CASE 96.---Private Jean-Baptiste Buisson, of the 116th Regiment, was wounded at Champigny, November 30th, 1870. A ball had entered near the humeral insertion of the left pectoralis major, producing a comminuted fracture of the head and a portion of the shaft of the left humerus. A piece of the ball also lodged and was embedded in the glenoid cavity, the remainder, as was subsequently discovered, entering the cavity of the chest. The patient was faint from loss of blood, and suffering from insufficient food and from exposure to the cold, which was at that time intense. December 2nd, excision was performed by a longitudinal incision in the deltoid, removing the head of the humerus and a portion of the shaft, which was comminuted. On the fifth day the wound was beginning to granulate, and was suppurating fully. On the sixth, the wound appearing indolent, was covered with lint dipped in nitric acid (sixty drops to a pint of water), and this was again covered with warm water compresses and oil-silk cloth. From this date healthy pus continued to be secreted. December 13th, a caoutchouc drainage tube was inserted, and the wound was gradually closed by strips of adhesive plaster. The patient sat up daily and continued to improve until December 21st, when he was considered convalescent. At this time the supply of coal gave out, and it was impossible to renew it before the expiration of twenty-four hours. The cold was then intense, and the patient, together with others in the same tent, suffered severely. He also began to complain of pains in the loins, of great difficulty in respiration, of loss of appetite, followed by severe vomitings and a distressing cough. December 22nd, he was taken with a chill. During several days the bad symptoms continued to increase, though the discharge of pus was healthy until the 25th, when it became watery. The patient continued to sink, and died on the 27th, twenty-five days after the operation.
CASE 105.---Private Felix Castet, of the 114th Regiment of the Line, was wounded at Champigny, November 30th, 1870. The ball entering the middle of the right gluteus, had passed directly into, and was lodged in, the pelvis. The patient was a man of strong constitution, and apparently healthy. From the date of admission to the date of the formation of an abscess, the practice of drawing off his urine twice a day was uninterrupted. Up to the 10th of December the progress of the wound was as good as could be expected. On that day pus was found to have been secreted in the rectum. December 14th, being constipated, his bowels were relieved by an enema. An enormous quantity of pus was discharged from the wound. An abscess was found to be forming also in the perineum. Notwithstanding these depressing influences patient continued cheerful. During the night of the 14th about two quarts of blood issued from the wound. After this he became very weak and irritable. December 16th, another hæmorrhage. About a quart of blood lost. December 17th, a third hæmorrhage, followed by death. A post-mortem showed that the ball had passed through the ischium, across the pelvis, and had lodged on the left side of the rectum, where it was found embedded in the soft parts. An enormous abscess had formed in the pelvis, breaking into the rectum and perineum, and carrying with it also fragments of bone.
CASE 106. --- Private Pierre Lambolez, 2nd Company, 3rd Battalion, 42nd Regiment of the Line, was wounded at Champigny, November 30th, 1870. The ball had entered the right forearm posteriorly, three inches below the elbow-joint, producing a fracture of the radius and ulna, and had passed out anteriorly lower down the forearm. On admission to the ambulance the patient was in a typhoid state ; previous exposure, want of nourishment, and hæmorrhage had completely exhausted him, and what little strength remained availed little, owing to his habits of intemperance, which had left his stomach in such a condition as to be unable to respond to food or to alcoholic stimulants. Great swelling followed, owing to infiltration of blood and serum in the tissues, and to such an extent that loss of vitality of the parts was threatened. Extensive incisions were then made to relieve the tension of the parts, which served, however, to afford only temporary relief. The vitality of the arm continued to decrease until December 7th, when amputation at the upper third of the arm was performed. The alleviation was manifest. The patient's appetite, which prior to this operation had been poor, now became much better. He also partook freely of cognac and wine, while before he had refused any drink but vinegar. Notwithstanding this apparent improvement the typhoid condition grew upon him day by day, the stump assumed an unhealthy gangrenous appearance, and he continued to sink until the 18th of December, when he died.
CASE 109.---François Renaudie, 114th Regiment of the Line, was wounded at Champigny, November 30th, 1870. The ball entered the left arm near the pectoralis major, one inch below the acromion process, and fracturing the head of the humerus, made its exit through the superior parts of the deltoid, a little below the spine of the scapula. December 3rd, the head of the humerus, with about one and a-half inches of the shaft, was removed. The longitudinal incision was employed, and the long head of the biceps was consequently preserved. The warm water and oil-silk applications, which were at first employed, were in a short time accompanied by dilute nitric acid lotions. December 7th, the surface of the incision had granulated, and was apparently secreting an abundance of healthy pus. The edges were brought together as far as possible by strips of adhesive plaster. The condition of the patient and of the wound continued good until the 21st of December, when the appetite of the patient began to fail, and the little that he partook of to distress him. December 23rd, the discharge became less creamy; appetite failed entirely. December 26th, patient became sick at the stomach, and vomited matter of a bilious nature. December 27th, the surface of the wound seemed less healthy, and was accordingly stimulated with the solution of sulphate of copper alternately with dilute nitric acid. December 28th, patient's indisposition so far decreased that there was an evident improvement both in the appetite and in the appearance of the wound. December 29th and 30th, he sat up for a short time. December 31st, the former symptoms returned with severity, while he became hourly weaker, until the following day, January 1st, life gradually and painfully ebbed away. From the day of the receival of the injury to the day of his death there had been no period,---save indeed that period above mentioned,---when the injured parts did not discharge an abundance of healthy matter. The post-mortem showed that a little bony reparation had ensued, but no abnormal conditions were observed.
