He stated that when hit he wag standing erect, and that the shot came from above and behind and from his left side. He did not fall, and could stand on the leg afterwards. The dressing was removed, the leg washed well, and the finger introduced into the wound, which was a round and gaping hole, half-an-inoh in diameter with inverted and contused edge?, situated two inches vertically above inner condyle of femur and in front of the line of the flexor tendons. No bullet could be felt by the finger passing down wards and outwardsone-anda-half inches towards the popliteal space through the deep fascia, nor by palpating gently with the fingers of the other hand in the popliteal space. Nelaton's probe gently inserted discovered nothing either; there was no wound of exit; neither was there any escape of synovia or any other evidence of injury to the joint. the wound was then syringed out with corrosive sublimate solution 1 in 2000, iodoform dusted in, a drainage tube introduced, and antiseptic gauze and boracic wool applied, and the leg laid on its outer side over a folded blanket. Ou examining the clothes worn no holes were found, and on looking carefully after replacing them in their position, a pouched depression was found in the khaki trowsers over the wound, blood stained on its inner surface, while there was a similar pouch in the inner calico drawers much stained with blood. The patient did very well; the drainage tubewas removed on the 25th; small bits of sloughy tissue came away, and when an advauce took place on the 7th April, he was transferred to the Base with the wound almost healed. In this case the absence of shock pointed to the absence of injury of bone or joint, though very severe injury may be unaccompanied by shock in a native as a subsequently recorded The case shows the importance of case shows. looking at the clothes worn before searching for the bullet. What hiippened here was that the bullet? probably a large one or a siug from a jezail? struek him with a low velocity and forced the tough khaki in before it, falling out subseSURGICAL NOTES FROM THE BLACK MOUNTAIN. By Surgeon F. K.
I.?Gunshot wound
3VIAYNARD, m.b.,
of thigh.?A
i.m.s,
sepoy aged Field Hospital at 6-30 P.M. on 23rd March 1891, having "been shot in the right thigh in action in the His specification of the afternoon. course tally stated that lie was wounded in right thigh above knee, but that the bullet had not been found. A first field dressing of carholised tow and antiseptic gauze had been applied, and when admitted, he had only slight pain and very little shock.
24,
was
admitted
to
the
quently. II.?Perforating gunshot
wound of leg.?A sepoy aged 24, while advancing up the crest of a hill against the enemy in action, received a bullet wound of the right calf, which brought him to the ground. On admission to the Field Hospital a few hours later, and removing the first field dressing whichhadbeenappliedonthefield,and was soaked with bloody discharge, the wound of entry was fouud to be the size of an 8-antia bit, situated one inch above the middle of the leg and one inch behind the inner border of the tibia, witn everted margin, while the wound ot entry was an inch lower down, in the middle line of the leg behind ;
Nov.
1891.]
MAYNARD'S SURGICAL NOTES.
surface distance between the two wounds two The calf was tense, painful, and swollen from extravasation of blood. Bone uninjured. His putties were perforated in six places ; the pieces being clean punched out. Wound syringed out with corrosive sublimate 1 in 2,000 and the same dressing as in Case I applied. As he was in much pain gr. \ of morphia was given hiin hypodermically and he slept fairly well. A few days subsequently he was transferred to the Base, where after somewhat protracted suppuration the wound healed well, and uo interference with the mobility of the limb ensued. III.? Gunshot wound of chest; multiple injuries ; death.?A mule driver, who had been aliot while on convoy duty, was brought in dead on April 9th with the following injuries. Bullet wound through the chest; probably a Snider or Enfield rifle, not a jezail, as the wound of entry was very small. The bullet had entered through the right first intercostal space in front, fracturing a bit off the second rib, and there were two wounds of exit behind over the left shoulder joint; two inches apart, rather larger, but, not much, than the entry, and with everted edges. There were three holes corresponding in his clothes. There was also a sword-cut on middle of inner border of right arm, dividing ulna and all the tissues except a few tendons and leaving the radius intact; such a wound as would have been received if he had tried to shield his head with his upraised arm. The left hand had the 3rd and 4th cut off by a almost fingers sword-cut extending down the metacarpal space nearly to the wrist. He also had two scalp wounds running fore and aft about, five inches long and one inch apart, one of which had opened the skull. When found shortly after the shot was heard, he was sitting in a pool of water just off the road, where it is presumed he went to drink, and was sniped by men waiting for such an opportunity behind the rocks. Apparently he was shot through the chest first, and in trying to defend himself against the attack with tulwars received the other wounds. The bullet wound having only one entry and two exits, rendered it probable that the bullet had split on the bone, or had forced on a piece of bone in front of it, and then the bullet and the new projectile (of bone) slightly diverging had come out in different places. It is difficult to believe that a man with a bullet through his chest? right in the track of the aorta and its large branches, could have had strength to defend himself by raising his arm as he did, and yet, from the circumstances uuder which he was found, there can be no doubt of the fact. IV-?Gunshot wounds with fracture of clavicle and scapula; death.?Late at night, 30th March, a sweeper, aged 25, with others against orders,went
inches.
