THE
MEDICAL EXAMINER,
AND
RECORD OF MEDICAL SCIENCE.
NEW SERIES. — NO. X C VII. — J A N U AR Y, 1853.
ORIGINAL COMMUNICATIONS.
Surgical Sketches, By AV. E. Horner, M. D.,Prof. of Anatomy
in the University of Pennsylvania, Senior Surgeon at the St.
Joseph’s Hospital, &c. &c.
A Military Hospital at Buffalo, New York, in the year YS\A.
(Continued.)
The following general results came w’ithin my experience:
1.	Buckshot wounds seldom did much harm, vital parts excepted.
Those that I saw were principally on the persons of prisoners of
war. They approach so near a simple laceration without con-
tusion, that they soon get well. I have now one sticking very
tranquilly in an os femoris, as if it had grown there. They are,
I understand, peculiar to the American service. They give a
more barbarous character to warfare, and probably without an
equivalent advantage. This, however, I submit to the decision
of military men. The English officers took that view of them,
and considered them simply as mangling unnecessarily, but in-
terfering with the effectiveness of the principal ball. Their
pomentum is too weak to penetrate far; really vital parts are
well covered and make but a small portion of the entire area of
the body. It would, perhaps, be better for our national credit to
discontinue such missiles, at least in war -with civilized nations.
The only recommendation that I ever heard of them was, that as
they inflict a wound, the character of which is of course unknown
to its recipient, he retires from the field of battle. They are
therefore advantageous simply in multiplying wounds, though
the latter may not be serious. If their use be a real advantage
in gunnery, they can be thrown by one party as well as by the
other, so that things are thus equalized. I have understood that
their use at present is not so indiscriminate as formerly, and that
they are resorted to principally in close contest.
Should they open articular cavities, then the mischief is of
course considerable. Col. Miller of the U. S. Army, in an ex-
pedition to Long Point, opposite Fort Erie, had his knee joint per-
forated in that way, and inflammation and suppuration followed ;
he finally, after a long treatment, submitted to amputation, but
without benefit, as he died shortly after.
2.	Bullet wounds which did no injury to the bones, or to the
great cavities, generally did well; a slight inflammation and stiff-
ness followed, which went off in a few days. Our most common
dressing in these cases, was basilicon, simple cerate, or tallow ;
poultices or discutients were seldom absolutely indicated. The
wound was cleaned by the efforts of nature, in eight, ten or
twelve days, it being succeeded by a copious discharge of pus,
which gradually diminishing, the wound healed.
3.	When the large cylindrical bones were broken, our resort
was, for the most part, amputation ; we had but few cases, the
result of which encouraged us to attempt the saving of others.
Out of many cases of fractured os humeri and os femoris
which I saw, a majority of the patients died, or were compelled
to submit finally to amputation ; there being but few instances of
perfect recovery from such accidents. The latter circumstance
was partly attributable to the largeness of the English musket
balls, which almost always produced an extensively comminuted
fracture when they struck a hard bone. Amongst the instances of
recovery, where the thigh bone was broken, was that of Lieutenant-
Colonel M’Neil of the 11th Infantry, and Captain Cilley of the
same regiment, and a few privates of other corps.
Col. McNeil was wounded at Bridgewater by a ball which passed
through the thigh, somewhat above the patella, and under the
tendon of the extensor muscles, breaking in its course some por-
tion of the condyles of the os femoris. The contusion was great.
Much inflammation and suppuration followed, but he finally re-
covered with a joint somewhat stiff. He was a man of vigorous,
healthy constitution, and stood more than six feet in height. The
probability is that the synovial cavity was not opened ; he was
attended by another surgeon.
Captain Cilley had his thigh comminuted near the middle by
a ball; his attending Surgeon, Dr. Trowbridge,* made four in-
cisions into the thigh, so as to afford room for the discharge of
the fragments ; they were passed out in a few weeks of inflam-
mation and suppuration, which extended but little beyond the im-
mediate region of injury. A rapid recovery with a useful leg
followed, though the length of the latter was reduced three
inches.
^Boston Med. and Surg. Jour. 1838, p. 341.
In the cases of recovery which came under my observation, the
thigh bone was broken somewhere in its lower half; this fact cor-
responds with the testimony of those surgeons who have had the
greatest experience in gun shot wounds.f A short time after a
gun shot fracture of a large bone, the limb became highly in-
flamed, and swollen to twice its natural size ; sinuses, which
opened into the wound, were the almost invariable consequences
of this inflammation ; after they had existed for a time, the pa-
tient’s health was destroyed ; he became afflicted with diarrhoea
and hectic fever, which were very frequently fatal.
j’See Thomson’s Reports of Military Observations in Belgium.
4. During the heat of the summer our large amputations were
very unsuccessful, so much so, as almost to discourage us from per-
forming them ; many of the recent stumps mortified ; in others that
did not, the patient gradually sank into the arms of death. In
the latter, I observed that there was great retraction of the mus-
cles, and frequently the periosteum separated from the bone, for
a considerable distance up. Mortification of the extremi-
ties from gun-shot wounds, was very common at' this period;
a variety of tonic and other means were adopted to arrest its
progress, and amongst the latter amputation ; | nothing succeeded.
Jbee Larrey, (Memoirs of Military Surgery,) who recommends this practice.
5. Wounds attended with much discharge were frequently
infested with maggots, the ova of which were deposited by flies
(Musca carnaria) in the bed-clothes and dressings. This accident
will probably be attributed to negligence, but the most diligent
attention from nurses could not prevent it. It was a most serious
evil, and frequently involved the life of the patient from the ir-
ritation produced.*
*An analogous fact is quoted from Alanson, by J. Bell.
It was marvellous to see how deeply these animalcules would
work their way into wounds, producing, in some instances, as com-
plete a dissection of the muscles, as if it had been performed by
the knife. I learned on this occasion from a common soldier
that the expressed juice of the Elder Bark, (Sambucus nigra,)
sprinkled on the dressings and bed of the patient, would keep the
flies away; and on trial I found it to be so. The suggestion was
made in the case of a gallant artilleryman from Virginia, John
Horton, in Captain Ritchie’s company, and who had suffered the
loss of both legs from a cannon shot, followed by amputation.
The interest felt in him induced me to place a special nurse to
prevent the approach of flies. lie was saved from the latter
accident, but died in a few days, from his wounds.