CASE 116.---Private Louis Rancy, 2nd Company, 1st Battalion, 113th Regiment of the Line, was wounded at Champigny, November 30th, 1870. A ball had passed through the middle of the patella, thence through the knee-joint, passing out just above the inner tuberosity of the femur, and crushing the same. From the moderate amount of injury done it was deemed a good case for resection. The knee was resected on the 3rd of December, the femur being removed just above the condyles, and the patella being enucleated from the under surface of the flap. A drainage tube was also passed laterally through the knee. The operation was performed by an anterior circular flap, and the wound reclosed by silk sutures. The limb was then placed in an iron-wire gutter well padded with oakum. The first dressings consisted of oakum and compresses wrapped around the limb, the whole being enveloped in oil-silk. More than half of the wound united by first intention. On the sixth day some inflammation supervened, which was combated by warm water applications. This treatment was continued till the 14th of December, eleven days after the operation, when pus was found burrowing in the muscles of the thigh. On the 15th of December he had slight rigors, then attributed to the considerable formation of pus. After its removal a re-accumulation was prevented by heavy compresses and bandages. On the thirteenth day after the operation his appetite failed and slight fever supervened. The wound, however, continued to look well, and secreted healthy pus. Up to the nineteenth day his condition remained about the same, and although the pus was not quite as laudable, the wound always maintained its healthy character. He then had a slight secondary hæmorrhage, and died soon after. A post-mortem examination showed the head of the tibia covered with good granulations, and one-fourth of the cut end of the femur denuded of its periosteum, presenting a nearly white appearance, from incipient necrosis. The residue of the femur exposed was not only healthy, but had thrown out a large quantity of healthy granulations.
CASE 117.---Private Jean-Paul Baizand, 35th Régiment of Line, was wounded at Champigny, November 36th, 1870. A splinter of shell had entered the left lumbar region, and had passed obliquely upwards into the cavity of the chest, wounding in its passage the abdominal viscera, fracturing the ribs and spine, and lodging under the skin. He had lost blood largely on the field and during transportation. On admission at the ambulance he was dying from excessive hæmorrhage; he expired two hours after his arrival.
CASE 120.---Private Laurent Villiet, 3rd Company, 3rd Battalion of the 123rd Regiment of the Line, was wounded at Champigny, November 30th, 1870. A ball had entered the right side of the neck, and gliding on under the skin, had its exit about two inches from its entrance, making only a flesh wound. A second ball entering posteriorly just above the right shoulder, passed through the spine of the scapula, and out, eight inches below the same shoulder, in the back. A third ball penetrated the right shoulder, injured and opened the joint without crushing the humerus, sped down between the skin and the bony tissue, and had its exit just above the crest of the ilium. The wounds were immediately covered with warm water applications enveloped in oil-silk cloths. At the expiration of five days pus had formed freely. In about thirty days several of the wounds had healed, but those immediately connected with the joint and scapula still remained open. The pus becoming thin and offensive, much similar to what would be discharged from a necrosed bone, and the wounds showing no disposition to cicatrize, the parts were stimulated by the officinal solution of nitric acid. About this time the patient began to suffer from headaches, thirst, stiffness and soreness of all his limbs, rigidity of the jaw, and fever. These conditions continued until two days prior to his death, when he was taken with chills induced by deficiency of fuel. From this moment he gradually sank, and on the 25th expired. The autopsy revealed the fact that there was necrosis of the head of the humerus and of the spine of the scapula.
CASE 122.---Private Jean-Baptiste Granger, 2nd Company, 2nd Battalion, 42nd Regiment, was wounded at Champigny, November 30th, 1870. On admission he was in an extremely exhausted condition from loss of blood, exposure, and difficulty of breathing. A ball had passed through the neck, wounding the pharynx and the larynx, causing great swelling of the parts, general. emphysema, and much difficulty in respiration. A second ball had entered the middle of the right arm, fracturing the shaft of the humerus, and making its exit posteriorly. The arm was properly supported in a wire gutter; the wounds were dressed with warm water applications enveloped in oil-silk. Great effusion, inflammation, and profuse suppuration ensued, succeeded by considerable necrosis of the broken ends of the shaft. On the 5th, breathing better, the effused air had mostly disappeared; but a distressing cough had set in. The air still continued to pass out and in at the openings in the neck during expiration, inspiration, and during the efforts to cough. On the 6th, swelling decreased, cough worse, and an abscess formed above the elbow; this was opened, and discharged freely. From this time until the 10th patient improved, though his cough was constantly troublesome; on that day several spiculæ of hard bone were removed from the arm; the suppuration was abundant. It was now found that both ends of the broken bone were necrosed. The patient continued, however, to eat and sleep well; his wounds discharged freely, and his breathing was good---except from an occasional disposition of the glottis to spasm---until the afternoon of the 17th, when the pus began to decrease, and the breathing to suffer from oedema of the glottis. He was placed in a steam-bath room, and his respiration was greatly relieved by twelve o'clock of the same night. On the 17th respiration better. Continued improving up to the 18th, when he became delirious---tearing off his dressings. On the 19th cough nearly gone---breathing better. On the 20th tore off bandages and bed-clothes during the night---pulse 130. Condition remained about the same, with good breathing, until the 23rd, when an abscess formed in the arm, and was opened. On the 24th, appetite failing, refused food, breathing good, pulse feeble. During the night, fever, delirium, and high pulse. On the following day delirium increased, breathing unobstructed. Died on the 26th at 1 o'clock.
CASE 126.---Private Victor Manne, 1st Company, 2nd Regiment of Engineers, was wounded at Champigny, November 30th, 1870. A large fragment f shell had passed through the spine and abdomen. He was insensible on arrival, and continued so up to the moment of his death, which occurred twenty-four hours after admission.