|
S37
beyond the line of pickets to micturate, find while there the enemy created an alarm, and they ran for shelter. The picket seeing men coming on them in the darkness naturally fired a vollev,and this man with another were hit by their MartiniHenri bullets. F'om the position of the wounds he probably had his head down as he ran, and it should be noted that the.picket fired from the roof of a house and so from higher ground. There was considerable bleeding at the time, and a first field dressing was applied after the wounds had been stuffed with lint to stop it. On arrival at the Field Hospital on 31st, he was much exhausted bv the long journey in the dandi and had to be given essence of mutton and On removing rum before he could be dressed. the dressings which were soaked with blood, the bullet, was found to have struck first on the left cheek close to the angle of the mouth and to have escaped at the :niufle of the lower jaw. The bone was not fractured, though the buccal cavity was opened. Passing on it struck the left clavicle at junction of inner and middle thirds fracturing it, and then smashing through the scapular spine, it made its final exit close to the inferior angle of the scapula. The wounds of entry were small. The exit at the angle of the jaw was larger and ragged, while the exit behind the shoulder was a large gaping chasm l?" across with ragged everted and uudermined edges. The shoulder had fallen forward and was much flattened by the arm with outer end of clavicle and acromion having fallen Tnere was no away from their connections. the of lint on pledgets gently removing bleeding and cotton with which the wounds had been plugged, and after syringing them out with perchloride solution 1 in 2000 and dusting iodoform boracic wool over them, antiseptic gauze and arm and the w?re supported applied, dressings His temperawith a triangular bandage sling. ture was 100? at night, and as he was in pain, a
hypodermic injection of morphia gr. ^ was given and gave him si fairly good night. He was given milk, sago, and essence of mutton as extras. April 1 st.? A thin ichorous discharge from wounds, surface of which looks unhealthy and sloughy. A drainage tube 8" long was passed right through the shoulder wound from top to bottom and wound well syringed out. Temperature at night 100*2?. April 3rd?A piece of woollen jersey and several small fragments of bone were removed to-day from lower shoulder wouud. Temperature at night 101*2?. April ktli.?Transferred to Base, where he died suddenly the same night. No chest symptoms had shown themselves, and there was no evidence that the thorax had been injured. He died apparently of syncope. V.?Gunshot fracture of right femur yinto kneejoint, flesh wound of opposite thigh ; recovery,?
338
This man, :i Chagarzai, fighting against us appaand aged about 21, was shot oirthe 26th March,, and was admitted to Jhe Field ,Hospital on tlie 26th. The bullet, a Martini-Henri, had struck him on the outer side?of right thigh-, about one-half inch above outer condyle of femur and had passed inward, and slightly upwards,.fracturing the thigh bone, emerging at,an opposite point; and then passing on it had inflicted a perforating flesh wound oil'left thigh, the bullet passing through the muscles in front of the bone. The right femur was mashed and had evidently split iuto the knee-joint, which was full of,-fluid. The leg lay everted and helpless, and there was much swelling up the thigh as well as in the joint. The wound of exitrwas not much larger than that of entry, with everted edges, and both wounds of left thigh resembled the entry The bullet had ,passed wound of right thigh. through both thighs with great -velocity. The question of amputation was raised but decided against, wisely as the sequel showed, by the senior officers present. The man did not appear to suffer much; pain, or would not show it, and it was not easy to make out whether lie looked upon our treatment in the light of kindness or punishment. After well washing the thighs with antiseptic solution and dusting iodoform, antiseptic gauze and boracic wood dressings were applied. An extension apparatus was rigged up of strips of plaister running down-both sides of leg from the knee and meeting round a square bit of wood to which a cord was attached for the extension, spiral strips of plaister holding the side strips in position. Then a long Liston's splint was fixed on, the leg and foot being bandaged to it, the fracture being held in position with three rattan splints and a couple of triangular bandages to bind them?a longer splint in front, a shorter behind, and a third on The upper end of the Liston the inner side. was fastened to the body by a roller, and the man's lower extremities raised. His temperature scarcely rose above the normal, and on the 29th he was transferred to the Base in a dandie. Seen at the Base on June 14th, he was found walking about on crutches. The wounds had healed almost by the first intention, and he had never had a bad symptom. There was much oedema of the whole of the leg (right), but very little shortening and mobility was fast returning lie had become more or less in the knee-joint. tamed and much impressed with the kindness of the Sircar, confessing that his own people would only have killed and mutilated a prisoner, never have taken him prisoner and treated him like a son. VI.? Case of typhus; recovery.?A Khaiberi, aged 25, was admitted to the Field Hospital ou March 29th, sent in as a case of measles, of which disease there had been nine cases within the preceding two or-three weeks.