6.	I saw a few cases of wounds, through the large joints. They
were more painful than any other wounds, the patient suffering
excruciating torture for several weeks. Somehealed by anchylo-
sis, but we most frequently had in the end to amputate, or to
lose the patient, in consequence of sinuses and hectic fever.
Sometimes a low delirium took place, particularly in gun-shot
wounds of the knee joint, in which the patient diedin a few days
after the injury. Wounds through the ankle joint were not at-
tended with so much danger.
7.	Gun shot wrounds of the brain were in some instances very
slow in being fatal. John Price, a private of the 1st regiment of
Infantry, was wounded at Bridgewater, on the 25th of July 1814;
the ball penetrated, transversely, the forehead, passed through
the brain above the ventricles, and fractured the opposite part of
the cranium; he died on the 2d of September following, five weeks
after the injury. Several other examples occurred, in which the
substance of the brain was wounded by balls and by tomahawks,
when the patients continued to live for many days ; but I saw no
instance of final recovery from such accident.
8. Several persons recovered who were shot through the throat,
in such a manner as to endanger the carotid arteries and the im-
portant nerves. Amongst them were Brigadier, afterwards Major
General Ripley,* and Lieutenant, afterwards Major MTntcsh,f
of the Rifle Corps. Both these officers lost the use of their up-
per extremities for a long time, and suffered exquisite pain in
them. The latter discharged the ball, per anum, several months
after he had been wounded.
*Case reported in the New York Medico-Chirurgical Journal, by his at-
tending Surgeon, Dr. Allen.
j-Case reported in the Eclectic Repertory, by Dr. W. II. Ilenning, of the
Rifle Corps. Lieutenant M’lntosh was at different times under the care
of us both. He lived for many years afterwards and was with distinction
engaged, I believe, in both the Indian war in Florida, and in the late Mexi-
can War.
9. Several recoveries from wounds through the thorax took
place. Amongst them were Lieutenant Colonel Trimble, after-
wards in the United States Senate from Ohio ; and an Ensign of
the 19th infantry. Bleeding to a very great extent, was used in
all these cases. Lieut. Col. Trimble received a ball near the
junction of the fifth costal cartilage with the sternum ; the ball
penetrated the lung and emerged from the back near the angle
of the fifth rib. The hemorrhage from the lung by the mouth
was most copious, and at each expiration blood poured freely from
the external wounds, which of course implied a large collection
of it in the pleura. Dyspnoea, feeble pulse, and cold extremities,
left him apparently but little chance of life, but on the fifth day
the symptoms mitigated. He was bled in the subsequent twenty-
two days, six times by his attending surgeon, Dr. Amos Trow-
bridge, J and finally recovered. While a member of the Senate of
the United States, he died at Washington in 1822, from a pulmo-
nary affection, brought on by exposure in the preceding season.
tFor details, see Bost. Med. and Surg. .Jour, for 1838, p. 344.
10. Wounds of the'abdomen, and its contents, were, in several
instances, recovered from ; amongst such were Lieutenant Cisna,
of the 19th infantry, and a Sergeant White. In the first, the ball
entered in the anterior part of his belly, below the navel, and
came out near the spine ; about six weeks afterwards a button
was discharged from the wound, near the spine, which had been
carried in along with the ball.
Sergeant White’s belly was penetrated by a ball, which also
took in some fragments off the breech of his musket. The frag-
ments were afterwards discharged at the orifice of the wound,
during a free suppuration of it.
11.	A case terminated happily where the ball had entered
above the symphysis pubis, and came out posteriorly ; the fundus
of the bladder was penetrated; for several weeks there was a
constant dripping of urine from the anterior wound; it at
length ceased to flow in this direction, and came in the na-
tural way.
12.	In four cases of wounds of the spine, they all had pretty
much the same symptoms; being attended with loss of sensi-
bility and motion in all the parts below the injury.
For the first few days the patients were unconscious of
their danger, the strength and activity of the upper extremities
and parts of the body; and the quickness of intellectual opera-
tions, being very encouraging. It was necessary to introduce the
catheter twice a day, or more often, in these cases ; and to expel
the contents of the bladder by pressing above the symphysis
pubis. Purgatives were also necessary. In all these cases mor-
tification took place on the sacrum, in consequence of pressure.
A great irritability of the stomach occurred in each, a few days
before death.
So far as I remember, in those and other similar cases,
hiccup has always attended, and also delirium, before the final
scene.
13.	In amputations of the leg, to get the flap from the integu-
ments, on its posterior part, was decidedly advantageous, in some
respects, regarding the healing of the stump. If, instead of this,
a circular flap was made, the part of it covering the sharp edge
of the tibia was most generally ulcerated through, and the ulcer
remained exceedingly painful and absolutely incurable, till the
absorbents rounded off the tibia. This disadvantage was very
striking with the circular flap adjusted transversely instead of
vertically, i. e. antero-posteriorly. The flap extending from be-
hind is, however, apt to separate, or rather not to attach itself
to the muscles; and, in such case, when suppuration came on,
it retained ihe matter, and sometimes ulcerated through. My sub-
sequent experience has led me now to prefer the circular cut
with the vertical adjustment, and a bevel cut upon the spine of
the tibia saves the absorbents a long work in rounding it off.
I saw an attempt to make a flap of the gastrocnemius and
solaeus muscles, on the principle recommended by Mr. Hey and
others. It succeeded badly, the flap became very much inflamed
and swollen, left entirely the surface of the ^stump, and could
not be brought back; it gave the limb the appearance of a club.
After a variety of means was fruitlessly tried to bring about
cicatrization, a second amputation became necessary in order to
save the patient’s life.
A similar attempt on my own part since, in the Philadelphia
Alms-House hospital, though not attended with such bad conse-
quences, was very unsatisfactory, from the difficulty in making
the flap unite.
Two amputations of the inferior extremities, a thigh and a leg,
were performed by an inexpert surgeon, in which no flap was left;
the patients recovered, however, after a very long confinement.
The stumps became conical from the retraction of the muscles,
and a second sawing of the bones was requisite to the cure.
Two amputations at a delayed period, that is when inflammation
had set in, were performed. The suffering of the patients was
much beyond the ordinary agony. The quickly fatal results
proved the necessity of attending well to the rule, that such ope-
rations are never to be performed for severe projectile wounds,
except in a few hours after their reception; or after several weeks
have elapsed, and the symptons of inflammation are entirely gone.