CASE 127.---Private Charles Maurice Arnaud, of the 125th Regiment of the Line, was wounded at Champigny, November 30th, 1870. A rifle ball had struck the left side of the skull obliquely, causing a depressed fracture of the left parietal bone, near its articulation with the occipital. Owing to the impossibility of removing the pieces of the inner table, which were depressed and rested heavily on the membranes of the brain, the skull was trephined, and the depressed portions elevated. During the operation the patient was nearly insensible. He rapidly, however, regained his consciousness, but never the complete use of his mental faculties. Cold water dressings were applied for four days, when there were no further signs of cerebral disturbance. On the fifth he had a severe chill, severe pains in the head, and nervous twitchings, accompanied by vomiting. Drowsiness and stupor set in, followed by partial paralysis of the left side. He was never afterwards fully rational. On the sixth he became delirious. On the seventh he was seized with convulsions. These continued until the next day, December 18th, when coma succeeded, and he died. No autopsy.
CASE 131.---Private Emil Bruno Saübe, of the 106th Regiment of the (German) Line, was wounded at Champigny, November 30th, 1870. The ball had entered about an inch below the middle of the spine of the ilium, and passed thence into the pelvis. On admission he had paralysis of the left leg, complete retention of urine, and great constipation. The wounds were dressed with warm water applications and with oil-silk . coverings. The retention of urine was relieved twice a day by the use of the catheter. This treatment was continued until the discharge of foetid matter compelled the use of oakum and carbolic acid to absorb and disinfect the secretions. Constipation was relieved by enemas. The condition of the patient continued with little variation until December 14th, when severe inflammatory fever intervened, succeeded by diarrhoea, neuralgic pains, and increasing inability to sleep. Large doses of chloral and opium failed to produce any relief. There was but little change in these symptoms up to December 19th, at which date he died. A post-mortem examination revealed the fact that the ball had passed obliquely downward and backward into the pelvis, thence through the psoas magnus and iliacus internus muscles, and had entered the sacrum, lodging in the sacrum externally to the right ilium, just at the right ilo-sacral junction. In its course the ball had destroyed a portion of the cauda equina, thus explaining the cause of the paralysis above-mentioned.
CASE 132.---Private Michel Hulard, 2nd Company, 3rd Battalion, 4th Regiment of Zouaves, was wounded at Champigny, November 30th, 1870. He lay nearly twenty hours on the field of battle. He was received at the Ambulance December 1st, with a fracture of the occipital and the two parietal bones. The missile had removed the superior angle of the occipital and dura mater beneath, and literally comminuted and carried away the whole top of the skull, including a large portion of the brain. On admission the brain substance protruded and was oozing out; but notwithstanding the loss of nearly half of the cerebral substance, he lived on until the 5th, taking food, though wholly unconscious, when convulsions supervened, followed by death, five days after the injury.
CASE 133.---Private Guillaume Paule, of the 123rd Sharpshooters, was received from Champigny, November 30th, 1870. He was mortally wounded through the spine, shoulder, and lungs, and died thirty hours after arrival.
CASE 135.---Private Gustav Schürig, a Saxon, of the 108th Regiment of the (German) Line, was received from Champigny, November 30th, 1870. A ball had passed through the left thigh; another had passed through the pubis. On admission to the ambulance he had retention of urine, and was exhausted from hæmorrhage, and vomited freely bile and stercoraceous matter. The bladder was emptied by the use of the catheter twice a day. His wounds were covered with warm water applications and enveloped in oil-silk. Constant vomiting of food and fæcal matter continued until death. Inflammation of the peritoneum was manifested by great tenderness and distension of the abdomen. Great constipation existed, and could not be wholly relieved by enemas. Chloral and opium were given to combat the pain, but without effect. These conditions continued without much variation until the fourth day, when he died. A post-mortem revealed the fact that the first ball had passed near the trochanter major, and through the gluteal muscles, having its exit through the middle and anterior part of the thigh. The second ball had passed under the skin, externally to the spine of the right pubis, thence obliquely downward and backward into the gluteal region, opening, in its course, the abdominal cavity over Poupart's ligament, about one inch from the spine of the pubis. The abdominal cavity was filled with serum, and the intestines glued together from the extensive peritonitis above alluded to.
CASE 147.---Private Joseph Coupé, a Mobile of Isle and Vilaine, was wounded at Champigny, November 30th, 1870, by a large fragment of shell. The projectile crushed his left leg so badly as to leave it hanging by the posterior muscles. He lay twenty-four hours on the field. December 1st, he was received at the ambulance, and was almost immediately put under the influence of chloroform ; the amputation was performed at the upper third of the leg, by a short anterior and long posterior flap. He had lost blood so largely on the field that he was nearly pulseless, and did not lose more than three ounces of blood during the operation. The flaps were brought together by adhesive plasters, and the stump dressed with oakum, and covered with dry compresses and oil-silk. Delirium intervened, and continued for five days; pulse 190. December 1st, 2nd, and 3rd, he repeatedly tore off his dressings; and on the 2nd, in the absence of the watcher, he left his bed and fell heavily upon his stump, terribly bruising it. So great was the shock caused by this injury, that it seemed as if the patient would succumb to it, but, under the influence of proper nourishment and stimulants, his general condition improved, though the delirium continued. On the 5th a large slough appeared on the upper and outer angle of the wound. This extended gradually downward until the 9th, when it separated, leaving a healthy granulating surface. The delirium passed off on the 6th, leaving him greatly reduced in strength, without appetite, and suffering from a severe pain in the stump, probably caused by the fall above spoken of. Profuse discharges from the stump tended still further to reduce his strength. The local pain was relieved by opium and chloral; the wound was stimulated by diluted nitric acid; the appetite was restored by tonics and stimulants; the limb was painted with iodine; suppuration was favoured by warm water compresses alternately with poultices enveloped in oil-silk; and the parts and dressings were deodorized with dilute carbolic acid, as often as necessary. It was soon found that in addition to the large slough of the soft parts, the exposed end of the tibia had become carious. The profuse discharge caused by the inflammation following the injury, the large amount of blood lost prior to the accident, the shock from the fall, the severe pain following the accident, and the fearful exertions during the five days of delirium, left but little hope for his recovery. Notwithstanding, his cheerful, buoyant nature---under vigorous stimulative and tonic treatment---aided in his rapid improvement from the 9th, when the slough separated, until the 15th, when, upon consultation, it was deemed advisable to remove the necrosed tissue of