rently,
~
INDIAN MEDICAL GAZETTE.
[Nov.
1891.
On admission the mail presented the heavy " " look seen in 'this disease, drunken | his face was dusky (the rest, of his body unusually fair even for a Khaiberi), conjunCtivie injected and complaining of intense headache. Had insomnia for four nights, and the rash had been out two days. Temperature 104?, much jactitation and some deafness. The rash was a typical mulberry eruption, most marked on chest and abdomen and back, also on arms and legs. No abdominal symptoms; bowels confined ; tongue dry and brown with sordes; spleen not enlarged. He was isolated Delirium marked at night. with his sick attendant and went on in the same condition until the 2nd April (11 th day of disease), when he slept 16 hours'straight off and awoke with a normal temperature which never He evidently was admitted on the rose after. seventh day of the disease, and allowing 12 days for incubation, he must have contracted it in a village near Tilli where some of his regiment had been quartered for a night or two. SurgeonMajor A. MacGregor, I.M.S., had no doubt about the case, and his large experience in the disease both in fever hospitals at home and in the hills out here, left no question as to the correct diagnosis of the case. VII.? Gunshot wound of ankle.?This man, an officer's bearer, was handling his master's loaded revolver when it went oft and shot him in the left ankle on May 15th, at the time he was sitting on the ground with the left leg semi-flexed and turned outwards (not the usual position a native assumes1, and the bullet entered two inches above the point of the inner malleolus and immediately behind its inner border, emerging just over the proximal end of the fifth metacarpal bone. He was seen at once by a surgeon, and as there was considerable hajinorrhage from wound of exit, the opening was enlarged and a small bleeding point tied. The wounds were then dressed with carbolised lint, a tourniquet placed loosely over the femoral artery and the man brought two On admiles in a doolie to the Field Hospital. mission he didnotseem to be suffering from shock; hia temperature was 99*4? and pulse good. Blood had soaked through the dressing and this was The wound of entry was the size and removed. of a 2-anna bit and situated as above desshape cribed. That of exit was larger and more irre-
drowsy,
gular.
Blood was oozing slowly from both wounds. There was considerable swelling about wound of exit, spreading upwards and backwards as far as external malleolus; none about entry. No fragments of bone had been felt at the first examination, and as the bullet had escaped and the leg being bate at the time, no clot possibly being in it, it was not probed. Slight crepitus could be felt on'moving the foot, and from the direction of the wound, some bones must have~been injured, which it would 'be difficult to specify,
Nov.
MAYNARD'S SURGICAL NOTES.
1891.]