[.Soldiers are much disposed to repress the expression of pain, con-
sidering it unmanly. When this natural mode of easing the circu-
lation of the lungs by groans and expiration was withheld, which
can only be done by holding the breath, I came to the conclusion
that it was highly disadvantageous to the individual. Chewring a
bullet is a resort which should also be discountenanced. The
introduction of ether since that period, will now make these
cautions less necessary. The amount of pain excited in different
persons varies very much. I assisted at an amputation of the leg
of a soldier who was smoking tranquilly during the whole ope-
ration, his ease not seeming to be an affectation.
I did not see a.case of recovery where amputation had been
performed on both legs, or on both thighs, in one subject; but I
saw a few recoveries where a leg and an arm, or two arms had
been resected. Several double accidents of this kind happened
during the seige of Fort Erie. In one instance, a cannon ball
entered a hospital, and ranged along the feet of a row of bed-
steads, carrying away several legs in its course. kIn another in-
stance, a young rifleman, of eighteen, belonging to Captain Ir-
vine’s company, had both arms taken off above the elbow joint,
by a cannon shot. The ball being nearly spent, he then started in
pursuit of it, not appalled by what had happened, but continuing
to kick it as an enemy until its motion gradually subsided. Ilis
gallantry and coolness on this occasion, procured him the notice
of several distinguished officers. I saw one case of recovery from
amputation at the shoulder joint. This operation was performed
by Dr. Gales, of the 23d infantry, whose services and intrepidity
gained a high distinction.
14.	Some cures, from extensively lacerated wounds, took place ;
amongst them, J. King, a private in Captain Biddle’s company
of artillery. lie had the whole posterior part of his thigh, from
the buttock to the ham, torn up by the fragment of a shell, and
the muscles laid bare, as in a dissection. This extensive wound,
in which there was a great loss of integuments, cicatrized, and
got nearly well in three or four months. A private in the In-
fantry already alluded to, was scalped in a circular line, just
above the tips of his ears. Granulations arose from the exposed
surface of bone and pericranium, in a few days, and cicatrized
very kindly; the discharge of pus was, for a long time, very
considerable.
15.	In one case I succeeded in a very rapid cure of fistula, in
the lower extremity, produced by fracture in the lower part of
the tibia. An intense and extensive inflammation of the whole
limb followed the injury; this was succeeded by the deposition
of matter all up the leg, and extending even above the knee.
When the suppuration was pretty well established, by pressing
carefully the matter from the sinuses for two or three days, so
as to empty them completely, I succeeded in obtaining a radi-
cal cure, by placing compresses on the course of the sinuses, and
securing them by a tight roller applied from the foot to the groin.
The fracture did very well.
This manner of treating inflammation of the extremities, has
since been very fully elucidated by the celebrated French Surgeon,
Velpeau, in his writings upon the principle of what he calls sys-
tematic compresses.	9
16.	I treated two cases of traumatic tetanus; the one was pro-
duced by a gun-shot wound through the pectoralis major muscle ;
the other by the same kind of wound through the sole of the
foot. The first was managed with large quantities of laudanum ;
the patient died. The second was treated with laudanum also ;
and according to the plan proposed and adopted by Larrey, the
surface of the wound was cauterized with a red-hot iron. A
temporary remission was produced in the spasm, but it returned,
and the patient died the day after the application.
Such were the general observations resulting from the surgi-
cal occurrences which came under my personal notice.
As in most active campaigns, the duties of the surgeon were
too urgent to allow time for the taking of very complete notes
on cases. Hence, general recollections have to be substituted, to
a large extent, instead of precise tabular statements. At this pe-
riod of time, when the^actors of that day have so generally passed
off the stage, it is a matter of sincere regret to me that so little
has been published by others ; and from recent enquiries at the
War Department, it appears that no reports are there to
supply this deplorable defect. It is to be hoped that the few
medical survivors of this remarkable campaign may yet be stimu-
lated to give in their full experience by publications, or at any
rate make a deposit of it in manuscript at the Medical Bureau
of the Army. How precious would such details of the American
Revolution be ; yet there are few or none.
The following account of the diseases and weather will pro-
bably be read with interest:
* Report of Hospital Surgeon Lovell, of the state of diseases among the
Troops on the Niagara Frontier, during the Campaign of 1814.
♦ From Medical Sketches of the Campaignsof 1812, ’13, 14, by Jas. Maun,
M. D, Hospital Surgeon, &c. Pp. 160 et seq. Dedham, 1816.
“The troops engaged in this brilliant campaign on the Niagara, began
to collect there about the beginning of April, under the command of
General Scott. They were encamped on an eminence north of Buffalo
village, having a thick wood in front, which extended to the bank of the
river, the ground being in part swampy and wet. On the left of the
encampment was a large marsh, extending from the high ground to the
margin of the lake. The winds from the lake, at this season, were
remarkably cold and chilling; resembling, in sensation, exactly the
east winds which prevail on the Atlantic during the spring; and had an
astonishing effect upon vegetation. The trees around the encampment
having the appearance of winter, while those five or six miles from the
lake shore, were covered with verdure. Notwithstanding this, the troops
were remarkably healthy; only one or two deaths occurring before they
crossed the Niagara, on the 3d of July—even the demon diarrhoea
appeared to have been exorcised by the mystical power of strict disci-
pline and rigid police.
In June a number of new recruits joined the army; and several were
collected from the various hospitals ; the latter principally composed of
the miserable refuse of society, who never had energy enough to demon-
strate that they lived, and scarcely enough to prove that they existed.
With these last detachments, arrived our old acquaintances, which, how-
ever, were easily checked; and much seldomer returned, than in any
former campaign. This was undoubtedly to be attributed to the improve-
ment in police.
During June, the weather became very warm, and a thick fog arose
from the marsh and woods at sunset, and remained for some time after
sunrise. During this month, intermittent fever, acute rheumatism, and
typhus fever were the prevailing complaints. The intermittents were
very irregular and obstinate. Arsenic, -which was the sovereign remedy
the last year, on this frontier, had now very little effect; while the bark,
which then failed, was now generally successful. Some obstinate cases,
in which every thing else had failed, were cured by the sulphate of copper.