the bone. December 15th, an exposed portion of the extremity of the tibia (1-3/4 of an inch) was sawn off. The operation was borne well, and the patient appeared to be progressing favourably. The bone granulated kindly, and the whole surface of the wound became healthy. December 26th, the stump was uniting finely, but there was still a small discharge of pus from the surface near the tibia. December 31st, it became evident that the knee-joint was involved. January 3rd, an abscess was opened below the knee, and from this opening pus discharged daily in increased quantities. The prostration occasioned by this suppuration prevented all hope from farther operative interference. January 10th, another abscess formed, and was opened, and a small portion of the femur became visible. On the 14th this abscess had granulated; but a large bed sore had in the meantime formed on the patient's back. An india-rubber drainage-tube was passed into the opening in the thigh, and maintained there. By means of this the wound was frequently washed out with dilute nitric acid. January 12th, diarrhoea. January 14th, was much weakened, though rallying somewhat under free application of stimulants. On the morning of the 15th the stump looked perfectly healthy and was rapidly healing; while the seat of the abscess above had granulated, and was discharging moderately. January 16th, sinking fast; tongue clean, teeth white, pulse feeble, no febrile symptoms, stump presents the same healthy appearance---fine suppuration and granulation ; at 5 P.M. rallied a little under repeated doses of brandy. On the 17th the stump looked well. The patient died at 5 P.M. on the 18th. There is no doubt that had he had strength to hold out a few more days the tibia would have sloughed out from the joint; nor can there be any doubt that death resulted from the continual drain on his system, induced by the increased suppuration from the violence of his fall, and the shock, and constitutional irritation occasioned by it, together with the great prostration ensuing from the quantity of blood lost during the twenty-four hours he lay upon the field of battle.
CASE 148.---Private Prosper Chrétien, of the 120th Regiment, was received from Bourget, December 21st, 1870. A shell had fractured the pelvis and the hip joint. Several large fragments of shell and of lead (nearly 30 ounces), with a mass of cloth, were extracted from the wound, which was some eight inches in diameter. Another fragment of shell had crushed the opposite knee-joint. When admitted, he was in a dying condition. Died one and a-half hours after arrival.
CASE 150.---Private Sylvain Johais, of the 120th Regiment of the Line, was wounded the 21st of December, 1870, at Bourget. A fragment of shell had entered the right arm at the external border of the biceps, at the junction of the middle and lower thirds, and passed obliquely downward and backward between the triceps and the humerus. The patient was much exhausted, and had a feeble circulation, caused by hæmorrhage, insufficient food, and exposure to intense cold. On admission, warmth was applied to the extremities ; hot drinks were given, and stimulants were freely used. Warm water dressings covered with oil-silk were used up to the 26th, when poultices of linseed-meal were substituted. December 31st, the large orifices of the wounds began to decrease, and healthy granulations in abundance had formed. The wounds continued to heal, and the patient became convalescent, when on the 4th of January he complained of stiffness of the muscles of the jaw, of pains in the glands of the neck, of difficulty in digestion, and of colics. Chloral, of the strength of one part to fifty of water and syrup, was given in doses of one tablespoonful per hour. January 5th, spasmodic action, and rigidity of the jaws, muscles of the mouth, and throat ensued. The spasms lasted about a quarter of an hour, and were succeeded by nausea and pains in the abdominal region. Doses of chloral were continued alternately with opium cigarettes of two grains each. January 6th, less rigidity of the muscles of the upper part of the body, but increase in rigidity of those of the trunk and lower members. Opium pills of one grain each were given every two hours in addition to the chloral and cigarettes. January 7th, retention of urine ensued, which was relieved with the catheter. The doses of chloral and opium were then increased. January 8th, increased rigidity and hardness of all the muscles; had great difficulty in swallowing. Muriate of morphia, of the strength of one grain to six drops, was given in doses of ten drops every three-quarters of an hour. Cigarettes of the increased strength of four grains each, together with the regular doses of chloral, and of opium pills, were also smoked by the patient. Linseed-meal fomentations were applied to the neck, chest, abdomen, and legs; treatment seemed to lessen the permanent muscular rigidity. January 9th, several spasms occurred during the day and night, and the jaws became firmly closed. Liquid food and anodynes were given through the space afforded by a missing tooth. January 11th, subcutaneous injections of sulphate of morphia (one grain to twenty drops) were administered every eight hours in addition to the doses of laudanum, chloral, and opium, by cigarettes. This day the patient was enabled to urinate freely and without assistance of catheter. The jaws relaxed and his appetite returned. January 12th, spasmodic action again became very violent. Anodynes were re-administered in increased doses. The spasms continuing, anodynes were used at discretion, their frequency and strength being diminished toward the end in proportion to the strength of the patient and the severity of the spasms. Throughout the whole period the patient was plied with as much of food and stimulants as could be, taken. January 15th, spasms with increased opisthotonos re-occurred. The entire body became stiff and rigid; patient's respiration was laboured, he foamed at the mouth and bit his tongue as one with epilepsy. Excessive debility and profuse perspiration followed. The wounds still remained healthy, and continued to heal; the mind and memory were at all times clear and good; urination now was frequent and free; simple injections kept the bowels open; perspiration was most profuse from all the upper parts of the .body, while fomentations were applied to such parts as exhibited excessive hardness or tension. This condition continued, with but slight variation, up to the 29th of January. Then syphilitic eruptions appeared over the entire body, for which iodide of potassa in five-grain doses was given every four hours. Subcutaneous injections of iodide of mercury (ten drops every two days) were commenced, and continued to the 6th of February. The patient, we subsequently learned, had been under treatment in a military hospital for nearly a year for syphilitic disease. January 31st, a troublesome cough supervened, with a secretion of tenacious mucus; had difficulty in expectoration and swallowing. Diarrhoea and vomiting now set in, followed by great weakness, which continued until February 4th, when the muscles became so relaxed that the patient was able to sit up for a short time, complaining, however, of oppression of the chest, cough, and constant expectoration. From February 5th to the 9th his weakness gradually increased, profuse perspiration ceased, the muscles and limbs relaxed, and stimulants of any kind failed to produce re-action. He coughed incessantly, and vomiting having recommenced, accompanied by frequent evacuation he became thoroughly exhausted, and died on the 10th of February, at 330 A.M., remaining conscious to the last. The disease did not interfere with the healing process, since, when death occurred, the wounds had entirely healed.