and cuboid. The toes quite patient could move the i*uier three. Considering the patient's age, healthy appearance, the. absence of shock, and apparent absence of injury to large vessels, it was decided to try and save the foot, so after washing the foot and wounds well with corrosive sublimate solution (1 in 2000), iodoform was dusted in, two drainage tubes introduced, and dressings of antiseptic gauze and wool applied, the leg being put up in a box splint. Pil. opii grain one was given to relieve pain. 16th May.?Fairly good night; temperature 102.? As it was impossible to dress the foot without removing the splint every time, besides the splint pads getting soaked with discharges, a splint was manufactured from telegraph wire on the principle of "Esmarch'sinterrupted splint for excision of the ankle," and consisting of a legpiece which fits on to the upper surface of the leg from the knee to just above the ankle, a foot piece which fits the sole of the foot and to which the foot is bandaged, the two being connected by a wire arch. The effect of this splint is that all the parts about the ankle are left exposed when it is applied, and dressings can be put on and changed without disturbing the parts at all. A sling, attached to the arch and to the leg piece, and hung on the running pulley of a Salter's Cradle suspends the^ leg, Avith the knee slightly bent, and allows the patient to move about from side to side or up and down without any fear of disturbing the dressings, while the cradle keeps the bed-clothes off. These parts of the splintpads nearest the wounds are covered with green silk protective to prevent their becoming dirtied in any way. A picture of the splint may be found in Esmarch's Surgeon's Handbook. An important point is, after applying the dressings, to put a triangular bandage under the heel, and fasten it on to the arch, thereby supporting the weight of the foot, which would otherwise depend for its security upon the few turns of bandage fastening the toes to uhe foot-piece. For the same reason while dressing the ankle, an assistant should always support the heel with his hand. This splint was applied and wound dressed on 16th, much swelling all about ankle, followed with fever, and on 20th an incision was made over inner side and pus escaped ; another being made on outer side on 22nd, drainage tubes being put in, and the-wounds washed thoroughly well out with sublimate solution. Discharges quite sweet all the time. With a probe some loose pieces of bone could be felt through outer wound, and through inner a large piece (fixed) of bare bone on 27th May. He was removed to the Base on June 14th, and about a fortnight later a large piece of dead bone was removed by enlarging one of the wounds. The case is still under- treatment, and all dead ^bone is not yet removed, but the
probably were
the
astragalus
warm
ami
339
is doing well and the foot will be saved, with what amount of mobility r< mains to be seen. Dislocation of sternal end of clavicle.? IX. Tliis sepoy was lying asleep on April 15th, in the shade of a stone wall which suddenly fell on him. He was lying on his side with his back to the wall ami the stones crushed him from behind forward. On admission he-was found to have well marked dislocation of the sternal end of the right, clavicle forwards and on to the sternum, where the large end of the bone could be felt just below the sternal notch and half It, was not fractured, and, as far as way across. could be made out, the rib did not seem to be There was much bruising fractured either. over both shoulders and lie had much pain in The dislocathe axilla. Shock considerable. tion was easily reduced, and a figure of eight bandage was put; across the shoulders, with a broad roller round the chest. On the 17th (3rd day) considerable emphysema appeared over right side of chest, extending up the neck, but he had 110 oppression of breathing, nor feeling of suffocation. Oii the 20th it was necessary to transport him in a dandie ^several miles'and up about 5,000 feet; the jolting made him suffer severely and his breathing became more rapid, and he was much exhausted after the journey. Some difficulty was found in retaining the bone in its position, as movement on his part displaced it forwards. He was kept lying on his back with a roller round chest and the arm fixed to chest by a triangular bandage, the shoulder being pushed forward, and the bone so held in place by an air cushion under it. The man did well, and 011 May loth was transferred to Base and thence to depot with the clavicle in good position, but considerable stiffness about shoulder joint, which would improve with time and massage. case
?
I.?Gunshot wound
3VIAYNARD, m.b.,
of thigh.?A
i.m.s,
sepoy aged Field Hospital at 6-30 P.M. on 23rd March 1891, having "been shot in the right thigh in action in the His specification of the afternoon. course tally stated that lie was wounded in right thigh above knee, but that the bullet had not been found. A first field dressing of carholised tow and antiseptic gauze had been applied, and when admitted, he had only slight pain and very little shock.
24,
was
admitted
to
the
quently. II.?Perforating gunshot
wound of leg.?A sepoy aged 24, while advancing up the crest of a hill against the enemy in action, received a bullet wound of the right calf, which brought him to the ground. On admission to the Field Hospital a few hours later, and removing the first field dressing whichhadbeenappliedonthefield,and was soaked with bloody discharge, the wound of entry was fouud to be the size of an 8-antia bit, situated one inch above the middle of the leg and one inch behind the inner border of the tibia, witn everted margin, while the wound ot entry was an inch lower down, in the middle line of the leg behind ;
Nov.
1891.]