Three patients, who had tried most of the remedies with which we were
supplied, without effect, cured themselves at once, by taking a pint of
brandy undiluted, in which was mixed a large quantity of ground black
pepper, on the accession of the cold stage. This was not followed by
inebriation nor any appearance of undue excitement. It led me to use
opium in much larger quantities than I had been accustomed. It was
begun with four or five grains at a dose, and increased until some stimu-
lating effects were produced, or the disease cured. The success of this
prescription was very great during the whole season. In fine, of the
remedies used this season, emetics had but little effect, even at first;
aud the mineral solution scarcely any—bark succeeded in the majority
of cases; and opium very seldom failed. A few obstinate cases were
checked for several periods, by the application of tourniquets to one leg
and one arm ; the disease however recurred; the tourniquets then had
no effect; but remedies, which had before failed, now succeeded, after
the interruption thus produced in the morbid associations.
Rheumatism, during the whole war, generally put on a remitting
form; this was particularly obvious whenever intermittent fever pre-
vailed, and more especially this season. Bleeding was but seldom
necessary; after a brisk cathartic, bark was given in the quantity of
from four to eight drachms during the remission, and a large dose of
opium on the accession of the fever; and always in sufficient quantity to
relieve the pain. This treatment was very generally successful. I was
induced to try it, in many cases, where the remissions were very slight,
and generally effected a cure. In these, however, bleeding or purging
were premised, which produced more perfect remissions. In short, I
considered the bark and opium the remedies for rheumatism, particu-
larly when intermittents prevailed, and for the most part succeeded.
Many of the cases of typhus, about the end of May, were remarkably
severe. The most prominent symptoms were great prostration of strength,
and delirium; of the species not attended with symptoms of great arte-
rial action in the head, local applications as usual having no effect upon
it. Symptoms of recovery were not observed in these cases, until the
end of the third week. The treatment adopted was strictly that of For-
dyce, and recovery took place in every instance.
On the first of August, a general hospital was established at Williams-
ville, eleven miles east from Buffalo. The number of sick, during the
remainder of the season, at this place, varied from 3 to 400; the num-
ber of wounded being somewhat greater.
The troops suffered much during the seige of Fort Erie; and soon
after it was raised, the rainy season commenced. Dysentery and diar-
rhoea were the principal diseases. I became fully convinced, after a
fair trial of every medicine to be obtained at this place, of the decided
advantage of ipecacuanha in various forms and doses, to any other
remedy. The remarkable effects of this medicine, which Fordyce con-
siders as acting specifically in typhus fever, led to the conclusion, that
the febrile symptoms attending the latter stages of diarrhoea were in
fact a true typhus, supervening upon the former complaint. Hasty in
his treatise on dysentery, he speaks of several complaints, which are
often combined with typhus fever ; and are then generally contagious ;
and I had observed that the nurses of the wards, where diarrhoea pre-
vailed, were often attacked with typhus, accompanied with diarrhoea, ora
great tendency to it. Decided benefit had often been observed from
small doses of ipecacuanha, with mucilaginous drinks, in an irritable
state of the stomach and bowels, which appeared to be owing to a degree
of inflammation extending through the mucous coats; and not attended
with febrile symptoms; and it is probable that the good effects of the
remedy, in the cases now referred to, were in some measure to be attri-
buted to this mode of operation. Intermittent fevers and rheumatism
prevailed during the whole season, and varied but little from the cases in
May and June. The cases of typhus among the regular troops were
generally mild.
About the end of September, a large detachment of militia crossed
the Niagara, under G-encral P. B. Porter. Diarrhoea, typhus and idio-
pathic dysentery very soon made their appearance among them; the
two latter were extremely severe. As these patients were not sent to
the general hospital, until they had been sick for some time, I saw only
the latter stages of these complaints. The dysentery was at this period
very obstinate; the bloody discharges and tenesmus incessant, and the
prostration of strength as usual most dangerous. In this state, relief
was very generally obtained from injections of a decoction of ipecacu-
anha, sometimes combined with laudanum; at others, the irritability
was first reduced by an injection of laudanum alone. The decoction
was often rejected immediately; it had, however, some effect even then,
so that by repeating it several times, it would finally remain, and give
relief. Blisters to the abdomen often had a very good effect; but no
application to the part appeared generally to prove so beneficial, as a
poultice of slippery-elm bark to the whole abdomen, often repeated. It
relieved the tenesmus, and produced a gentle diaphoresis, which was
promoted by warm mucilaginous drinks, a mixture of tinct. opii. and
tinct. ipecac. This was the only treatment found beneficial in the latter
stages of this complaint, and it very generally succeeded. Typhus,
among the militia, was very severe. Patients were seldom sent to the
general hospital, until the third week of the fever; and the treatment
had been different, as the whims of the attending surgeons. The most
usual practice, however, among them, was to blister the patient almost
from the crown of his head to the soles of his feet; so that the chief
difficulty was to remove the irritative fever induced by this empirical,
slovenly practice. In some, calomel had been employed, but generally
without any obvious effect, except increasing the danger of the patient.
At this stage of the complaint, and under these circumstances, no gene-
ral method of treatment could be adopted, except remedying the mischief
which had been done. The cure was principally attempted by remov-
ing every cause of irritation, as appeared most urgent, and trusting to
nursing and nourishment. Under this plan many appeared to be in a
fair way of recovery; but in the course of the fourth week, a small cir-
cumscribed spot of inflammation showed itself in the face, generally,
near the angle of the mouth. In a few days the whole side of the face
swelled; this tumor was hard and pale, resembling the color of a white
swelling of the joints. It was not in the seat of the parotid gland, but
anterior to the branch of the lower jaw, and was attended with a most
profuse and fetid salivation, apparently from irritation communicated
along the salivary duct, as the liver and gall-bladder are excited by the
chyme. In a few days more the red spot began to assume a livid
appearance, and symptoms of incipient mortification. In a short time,
the mouth was literally extended from ear to ear, exposing the backmost
grinders on both sides. All the remedies usually employed in this spe-
cies of disease, were employed without visible benefit. The only article
which appeared to produce any good effect was charcoal, which, how-
ever, seemed only to prolong the sufferings of the patients. Three
attacked with this affection had severally so far recovered as to have a
good appetite, and sit up a great part of the day. Their strength and
appetite held out surprisingly, after mortification had taken place. I
have since seen two instances among citizens; one in Boston, on a young
boy. He had so far recovered as to sit up; he took nourishment with a
good appetite, and every symptom of fever had disappeared ; when, about
the middle of the fourth week, the swelling, salivation and mortification
took place, and shortly he sunk. It should be added, that in the majority
of these cases not a particle of mercury had been usedin any form.”*
♦The same disease was observed by Surgeon Purcell in the Military Hos-
pital, Burlington, Vt., in the autumn of 1814. See Mann, loc. cit.. p. 164.
