs in the first instance, however
important or trivial. It is, I believe, an admitted maxim, that the
right men should be in the right place--the square ones in the square
holes, the round ones in the round holes; but there is another one of
equal importance, viz., that the right thing should be in the right
place at the right time, without which teaching or practicing surgery
becomes of little value.
Amputation at the knee-joint has been done, I hear, in six cases since
the taking of Sebastopol; four are dead; one is doing well under Mr.
Blenkins, of the Guards, and the other yet survives. Excision of the
knee-joint has been performed since the taking of Sebastopol in one
case by Staff-Surgeon Lakin, and is doing well.
The excisions performed on the head of the humerus, and on the bones
composing the elbow-joint, have been very successful. There is,
however, a circumstance to which I am desirous of drawing attention,
viz., that the head of the humerus should never be removed in
amputations, when it is uninjured, however close the destruction below
may have approached it. The round head of bone left in the socket
preserves the squareness of the shoulder, and renders the loss of
the arm less unseemly. It tends to prevent the inclination the body
generally has to the opposite side, and its being left adds nothing to
the difficulties of the operation. The excisions of the ankle-joint
have been numerous and more successful than might have been expected
under the depressing causes alluded to.
For the preparations of the head of the humerus and of the astragalus,
referred to at pages 110 and 128, I have since learned I am indebted
to Deputy Inspector-General Macgregor; and I am particularly so to
Assistant-Surgeon Gregg, of the 17th Regiment, for the great care he
has bestowed on several of the specimens of injury sent to me.
Wounds penetrating the cavities of the chest and abdomen have been no
less fatal than those of the lower extremities. The same want of power
has been exhibited in them; the same inability to bear the means of
cure which, under happier circumstances, have proved successful.
I hope to receive reports on wounds of arteries, on secondary
hemorrhage, and on injuries of the head, so as to enable me to remove
any doubts which may exist on these points; and I beg to assure those
officers who will favor me with their opinions and facts, that they
shall be duly reported in another “Addenda.”
I cannot conclude these remarks without expressing my sense of the
great practical ability displayed by very many of the medical officers
in the Crimea, of their devotion, of their self-denial--qualities which
ought to obtain for them the special approbation of the nation.
_October 18, 1855._