MAYNARD'S SURGICAL NOTES.
surface distance between the two wounds two The calf was tense, painful, and swollen from extravasation of blood. Bone uninjured. His putties were perforated in six places ; the pieces being clean punched out. Wound syringed out with corrosive sublimate 1 in 2,000 and the same dressing as in Case I applied. As he was in much pain gr. \ of morphia was given hiin hypodermically and he slept fairly well. A few days subsequently he was transferred to the Base, where after somewhat protracted suppuration the wound healed well, and uo interference with the mobility of the limb ensued. III.? Gunshot wound of chest; multiple injuries ; death.?A mule driver, who had been aliot while on convoy duty, was brought in dead on April 9th with the following injuries. Bullet wound through the chest; probably a Snider or Enfield rifle, not a jezail, as the wound of entry was very small. The bullet had entered through the right first intercostal space in front, fracturing a bit off the second rib, and there were two wounds of exit behind over the left shoulder joint; two inches apart, rather larger, but, not much, than the entry, and with everted edges. There were three holes corresponding in his clothes. There was also a sword-cut on middle of inner border of right arm, dividing ulna and all the tissues except a few tendons and leaving the radius intact; such a wound as would have been received if he had tried to shield his head with his upraised arm. The left hand had the 3rd and 4th cut off by a almost fingers sword-cut extending down the metacarpal space nearly to the wrist. He also had two scalp wounds running fore and aft about, five inches long and one inch apart, one of which had opened the skull. When found shortly after the shot was heard, he was sitting in a pool of water just off the road, where it is presumed he went to drink, and was sniped by men waiting for such an opportunity behind the rocks. Apparently he was shot through the chest first, and in trying to defend himself against the attack with tulwars received the other wounds. The bullet wound having only one entry and two exits, rendered it probable that the bullet had split on the bone, or had forced on a piece of bone in front of it, and then the bullet and the new projectile (of bone) slightly diverging had come out in different places. It is difficult to believe that a man with a bullet through his chest? right in the track of the aorta and its large branches, could have had strength to defend himself by raising his arm as he did, and yet, from the circumstances uuder which he was found, there can be no doubt of the fact. IV-?Gunshot wounds with fracture of clavicle and scapula; death.?Late at night, 30th March, a sweeper, aged 25, with others against orders,went
inches.
|
S37
beyond the line of pickets to micturate, find while there the enemy created an alarm, and they ran for shelter. The picket seeing men coming on them in the darkness naturally fired a vollev,and this man with another were hit by their MartiniHenri bullets. F'om the position of the wounds he probably had his head down as he ran, and it should be noted that the.picket fired from the roof of a house and so from higher ground. There was considerable bleeding at the time, and a first field dressing was applied after the wounds had been stuffed with lint to stop it. On arrival at the Field Hospital on 31st, he was much exhausted bv the long journey in the dandi and had to be given essence of mutton and On removing rum before he could be dressed. the dressings which were soaked with blood, the bullet, was found to have struck first on the left cheek close to the angle of the mouth and to have escaped at the :niufle of the lower jaw. The bone was not fractured, though the buccal cavity was opened. Passing on it struck the left clavicle at junction of inner and middle thirds fracturing it, and then smashing through the scapular spine, it made its final exit close to the inferior angle of the scapula. The wounds of entry were small. The exit at the angle of the jaw was larger and ragged, while the exit behind the shoulder was a large gaping chasm l?" across with ragged everted and uudermined edges. The shoulder had fallen forward and was much flattened by the arm with outer end of clavicle and acromion having fallen Tnere was no away from their connections. the of lint on pledgets gently removing bleeding and cotton with which the wounds had been plugged, and after syringing them out with perchloride solution 1 in 2000 and dusting iodoform boracic wool over them, antiseptic gauze and arm and the w?re supported applied, dressings His temperawith a triangular bandage sling. ture was 100? at night, and as he was in pain, a
hypodermic injection of morphia gr. ^ was given and gave him si fairly good night. He was given milk, sago, and essence of mutton as extras. April 1 st.? A thin ichorous discharge from wounds, surface of which looks unhealthy and sloughy. A drainage tube 8" long was passed right through the shoulder wound from top to bottom and wound well syringed out. Temperature at night 100*2?. April 3rd?A piece of woollen jersey and several small fragments of bone were removed to-day from lower shoulder wouud. Temperature at night 101*2?. April ktli.?Transferred to Base, where he died suddenly the same night. No chest symptoms had shown themselves, and there was no evidence that the thorax had been injured. He died apparently of syncope. V.?Gunshot fracture of right femur yinto kneejoint, flesh wound of opposite thigh ; recovery,?