Several interesting cases of wounds occurred in our hospital
after the battle of Chippewa; many operations were performed
by the regimental surgeons on the field of battle, but a majority
of them were left for the hospital staff. I shall relate a few
cases, with the success attending their treatment.
Case 1.—A private in the 11th regiment of infantry, received. I
a wound from a grape shot m the right breast, between the nip-
ple and sternum7~lbe ball passed un dcELt Heister num, obliquely
downwards, and emerged about four inches from the sternum on
the left side, beneath the edge of the pectoralis major. The
first time I saw this patient was on the third day after the recep-
tion of the injury; he said he had bled a great deal, and his
^clothes still showed the marks of considerable hemorrhage. I
presumed that the internal mammary artery was cut or rup-
tured ; however, as the wound had ceased to bleed before I
saw him, the condition of the artery did not excite much at-
tention.	/
The patient’s pulse was feeble and quick, and he complained
of great stiffness in his breast; his breathing was regular but
hurried ; I prescribed a light diet for him, and applied the common
adhesive plaster to his wound on each side. I was much struck
•with the circumstances of this case, for the ball had passed be-
tween the sternum and mediastinum without producing a solution
of continuity in either, which, had it injured the latter, would
have been known by the state of respiration. I went to visit
him on the fourth day, having obtained the advice and assistance
of Dr. Thomas, hospital surgeon. The patient’s pulse had become
full, he had a slight cough, and complained of wandering pains in
his breast, superadded to those occasioned by the wound. The de-
pleting plan was here evidently indicated. I bled him to the amount
of sixteen ounces, and dressed the wound as usual; in the after-
noon I bled him again, as the symptoms had not been mitigated.
By bleeding four or five times more, once a day, or on alternate
days, the inflammatory symptoms were thoroughly subdued,
and he no longer complained of his breast, except in the wounded
part.
About the tenth or twelfth day the suppuration was so profuse
as to require three or four dressings in the twenty-four hours.
Ilis appetite finally returned, and his excretions were regularly
performed; he was, however, from being a robust man, much
reduced. As the suppuration diminished, the granulations sprung
up; in about fifty days the cicatrix was completed, and his
health, in a considerable degree, restored.
Case 2—Sergeant Smith, of the 11th infantry, was wounded
the 5th of July, in the breast, by a musket ball. The ball en-
tered on the left side, between the sixth and seventh ribs, and
came out near the spine on the same side. I saw him on the
third day after the injury. He then labored under oppression
of breathing, and his muscular strength was much prostrated. The
sides of the wound were tumefied and inflamed ; I, therefore,
could not make a satisfactory examination of the direction of
the ball. I supposed, however, from his anxious and hurried
breathing, that the lungs were wounded. I bled him to the
amount of a pint, and dressed his wounds with yellow basilicon.
On the fourth day I bled him again ; this bleeding seemed to
relieve him much. I enjoined on him the strictest antiphlogis-
tic diet that the nature of our hospital stores admitted of.
By some new arrangement in the wards of the hospital, he
was left out of my list, and transferred to my assistant, Dr.
Coltrin ; I therefore did not see him again for eight or ten days.
At that time the wounds in his side were discharging matter
very profusely, and a few granulations had risen up.
Air was inhaled and exhaled through the wound in the fore
part of his breast, but not through the posterior wound. He
believed himself to have been struck by two balls at the same
time ; if this be the fact, it will account sufficiently for the air
rushing only through the anterior wound. About the last of
August I saw him again; he was then emaciated almost to a
skeleton, and had a harassing cough, with purulent expectoration,
which threatened to terminate his existence in a few days. He
continued in this unpromising way for several weeks longer; the
wound in the fore part of the chest healed up, but that in the
back continued running. Ilis wounds, during this period, had
been dressed with yellow basilicon or cerate, and his cough pal-
liated by demulcents. The cough left him about the first of
November, but his extreme emaciation and weakness continued
From this time he began to recruit a little, and in fair weather
sometimes ventured out of his apartment. We now entertained
hopes of his recovery. About the first of December, the wound
in his back discharged but little, and was nearly healed. lie
was suddenly seized with lancinating pains near the wound, and
spasms of the intercostal muscles and diaphragm, which some-
times suspended his respiration for a minute or more. Our hopes
now vanished, and the attendants were frequently in the act of
laying him out for dead.
Dr. Coltrin and myself visited him in concert. On examining
the wound in his back, I perceived an obscure fluctuation near
t. Having made an incision with my lancet, a few spoonfuls of
healthy pus were discharged, and relief obtained for the time.
He was ordered to take twenty drops of tinct. thebaic, at night.
The next day, a small spiculum of bone was taken out. The
spasm and pain now left him, and he recruited again. The
wound in his back healed in about ten days, and he had a second
return of this affection, as alarming as the first; a similar treat-
ment was.pursued, which relieved him. On the 24th of Decem-
ber, he was sent to the general hospital, at Williamsville, in a
convalescent state, having had no subsequent return of his
paroxysm, and bidding fair to recover entirely.
Case 3.—A private, in the 9th infantry, had his radius
broken about the middle, by a musket ball, which passed ob-
liquely through the arm. He was admitted into the general hos-
pital on the third day after the accident. The arm was then
slightly tumefied and painful; only a common dressing,with splints,
was applied to it. Between this time and the twenty-fifth day,
frequent hemorrhages had occurred, which were commonly sup-
pressed by a compress of square pieces of muslin, confined with
a roller. The arm had become greatly tumefied, probably to three
times its natural size, and a copious suppuration had followed,
which relieved the inflammation and pain, but the patient’s
health was much impaired by diarrhoea and hectic symptoms.