CASE 153.---Captain Emile Dassonville, commanding the 21st Artillery, was wounded at Bourget, December 21st, 1870. A large fragment of shell had struck the back just below the left scapula and entered the pleural cavity. The soft parts of the back were fearfully bruised. On admission he was exhausted, weak and nervous. Rapidly sinking, he died within forty-eight hours after arrival.
CASE 155.---Private Ernest Guilbert was wounded at Bourget, December 21st, 1870. A splinter of shell, about a cubic inch in size, had entered just above the left nipple, passed obliquely upward across the chest, and had made its exit about three inches vertically above the right nipple. It had thus caused a jagged wound of some ten inches in length. In its course three large openings were made in the skin, while the sternum had been crushed and depressed so as to rest upon the thoracic viscera. On admission to the ambulance the patient was suffering considerably from his wound, previous exposure and insufficient food, but had lost little blood. Three hours after admission, when full re-action had taken place, hæmorrhage supervened so severely, that it was only arrested by plugs and compresses of lint saturated in perchloride of iron, covered by large compresses, and bandaging of the chest. On the fifth day a piece of shell was found near the point of exit. On the sixth, slight hæmorrhage of the left side occurred. Compression, tight bandaging, and an astringent application again controlled the bleeding until the 29th of December, when pus was fully secreted. Subsequently to this date the dressings consisted of warm water applications with dilute nitric acid. January 1st, the broken portion of the sternum showed evidence of necrosis. January 2nd, it had a more honeycomb appearance, and was rapidly dissolving by the secretions. January 3rd, diarrhoea set in, which continued two days, when the patient died, worn out by the great drain from a system much enfeebled by exposure and want of food, and an inability to take it after admission. Diarrhoea probably accelerated the fatal issue, though the exhaustion produced by such a severe suppurating wound, and in such close proximity to vital parts, was the more direct cause of death.
CASE 156.---Adjutant Ferdinand Barbier, 15th Battery, 7th Regiment of Artillery, was wounded at Bourget, December 21st, 1870. He had received two wounds. A piece of shell, about two inches long by one inch broad, had entered the middle of the right gluteal muscle, crushing the neck of the femur and trochanter; it was extracted just over the right trochanter major. A piece of shell had entered the opposite knees crushing the whole joint. Treatment consisted of palliatives only. Patient died twenty-four hours after his arrival at the ambulance.
CASE 162.---Private Edward Hedouin, 5th Battalion, 50th Regiment of March of the Lower Seine, was wounded at Bourget, December 21st, 1870. A ball had struck his head under the right ear, near the mastoid process, fracturing the skull but not entering the brain. On admission the patient was in a state of semi-consciousness. This state continued to exist with little or no variation until December 26th, five days after arrival, when symptoms of inflammatory action having appeared, bags of ice were applied to the head, while ice was also given internally. December 27th, delirium set in accompanied by diarrhoea. For the former the ice treatment was continued; for the latter mistura cret was administered. Chloral was freely used to arrest spasmodic action and to produce quietude. The diarrhoea was checked, but the cerebral symptoms and spasms continued unabated until January 11th, when patient died. A post-mortem disclosed a fracture through the base of the skull and the presence of meningitis, with the formation of pus within the cranium.
CASE 164.---Private Rhodolphe Pierre Breillot, 2nd Company, 1st Regiment of the Scouts of the Seine, was received from Bourget, December 21st, 1870. A ball had entered the skull between the frontal and temporal bones, fracturing and depressing the bone. The ball was extracted on the field. He was unconscious on admission. This condition continued, with more or less variation, until the 29th. During this period he ate little. On the 29th, eight days after admission, inflammatory action with great local heat, restlessness, and delirium ensued. For these conditions bags of ice were applied to the head; ice was also given internally. From this date to the day of his death, a period of four days, he continued unconscious and delirious. Towards the last his pulse became very quick and hard, his respiration short and laboured; convulsions followed, and continued until the 2nd of January, when he died.
CASE 168.---2nd Lieutenant Jules Michel, of the Scouts of the Seine, was wounded January 13th, 1871. A ball had entered the left chest, about three inches from the sternum, fractured the third rib, traversed the lung, and passing out through the ninth rib, with fracture of same, was found lodged in the muscles of the back about 2-1/2 inches from the spinous process of the vertebra. The patient was very weak o admission, from loss of blood, exposure, deficient nourishment, &c. He continued to sink, notwithstanding stimulants and nourishment were freely given, until the 24th, ten days after admission, when he died.
CASE 169.---Corporal John Charles Bruneteau, 8th Company, 90th Battalion, Paris National Guards, was wounded January 14th, 1871. He had sustained, from a fall on a large pointed picket, a compound and comminuted fracture of the left fibula, just below the articulation with the tibia, with great destruction of the muscles of the anterior part of the leg---a badly lacerated wound. He was in a low typhoidal state of health, and very feeble on arrival, having for many days been deprived of a proper quantity of food and fuel. His wound was dressed with lint and alum, to arrest hæmorrhage. At the end of six days a slight amount of pus was discharged. The limb was then covered with cold water applications and oil-silk, and properly supported. At the end of ten days inflammation extended to the knee-joint, where pus formed, and was removed from time to time by Dieulafoy's apparatus. The pus from the wound was offensive, and mixed with blood. From his entrance into the ambulance the patient continued in a typhoid, soporific state. He took some food and stimulants, but to no avail. He became weaker day by day, and finally died January 31st, seventeen days after the injury.