338
This man, :i Chagarzai, fighting against us appaand aged about 21, was shot oirthe 26th March,, and was admitted to Jhe Field ,Hospital on tlie 26th. The bullet, a Martini-Henri, had struck him on the outer side?of right thigh-, about one-half inch above outer condyle of femur and had passed inward, and slightly upwards,.fracturing the thigh bone, emerging at,an opposite point; and then passing on it had inflicted a perforating flesh wound oil'left thigh, the bullet passing through the muscles in front of the bone. The right femur was mashed and had evidently split iuto the knee-joint, which was full of,-fluid. The leg lay everted and helpless, and there was much swelling up the thigh as well as in the joint. The wound of exitrwas not much larger than that of entry, with everted edges, and both wounds of left thigh resembled the entry The bullet had ,passed wound of right thigh. through both thighs with great -velocity. The question of amputation was raised but decided against, wisely as the sequel showed, by the senior officers present. The man did not appear to suffer much; pain, or would not show it, and it was not easy to make out whether lie looked upon our treatment in the light of kindness or punishment. After well washing the thighs with antiseptic solution and dusting iodoform, antiseptic gauze and boracic wood dressings were applied. An extension apparatus was rigged up of strips of plaister running down-both sides of leg from the knee and meeting round a square bit of wood to which a cord was attached for the extension, spiral strips of plaister holding the side strips in position. Then a long Liston's splint was fixed on, the leg and foot being bandaged to it, the fracture being held in position with three rattan splints and a couple of triangular bandages to bind them?a longer splint in front, a shorter behind, and a third on The upper end of the Liston the inner side. was fastened to the body by a roller, and the man's lower extremities raised. His temperature scarcely rose above the normal, and on the 29th he was transferred to the Base in a dandie. Seen at the Base on June 14th, he was found walking about on crutches. The wounds had healed almost by the first intention, and he had never had a bad symptom. There was much oedema of the whole of the leg (right), but very little shortening and mobility was fast returning lie had become more or less in the knee-joint. tamed and much impressed with the kindness of the Sircar, confessing that his own people would only have killed and mutilated a prisoner, never have taken him prisoner and treated him like a son. VI.? Case of typhus; recovery.?A Khaiberi, aged 25, was admitted to the Field Hospital ou March 29th, sent in as a case of measles, of which disease there had been nine cases within the preceding two or-three weeks.
rently,
~
INDIAN MEDICAL GAZETTE.
[Nov.
1891.
On admission the mail presented the heavy " " look seen in 'this disease, drunken | his face was dusky (the rest, of his body unusually fair even for a Khaiberi), conjunCtivie injected and complaining of intense headache. Had insomnia for four nights, and the rash had been out two days. Temperature 104?, much jactitation and some deafness. The rash was a typical mulberry eruption, most marked on chest and abdomen and back, also on arms and legs. No abdominal symptoms; bowels confined ; tongue dry and brown with sordes; spleen not enlarged. He was isolated Delirium marked at night. with his sick attendant and went on in the same condition until the 2nd April (11 th day of disease), when he slept 16 hours'straight off and awoke with a normal temperature which never He evidently was admitted on the rose after. seventh day of the disease, and allowing 12 days for incubation, he must have contracted it in a village near Tilli where some of his regiment had been quartered for a night or two. SurgeonMajor A. MacGregor, I.M.S., had no doubt about the case, and his large experience in the disease both in fever hospitals at home and in the hills out here, left no question as to the correct diagnosis of the case. VII.? Gunshot wound of ankle.?This man, an officer's bearer, was handling his master's loaded revolver when it went oft and shot him in the left ankle on May 15th, at the time he was sitting on the ground with the left leg semi-flexed and turned outwards (not the usual position a native assumes1, and the bullet entered two inches above the point of the inner malleolus and immediately behind its inner border, emerging just over the proximal end of the fifth metacarpal bone. He was seen at once by a surgeon, and as there was considerable hajinorrhage from wound of exit, the opening was enlarged and a small bleeding point tied. The wounds were then dressed with carbolised lint, a tourniquet placed loosely over the femoral artery and the man brought two On admiles in a doolie to the Field Hospital. mission he didnotseem to be suffering from shock; hia temperature was 99*4? and pulse good. Blood had soaked through the dressing and this was The wound of entry was the size and removed. of a 2-anna bit and situated as above desshape cribed. That of exit was larger and more irre-
drowsy,
gular.