Opium and bark having been tried in vain, to arrest the latter,
it wras determined, on the thirty-fifth day after the accident, to
take off his arm. I amputated it just below the insertion of the
deltoid muscle. On the fourth day afterwards, I undressed it,
and was much chagrined at finding that the adhesions of the flap
to the muscles had been prevented by a number of maggots find-
ing their way through the dressing into the stump, notwithstand-
ing every precaution had been taken to prevent such an occur-
rence. I cleared them out by injecting warm water and spirits
of turpentine. On the fifth day, a new brood had come in, and in-
sinuated themselves into the interstices of the muscles, producing
considerable pain and irritation. The muscles had retracted, and
left the bone jutting out about an inch, completely denuded of its
periosteum. A very slight suppuration occurred. The patient’s
health became worse; for, besides an aggravation of the afore-
mentioned symptoms, a comatose condition was present. I
sawed off the protuberant extremity of the bone, cleaned the
wound with warm water, and ordered the tonic and stimulating
treatment to be strictly pursued. Nothing seemed to relieve
him, and on the tenth day after the operation, and the forty-
fifth from the reception of the injury, he died.*
* This case is inserted in order to show the effects of local irritation on a
stump.
Case 4____John McGulrick, aged 45, of a dark complexion,
and full habit, a private in 100th British regiment, 4th company,
was wounded and taken prisoner at Chippewa, on the 5th of
July, 1814. On the 7th of the same month, he was brought to
the general hospital at Buffalo, with the rest of the wounded of
the two armies. On examination by the superintending surgeon,
the thigh was discovered to be fractured by a musket ball, about
six inches above the knee joint. The limb wras much swelled,
and extremely painful from the bandage applied in the first
dressing being stiffened with blood, and too closely rolled. He
was ordered to live on light food, have the limb frequently
moistened with lead water, and secured with a bandage and
splints. A dressing of cerat. simp, was used.
In consequence of the great number of wounded, the surgeons
and mates of the general hospital were unable to attend to all
the patients, and it became necessary to employ some of the
neighboring practitioners. It fell to the lot of this man to be
placed under the hands of one of them, and I did not see him
a^ain till about the middle of October; I am, therefore, unable
to say what treatment was pursued in the interim ; from circum-
stances, however, I am induced to believe it was not of the most
judicious kind. About this period, the services of the aforesaid
practitioner being no longer wanted, he was discharged, and the
soldier placed under the care of my assistant, Dr. Coltrin. On
visiting the patient, he was struck with the peculiarity and pre-
cariousness of his situation, and was sensible that the preceding
surgeon had not done his duty. The case presented such diffi-
culty that he requested assistance.
Oct. 16th. We visited the patient in concert, and found the
following symptoms : lie was reduced almost to a skeleton, there
being little else but skin and cellular substance on his bones;
his pulse quick and feeble; a wasting diarrhoea had been on him
for several weeks; he was subject to profuse sweats at night,
and had no appetite. To these general symptoms was added a
most unfortunate condition of the broken limb. The thigh was
shortened about four inches, in consequence of the extremities
of the broken bone being allowed to pass each other; the
orifices, where the ball had entered and made its exit, were still
open, and discharged daily a large quantity of thin semi-trans-
parent pus ; a fistula was found running nearly up to the tro-
chanter minor, and a large ulcer had formed on the sacrum from
continued lying in one position.
Weighing all these circumstances, we were not slow in pro-
nouncing an approaching dissolution: had our opinion been
otherwise, we should have determined immediately on amputa-
tion. There seemed so little chance for the patient’s life, that
nothing else could be done but to pursue vigorously the tonic
plan; this we did, more from a sense of duty than from hopes
of success. He was ordered to take Peruv. bark four or five
times a day, and also a pint of port wine.
JI. Kino. gr. xv. To be taken three times a-day.
It was too late to think of restoring the limb by extension and
counter-extension, as an adhesion had taken place between the
bones, and an artificial joint had formed. We, therefore, only
directed the limb to be dressed with basilicon twice a-day, the
matter to be carefully pressed out of the sinus, and a spiral
roller, with a compress on the fistula, to be applied from the
foot to the groin. The ulcer on the back was dressed also with
basilicon.
This treatment was persevered in, with the addition of bitters,
till the 1st of November, and with no amendment on the part of
the patient; we, however, were pleased, and thought him for-
tunate in not dying.
The patient adhering to life with such tenacity, made us agitate
the propriety of amputation, and we almost made up our minds
for it, but as he was in the same precarious situation, it was thought
advisable to wait a few days longer, as they would probably de-
termine his fate, or produce an amendment.
Nov. 5th. The same treatment continued to this date ; the pa-
tient no better, diarrhoea and hectic symptoms rather more urgent.
As a dernier resort, we this day determined on amputation ; every-
thing was prepared, and the knife placed in the hands of Dr.
-----, hospital surgeon, who, not belonging to the hospital, as a
mark of attention, had been invited to perform the operation. He
was dissuaded from it by Dr.--------, of the------- infantry, also a
visitor, who, forming his opinion from the present condition of the
patient, without taking into consideration the preceding circum-
stances, denounced the operation as fatal to the patient, and in-
volving the reputation of the surgeon; advising us, at the same
time, to pursue the tonic treatment. But a full trial of that had
been already made. I was myself inclined to believe, that the
opeiation might probably be fatal immediately, or in a few hours
afterwards : but as I considered it the only possible means of relief,
and had maturely reflected on the advantages and disadvantages
likely to result, it was with reluctance that I submitted to the
opinions of the consulting surgeon for the present.
Dr. Coltrin and myself having both acquired confidence from
seeing the happiest issue from amputations, under circumstances
similar, but not so aggravated, determined, let the event be what
it might, on performing the operation by ourselves, without con-
sulting or letting it be known to any other surgeons; we accord-
ingly proceeded to the operation on the
10th Nov. At this time the patient’s strength was completely
prostrated, the diarrhoea and hectic fever still continuing in all their
force ; the sores on the back and thighs were no better. The
limb was amputated about two inches.below the trochanter minor;
the patient lost but little arterial blood, and bore the operation be-
yond our expectations. He was put to bed and ordered T. Opii,
gtt. xl.
Nov. 11th. The patient somewhat better, rested tolerably well
last night, less troubled with the diarrhoea.
R. Pulv. Cort. Peruv. coch. min., still to be taken four times a
day, and Elix. Vitriol, gtt. xv., to be added to each dose. A pint
of port wine a day continued. Allowed to eat anything he fancied,
which could be procured.