CASE 178.--- Private Simon Goudrier, 1st Company, 211th Battalion, 18th Regiment, National Guards, was wounded at Montretout, January 19th, 1871. A ball had entered the left foot at the junction of the tarsus and the metatarsal bone of the great toe, and, passing obliquely upwards and backwards through the superior part of the arch of the tarsus, had its exit anterior to the external malleolus, cutting in its course the anterior tibial artery, but not opening the ankle-joint. The patient was much exhausted from loss of blood and from intemperate habits. Hæmorrhage occurred at intervals for some days after arrival, but this was arrested by astringents and cold water applications. When admitted he was greatly enfeebled from want of' proper nourishment and from inability to receive or digest food. This feeble state continued until February 9th, when his appetite completely failed. The wounds were enveloped in compresses covered with oil-silk cloth. Subsequently linseed-meal poultices were added. January 24th, suppuration commenced. January 28th, several small spiculæ were removed from the wound of exit. February 5th, an abscess formed near the external malleolus, and was opened. There was a copious discharge of healthy pus. February 8th, the suppuration from wounds and flow of pus and discharge from the abscess were healthy and abundant. February 9th, brandy, with eggs and milk-punch, were added to the other stimulants, but without effect, the patient refusing food altogether. Death ensued February 12th.
CASE 184.---Private Henri Molin, of the 136th Regiment, was wounded at Montretout, January 19th, 1871. A ball had entered the left leg, on the inner side, about one inch below the knee-joint, between the epiphysis and the shaft, and near the posterior angle of the tibia, and passed obliquely backward through the posterior face of the tibia, having its exit posteriorly to the fibula. As it was doubtful whether or not a fissure had been made in the joint, it was deemed to be a suitable case for conservation. On arrival the patient was unable to eat, and was therefore sustained as far as possible by stimulative and concentrated liquid food. Ice and other cold applications not sufficing to reduce the inflammation, recourse was had to irrigation. This treatment was continued to the 23rd, when, the inflammation having in a measure subsided, and the patient having experienced a feeling of discomfort therefrom, it was discontinued, and warm-water dressings with oil-silk cloth substituted. From the first the man did not rally, nor did he even respond to food and stimulants; his strength gradually failed until the 27th, when he died.
A post-mortem examination revealed they fact that the bone was fissured extensively into the joint, and for a distance of almost three inches. The joint had also freely secreted healthy pus.
CASE 188.---Private Jean de Menitroux, 4th Regiment of Artillery, was wounded at Montretout, January 19th, 1871. A ball had entered the left arm near the insertion of the deltoid, and had passed through and made its exit at the posterior face of the triceps, fracturing in its course the humerus in the upper third below the head, but not involving the joint. The patient was much exhausted from loss of blood on the field. This condition was aggravated by a severe cough and by a pulmonary disorder, which disorder was probably occasioned by long exposure anterior to the date of the injury. The patient was also suffering from rheumatic pains and swelling in both legs and the right arm and hand, to such a degree that the day after arrival he could not move without assistance. The wounds were enveloped with warm water dressings and covered with oil-silk cloths. January 25th, suppuration began; a caoutchouc drainage-tube was inserted, and the wounds were syringed with a weak solution of carbolic acid. Immobility of the arm was obtained by splints and bandages and compresses, which were removed and cleaned daily. On the 7th of February the discharge of pus was free and healthy; granulations appeared around the edges of the wounds. There was no inflammation in the arm. The cough still continued, violently racking patient's whole frame, and causing suffering as well as exhaustion. February 10th, the appearance of the arm and of the wounds was favourable; the appetite and spirits of the patient had improved; the discharges were abundant and healthy. At 6 o'clock P.M. of this day a violent fit of coughing was the cause of a sudden hæmorrhage, which lasted some ten minutes before it was effectually arrested. The arrestation was effected by compression. The loss of blood had been so considerable that it was thought most advisable to ply the sufferer with stimulants. At 2 A.M. of the night of February 11th, a second hæmorrhage, induced by the same cause, took place with such violence that, prostrated by loss of blood, the patient died in about fifteen minutes, and before the arrival of the surgeon. A post-mortem showed that the pointed inferior end of the fractured humerus had cut the tissues, and thereby caused the hmorrhage. It was apparent, however, that death had been caused by hæmorrhage in a subject already much enfeebled by previous disease.
CASE 189.---Private Louis Seppe, 3rd Company, 78th Battalion, 16th Regiment, National Guard, was wounded January 19th, 1871. A ball entering the right foot at the centre of the tibio-tarsal articulation, had passed obliquely backwards and inwards, and out through the internal malleolus, injuring the posterior tibial artery. A second ball entering the nates near the os sedentarium, had passed obliquely down through the thigh anterior to the femur, a distance of ten inches, before making its exit. A third ball entering the right forearm two inches .below the external condyle of the humerus, had passed obliquely downwards and backwards, and out on the inner side of the middle of the forearm. The patient had just been discharged from a hospital as convalescent from small-pox. He was much exhausted from loss of blood, exposure and insufficient food. The first wound was enlarged and all loose spiculæ removed, and covered with compresses saturated in cold water, to arrest hæmorrhage and inflammatory action; and subsequently with ice to effect the same end. When inflammation had subsided, the ankle was enveloped in warm water applications covered with oil-silk. The leg and foot were placed in a wire gutter well padded with oakum. From the first there was disinclination to take food and wine. There was no general re-action of the system. Though the wound of the ankle-joint suppurated freely, neither of the upper wounds secreted pus. The patient never fully rallied, though stimulated liberally, but gradually sank, and died February 2nd.