Blood was oozing slowly from both wounds. There was considerable swelling about wound of exit, spreading upwards and backwards as far as external malleolus; none about entry. No fragments of bone had been felt at the first examination, and as the bullet had escaped and the leg being bate at the time, no clot possibly being in it, it was not probed. Slight crepitus could be felt on'moving the foot, and from the direction of the wound, some bones must have~been injured, which it would 'be difficult to specify,
Nov.
MAYNARD'S SURGICAL NOTES.
1891.]
and cuboid. The toes quite patient could move the i*uier three. Considering the patient's age, healthy appearance, the. absence of shock, and apparent absence of injury to large vessels, it was decided to try and save the foot, so after washing the foot and wounds well with corrosive sublimate solution (1 in 2000), iodoform was dusted in, two drainage tubes introduced, and dressings of antiseptic gauze and wool applied, the leg being put up in a box splint. Pil. opii grain one was given to relieve pain. 16th May.?Fairly good night; temperature 102.? As it was impossible to dress the foot without removing the splint every time, besides the splint pads getting soaked with discharges, a splint was manufactured from telegraph wire on the principle of "Esmarch'sinterrupted splint for excision of the ankle," and consisting of a legpiece which fits on to the upper surface of the leg from the knee to just above the ankle, a foot piece which fits the sole of the foot and to which the foot is bandaged, the two being connected by a wire arch. The effect of this splint is that all the parts about the ankle are left exposed when it is applied, and dressings can be put on and changed without disturbing the parts at all. A sling, attached to the arch and to the leg piece, and hung on the running pulley of a Salter's Cradle suspends the^ leg, Avith the knee slightly bent, and allows the patient to move about from side to side or up and down without any fear of disturbing the dressings, while the cradle keeps the bed-clothes off. These parts of the splintpads nearest the wounds are covered with green silk protective to prevent their becoming dirtied in any way. A picture of the splint may be found in Esmarch's Surgeon's Handbook. An important point is, after applying the dressings, to put a triangular bandage under the heel, and fasten it on to the arch, thereby supporting the weight of the foot, which would otherwise depend for its security upon the few turns of bandage fastening the toes to uhe foot-piece. For the same reason while dressing the ankle, an assistant should always support the heel with his hand. This splint was applied and wound dressed on 16th, much swelling all about ankle, followed with fever, and on 20th an incision was made over inner side and pus escaped ; another being made on outer side on 22nd, drainage tubes being put in, and the-wounds washed thoroughly well out with sublimate solution. Discharges quite sweet all the time. With a probe some loose pieces of bone could be felt through outer wound, and through inner a large piece (fixed) of bare bone on 27th May. He was removed to the Base on June 14th, and about a fortnight later a large piece of dead bone was removed by enlarging one of the wounds. The case is still under- treatment, and all dead ^bone is not yet removed, but the
probably were
the
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is doing well and the foot will be saved, with what amount of mobility r< mains to be seen. Dislocation of sternal end of clavicle.? IX. Tliis sepoy was lying asleep on April 15th, in the shade of a stone wall which suddenly fell on him. He was lying on his side with his back to the wall ami the stones crushed him from behind forward. On admission he-was found to have well marked dislocation of the sternal end of the right, clavicle forwards and on to the sternum, where the large end of the bone could be felt just below the sternal notch and half It, was not fractured, and, as far as way across. could be made out, the rib did not seem to be There was much bruising fractured either. over both shoulders and lie had much pain in The dislocathe axilla. Shock considerable. tion was easily reduced, and a figure of eight bandage was put; across the shoulders, with a broad roller round the chest. On the 17th (3rd day) considerable emphysema appeared over right side of chest, extending up the neck, but he had 110 oppression of breathing, nor feeling of suffocation. Oii the 20th it was necessary to transport him in a dandie ^several miles'and up about 5,000 feet; the jolting made him suffer severely and his breathing became more rapid, and he was much exhausted after the journey. Some difficulty was found in retaining the bone in its position, as movement on his part displaced it forwards. He was kept lying on his back with a roller round chest and the arm fixed to chest by a triangular bandage, the shoulder being pushed forward, and the bone so held in place by an air cushion under it. The man did well, and 011 May loth was transferred to Base and thence to depot with the clavicle in good position, but considerable stiffness about shoulder joint, which would improve with time and massage. case
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