Nov. 12th. Rather better, medicine continued.
Nov. 13th, The symptoms considerably ameliorated, appetite
excited, had but one stool yesterday, and one last night, nocturnal
sweats less profuse, rested well, medicine continued.
Nov. 14th. Mending perceptibly ; the first dressing was removed
from the stump; it had partially united by the first intention, and
was beginning to suppurate finely. The ulcer on the sacrum throwing
out healthy granulations, and diminishing in size.
Nov. 20th. The patient much in the same state as on the 14th,
except that the powers of life were so feeble in the sound limb,
that a dry gangrene came on the big toe, and the two adjacent
toes, being probably induced by the cold state of the atmosphere.
The extremity was cold and without perceptible pulsation, from
the toes to the knee. The nurse was ordered to wash it twice a
day with hot brandy, and apply a flannel roller from the toes to
the groin ; medicine continued.
Dec. 1st. The patient’s health and strength considerably im-
proved, appetite good. The dry gangrene still continued on the
toes, without any effort of nature to separate the mortified parts ;
the heat of the limb was restored after a few applications of the
hot brandy ; pulsation perceptible in the anterior tibial artery. The
stump and ulcer doing well, the latter nearly healed. We now
considered the patient almost out of danger, a Prescription of the
11th November continued.
Dec. 20th. The patient completely exempt from apparent danger,
and convalescing rapidly. He had picked up a little flesh, his ap-
petite good, diarrhoea and hectic symptoms entirely gone; but one
or two stools in the twenty-four hours; the ulcer on the sacrum
healed, and the stump nearly so. Bark, Elix. Vitr. and wine con-
tinued.
Dec. 23d. The general hospital being broken up at Buffalo, this
patient was sent, with others, to Williamsville, eleven miles off;
no question of his recovery was then entertained, and the only
unfavourable circumstance was the gangrene on his toes, which
still continued, nature showing an indisposition to separate the
living from the dead parts. He arrived at his journey’s end with-
out accident. The final conclusion of this case I have to be in-
formed of, as I left the frontier the following day.*
* The amputated part of the os femoris is now in the Wistar Museum,
and presents a striking example of the effort at union by callus thrown
out laterally.
Gun-shot wounds having got their name originally from a super-
stition connected with them, 'that is of their being poisoned or
placed under some pecu'iar influence from the material projecting
the ball, they have been considered as forming a class to them-
selves, and a special treatment was introduced, now to a great
extent abandoned. If the term itself were laid aside, and we had a
class of wounds called Projectile, surgical phraseology would be im-
proved by accommodating it to the sentiments now generally enter-
tained. The mere instrument of projection in its own nature has no
influence, further than its special force, upon the body projected.
At the present day, when steam is so much employed in navigation
and in machinery; from the frequency of accidents from its explo-
sion, we might, upon the principle of the nomenclature adopted,
have a class of steam-shot wounds, and formerly there could have
been one of balister-shot wounds. It is probably the more re-
quisite to have a reformed nomenclature in the present day, be-
cause [really great modifications have been introduced into the
manner of inflicting wounds. The injury from musket balls for-
merly occupied almost exclusively the mind. Now artillery is so
much used in combat, that its grape and its cannister shot figure
largely. The projection of hollow balls calculated to explode at
certain points, and by their fragments produce destruction, has also
advanced much in use. And lastly, the modes of injury con-
nected with the industrial pursuits of society, (as the disrupture of
machinery, and the tearing and crushing of railroad cars,) stand much
in the category of projectile wounds, though not exactly according
to our pre-conceived idea of them. The whole of the preceding
category belong in their phenomena to wounds resulting from
laceration and contusion blended together. The entire train may
indeed be said to commence with the buckshot used in the Ame-
rican service, and to end in the explosion of the radiating fragments
of a bomb shell, or in the most extreme form of railroad ac-
cidents. The injury from the first is very insignificant, unless it
touch a vital part, as the brain or a large vessel ; while the injury
from the two last, though falling upon parts easily spared from
the system, yet come with such destructive violence, that the
system is unable to rally from it, and hence death is most lamenta-
bly frequent, without our being able to point out any very intelli-
gible cause. We call it, however, a shock to the system.
Tf it were in preceding times difficult to give a formula, which
represented universally the progress of wounds from projectiles,
(gun-shot,) and the exact mode of treatment, that difficulty it is seen
by the above is much augmented, at the present day. The enquiry
has therefore to be made conformably, and resolves itself as fol-
lows :
The circumstances of force and resistance, being the same in
both instances, what1 are the phenomena attending the entry and
exit, or lodgement of spherical shot or bodies, connected with the
material forming the latter? What of angular bodies, made so by
design or by explosion ?
How is their passage modified by the various degrees and angles
of resistance ?
What are the most appropriate dressings in each case ?
What are the different constitutional effects?
What are requisitions for amputation, and at what time after the
injury should it be performed ? This is perhaps the most important
and pressing question of modern surgery; from the revolution, 1 say,
which has taken place in the projectiles of modern warfare, and
in the use of transporting and of manufacturing steam machinery. Ils
paramount interest is seen every day. Formerly a stump, either in
arm or in leg, was one of the rarest of sights in our streets, and
was sure to obtain attention from its infrequency; now it is so
common that we do not think of it in passing. A death after an
amputation was formerly scarcely looked for except from the general
condition of the patient at the time; now it is one of frequent occur-
rence. The question, therefore, has been most forcibly elicited,
what are we to do with limbs extensively crushed and lacerated ?
Are they to be cut off before re-action—are they to be cut off upon
re-action—are they to be left as we find them, and to await the sana-
tive process of nature, which will cause to slough off a part whose
life can no longer be retained ? Or are we, in case of restoration being-
hopeless, to make a simple muscular resection of the part, at the poin
which is the most disjointed from the rest, and to leave the resection
of the bone and its squaring off, for a future time ? It is impossible
for any one man to find in his own experience a solution for al
these questions, but a collective attention of the profession from
all quarters of the world, in making a simple report of each case,
would enable us to see whether the existing rule of speedy ampu-
tation is to be observed ; or whether a new state of things, by its
greater frequency of occurrence, may not invite to another ride of
practice, by affording a higher and a more discriminating expe-
lience.