CASE 204.-Private Edward Baudette, of the 120th Regiment, was wounded at Montretout, January, 19th, 1871. A ball had lodged in the frontal bone, about two inches above the right eye; had crushed in the entire skull, and had also torn the dura mater from its attachments. Several large fragments of both the outer and inner tables were removed. A second ball had passed between the thumb and index finger of the left hand. On arrival the mental powers of the patient were apparently unimpaired. Cold water compresses were the only dressings for the first two days. January 21st, severe re-active inflammation having ensued, accompanied by delirium, bags of ice were substituted. January 24th, the delirium increased during the day; violent spasmodic action followed, and at 10 P.M. of this day, and four days after the injury, death terminated his sufferings.
CASE 205.---Private Victor Auger, a Sharp-shooter of the 120th Regiment, was wounded at Montretout, January 19th, 1871. A ball entering the left shoulder about the middle of the external surface of the deltoid muscle, had passed obliquely downward to the right, and entered the chest, fracturing the fourth rib in its passage; thence through the lung and out of the chest, fracturing the tenth rib, speeding along in the soft parts under the skin to the lumbar region, where it made its exit. On admission, the circulation of the blood was so far arrested as to produce lividity of the countenance. The patient expectorated blood and mucus freely. Circulation was soon fully restored by the application of hot water, and stimulating drinks. Difficulty of breathing, severe cough, and expectoration of blood continued; delirium and fever soon followed, and continued until death. On admission the patient was much exhausted from exposure and want of food, and when compelled to take food, notwithstanding his loathing for it, the stomach did not respond. He continued to sink until the 25th, when he died. The post-mortem revealed pleuritis, with effusion of blood and pus in the pleura.
CASE 222.---Private René Delaunay, 1st Company, 1st Battalion, 109th Regiment of the Line, was wounded at Montretout, January 19th, 1871. A ball had entered the external and superior part of the leg, and passed out on the internal side of the calf; breaking the fibula in its passage. On arrival at the ambulance, the patient was suffering from a cough and the effects of bad food. The limb was much swollen, and the circulation below the knee very feeble. A rubber drainage-tube was immediately passed through the wounds to relieve effusion. On the day after admission less vitality was manifested in the limb, and on the following day vitality had entirely ceased. This was probably due to the destruction of the arteries in the passage of the ball, the leg being more or less gangrened from the knee down. Immediate amputation was performed above the knee by a long anterior and a short posterior flap, the patella being enucleated after it had been raised and the flaps were united with sutures. The patient received the chloroform well, and lost no appreciable quantity of blood. The stump was covered with oakum and a large compress, oil-silk covering the whole. The same dressing was re-applied forty hours after. On the third day, in addition to the other treatment, the thigh was bandaged from the groin down, to give better support to the stump. On the fifth day healthy pus was secreted in abundance. A lotion of nitric acid was used to increase the action of the wound. No union was obtained by first intention. On the twelfth day the whole wound was covered with healthy granulations. The parts were carefully drawn together with diachylon. The same treatment was continued, and by the twentieth day after the operation the wound was nearly closed. On the twenty-fifth day, when he was considered entirely out of danger, he suffered from the great cold occasioned by want of fuel, and was seized with severe chills. Fever and loss of appetite ensued. From this time he rapidly sank, dying on the twenty-seventh day after the operation, evidently from general congestion produced by exposure to cold. During the whole treatment the pus continued healthy, and on the day of the patient's death the wound was about closed.
CASE 223.---Private Jules Alluard, 2nd Company, 2nd Battalion, 136th Regiment of the Line, was wounded at Bougeval, January 19th, 1871. On admission he was suffering from pneumonia. It was found that he had been wounded through the lungs, diaphragm, liver, and intestines. The ball had entered on the left side of the chest, three inches below the nipple, and passing obliquely downward to the right, made its exit just above the centre of the crest of the ilium, fracturing the ribs. Warm water applications were spread over the whole abdomen and chest. Stimulants were freely administered, and anodynes were given to assuage pain. Little or no re-action took place. He continued to sink from the combined effects of pneumonia and the severe character of his injury, and died January 24th, 1871.
CASE 229.---Private Léon Combin, 4th Company, 3rd Battalion, 109th Regiment of the Line, was admitted January 19th, 1871. A ball had entered the shoulder, passing through and fracturing the scapula, and lodging behind it. It was extracted on the field. Combin had been also struck by splinters of shell on the right side of the face. One of these penetrated the left eye and lodged in the brain. On admission he was exhausted from previous hæmorrhage; on account of exposure, he was suffering from cold and cough. His shoulder and chest were red and swollen; breathing laboured, and pulse quick. Warm water applications constituted the dressings. He daily grew feebler, though plied with stimulants. Ice was applied to the head, and given internally. He gradually sank, and died unconscious, January 27th.
CASE 240. ---Private Adolphe Warocquier, 3rd Company, 78th Battalion, National Guard, was wounded January 19th, 1871, to wit: a fracture of the left ankle-joint---a ball had entered at the junction of the tarsal and metatarsal bones, passed obliquely through the anterior face of the tarsus, cutting in its course the anterior tibial artery; a section of the thigh---a ball had entered the middle of the thigh, passing obliquely upwards posteriorly to the femoral artery; a slight shell wound in the right nostril at the aperture. The general condition of the patient was unpromising. He was very delicate, of a highly nervous temperament, anæmic, emaciated, and had much irritative fever. The treatment was limited to warm-water dressings. The joint was very sensitive when handled. There was much pain, which was greatly increased on moving the limb. The limb was maintained in an easy position, and attention directed to improve the general condition of the patient by a nourishing diet and stimulants, which he refused. Notwithstanding these unfavourable circumstances, the case progressed favourably until January 30th, when secondary hæmorrhage supervened, from ulceration of the anterior tibial artery. The usual local remedies were applied to guard against its return. February 1st, there was again profuse hæmorrhage. From this time onwards he steadily lost ground. He became much emaciated. Daily his powers of resistance failed. From the 5th of February his wounds presented no active appearance. His strength had been so exhausted by loss of blood and his previous condition, that recuperation was impossible. The febrile symptoms increased, accompanied by nausea; on the night of the 7th there was delirium. Death took place on the morning of the 8th.