In hopes of eliciting from other quarters their own experience, and
by that means obtaining a total revision of the ground of surgery in
its relation to wounds inflicted by projectiles, I shall now proceed
to present my own observations and conclusions.
In regard to the lighter conditions of projectile wounds, the fol-
lowing phenomena and proceedings may be stated:
When a wound is first inflicted, say by a musket ball, because it
is the most frequent cause of injury, a round hole is made, into
which the surgeon can easily introduce his finger : in twelve or
twenty-four hours an inflammation and tumefaction take place in
the walls, or circumference of the wound, which close it up so com-
pletely, that a small probe cannot be introduced without force, and
without giving a pain to the patient. I mention this latter, because
theoretical writers on the subject talk of introducing their bullet
forceps, and extracting a ball with the same facility as they would
extract a ball from a large auger hole.
I saw at the period in question a pair of bullet forceps, from an
instrument maker, for the army, who, no doubt, acted up to this
idea, nearly as large and long as a pair of small fire tongs, and
which no experienced surgeon would ever think of employing on
the living body. In a vast majority of cases, no instrument larger
than the common dressing forceps could be used in extracting a
ball: they answered every purpose to which instruments of this kind
could be applied. They are long enough, and if any objection to
them can be found, on trial, it will be invariably as to their bulk,
which might, with great advantage, be diminished for this pur-
pose. When I first began to dress gun-shot wounds, and extract
balls, I laid hold of the common bullet forceps, and attempted to
introduce them into the wound, in which I seldom succeeded, for two
reasons; the first was, because it was impossible to do so, without
dilating the wound with a scalpel; and the second, because few
patients will allow the excessive aggravation of pain which their
unwieldly size occasions. After unavailing efforts with them, till
my own patience, and that of the patient, was exhausted, I com-
monly finished the business with the dressing forceps.
If any person will take the trouble to compare a pair of bullet
forceps, of that period, with the bullets used in our service, he will
find that the diameter of the extremity of the forceps is nearly equal
to the diameter of the ball ; so that, admitting it practicable to
insert the forceps into the wound, and to pass them along its chan-
nel till the point reaches the ball, it will then be necessary to stretch
the wound to twice its diameter before the blades of the forceps can
be passed over the ball, and include it in their grasp ; after which
the whole length of the wound is to be stretched in the same man-
ner, in extracting the ball, and that to the very great misery of the
patient. The common dressing forceps are objectionable on this
account, but less so than the others, because their points are tapering
and thin, and, therefore, occupy less room; and as regards firmness
of grasp, it is sufficient to extract a ball out of any soft part in the
human frame.
To return to the progressive condition of wounds: the tumefac-
tion and inflammation, of which I have before spoken, generally
continue, with little variation, till the fourth or fifth day; from that
time a secretion of pus takes place from the walls of the wound,
which continues to increase for several days, and sometimes it be-
comes very profuse. This secretion of pus cleanses the wound, and
terminates the inflammation and tumefaction, commonly about the
tenth or twelfth day. It is at this period that it is practicable to ex-
tract the ball, and pieces of ylothing, which may not have been at-
tended to at the first dressing; the wound has now a gaping orifice,
and the dressing forceps may be introduced. If it be delayed much
after this time, granulations rise up and close the orifice. We can
then only trust to nature for expelling those foreign bodies, and it
is seldom that she does not, sooner or later, bring them to the sur-
face.
Major General Brown presented an instance of the injurious
effects of portions of clothing remaining in wounds. At Bridgewater
a musket ball entered somewhat in front of the trochanter major and
passed out over the inguinal glands. He suffered for three weeks
from inflammation and suppuration; became better, and leaving the
southern shore of Lake Erie, was accommodated in an armed
schooner off the Fort. He then relapsed, with great irritation and
discharge of matter, which continued until a piece of woollen panta-
loons carried in by the ball, was discharged. The wound then
soon healed, he resumed the immediate command of the troops,
and consummated his military reputation by directing the sortie of
Sept. 19th.
Not an unusual point of discussion, is the comparative size of the
place of entrance and of departure of a ball. It will be impossible
to find a rule on this subject because the proposition is variable.
If a ball pass through a part with a velocity not materially impaired,
the hole for its exit will be the larger from its imperfect support in
being made, but it will be found generally that the point of exit is
a simple laceration, the edges of which come almost or exactly to-
gether. Cases of this kind are met with when the ball is so far
expended in force that it does not penetrate the clothing a second
time, but is caught by it and drops down into the boot or shoe.
The sloughing of wounds is described by many writers in such a
manner as to produce the belief that the parts injured by the ball
are separated from the living parts, and come out, in pretty much
the same way as the lining would from the sleeve of a coat. I
never saw this, or any thing like it; if a sloughing does take place,
it is insensible, and so dissolved in pus, that nothing of it can be
seen. Occasionally parts of the fascia and of the cellular substance
are detached, but there is nothing like muscular flesh.
I should myself be more disposed to describe the process as a
deliquescence of the contused parts, than a regular sloughing.
From the tenth or twelfth day, the secretion of pus gradually di-
minishes, granulations arise quickly, and die cicatrix commences
from the circumference of the wound, contracts and advances to
the centre; when it has nearly closed up, the further progress of
the cicatrix is frequently checked, and it remains stationary for some
time, in consequence of a small button-like fungus, which shoots
up considerably above the surface of the wound. If this fungus is
touched once or twice with lunar caustic,it disappears, and the wound
is completely healed, geneially between the 20th and 30th day. Gun-
shot wounds seldom bleed much at first, or indeed at any period
of their course.
I often had my fears excited by the accounts of secondary hemor-
rhage, proceeding from the sloughing process involving the large
trunks of arteries. It is true, this event does take place some-
times, but I think it one of comparatively rare occurrence.
The discharge from a gun-shot wound is, for several days, of the
most fetid and intolerable kind, and while the deadened flesh is
coming away, this discharge is of a black color, mixed with yellow;
it soils, very much, the dressings, and they cannot be washed clean
without a great amount of labor. Owing to this we could scarcely
keep a bandage in use for more than one dressing. But the ex-
pense of this profusion was very serious, from the scarcity of woven
fabrics and the high price of cotton which had to be transported
inland on wagons from South to North, in consequence of the strict
blockade of the sea-coast. The existence of war precluded the
introduction of supplies from abroad, through our sea-ports.
(To be continued.)