T is a noticeable fact, that up to the 1st of December, about the time the battle of Champigny was fought, the wounded suffered little, if any, from surgical diseases. Up to that date there was nothing notable in the condition of any of the wounded that would lead to the belief that causes were at work which would in any wise deteriorate the blood, and thereby jeopardize our surgical results.
Notwithstanding this, the wounded from that battle presented from the very first an appearance unlike that with which we had been previously familiar. The wounds were mainly of a very grave character, and many proved fatal. Besides this, the greater number of the men were suffering, more or less, from the effects of insufficient and improper food; from vitiated air in close and ill-ventilated sleeping apartments; from insufficient cooking facilities for those who had always been accustomed to the best; from camp accumulations of filth; from wet, exposure, and cold: in short, the whole course of their lives had been suddenly and violently changed, either from proper camp conveniences to such as their systems had not yet become accustomed to, or from civil life, where they had enjoyed, in a gastronomic, sanitary, and hygienic point of view, all that science demands.
And to these causes of disease should be added the fact, that enclosed within a cordon of five hundred thousand soldiers was a city of nearly two millions of people suffering from the causes above enumerated, and the additional fact, that this city had become one vast hospital for the reception of the sick and wounded, not only from within, but from the great army without.
The whole story would not be told were I to neglect to state that, outside of the cordon of soldiers, there still existed the enemy's numerous hordes, with such surroundings as an army only can create, poisoning the air from whatsoever point of the compass it might come to us ; mingling also with the already excessive accumulation of starving animal, fæcal, and other offensive and deleterious exhalations of the thousands of sick and wounded, who were already suffering from blood-poison, excreta which fouled even the beautiful stream that winds through the city, and which, in rendering putrescent even the sources of our water supply, became a potential source of poison.
Thus by the presence of two such armies as the world has rarely seen before, together with the local city causes, including insufficient and improper food, overcrowding of apartments, insufficient clothing, and insufficient fuel, during one of the most inclement winters known in Paris, is it surprising that buildings, clothing, and bedding became foul, and pestilence should stalk abroad in the shape of blood-poison, so that every individual, whatever his condition in life or facilities for obtaining food, felt the evil influences of the extreme times ? A moderate cold became typhoid fever, or a low species of bronchitis, pneumonia, pleurisy, peritonitis, or some other inflammatory disease of a typhoid form; indicating clearly that every system had been insensibly and insidiously invaded by an unseen foe.
There is now no difference of opinion among intelligent students of medicine as to the fact of there being a condition of the system under which can be grouped a large number of diseases treated of as distinctive, but which, in fact, are due to some uniform, abnormal state of the circulating medium, although the condition may vary in intensity according to circumstances. From this condition comes erysipelas---whether of the skin, internal organs, tissues, membranes or veins---or low forms of cellular inflammation, low types of fever, traumatic, spreading, or other forms of gangrene, and a multiplicity of affections described and known as closely allied to, if not the sequels of, the so-called pus-poisoning. There can be little doubt that this cause, whatever its distinctive character may be, is in the blood; and that it may remain dormant an indefinite period, or until eliminated, unless some great, exciting cause, such as severe cold, insufficient and improper food, serious injuries, wounds, or surgical operations, arouse it into activity.
It is not my intention here to discuss the manner and mode of the introduction of this poison into the system, the particular form in which it exists prior and subsequent to its introduction, or whether it is animal, vegetable, gaseous, or a simple change in the constituents of the blood; but I shall rather endeavour to present a correct summary of the conditions which have existed among those treated at the American ambulance, and the conclusions which I have drawn from them.
1. The records show one case only of erysipelas, and this presented itself in a patient suffering from a slight wound in the scalp, in whom, the third day after his arrival, the disease was at its height; on the sixth the patient was well.
2. There have been no fevers of a typhoid, or of any other type, except as are detailed in the Report.
3. There has occurred one case of traumatic gangrene only, and this was developed within forty-eight hours after the patient's admission. The details of this case are given on the following page.
4. There have been no well-marked cases of pus-poisoning; but in order that the public may rest fully satisfied on this point, I have given a detailed history of every death.
5. During the last part of December, and during January and February, there was a want of recuperative power in nearly all the wounded who were received; and this was most perceptible among the more severely wounded, and those having compound comminuted fractures. By a careless observer, this peculiar condition of the system, with its sequels---imperfect recuperative action followed by more or less bony necrosis---might be confounded with the condition commonly known as pus-poisoning. But a more careful analysis of the whole report will show that, if any such poison were present, it existed in the patient's system prior to his admission into the ambulance, and was not due to any causes that lurked therein.
Viewing the question from any point, there were but four deaths as to the causes of which there could be any discussion. In my mind there is no doubt that those, together with several others, were due to the extreme cold---at a time when we were unable to procure fuel and proper food---acting upon systems already impaired by causes above enumerated.
Before proceeding further, I deem it proper, that you may fully appreciate what follows, to give a synopsis of the only case of the four above alluded to, which is really worthy of an especial consideration.
CASE 106.---Was treated in barrack No. 5, which, together with its furniture, bedding, and clothing, was entirely new, and into which no sick or wounded had before been admitted. The patient came into the building in a typhoid state, suffering from a gunshot fracture of the radius and ulna. Great infiltration of the parts ensued; forty-eight hours after arrival traumatic gangrene of the cellular tissues commenced in the forearm. Free incisions, warm applications, disinfectants and dilute nitric acid, gave only temporary relief, and did not prevent the extension of the disease or the continuation of the unfavourable symptoms. Amputation was performed through the superior third of the humerus, where the parts were entirely free from disease. The cut surface soon granulated finely, and secreted an abundance of healthy pus. Yet the stump soon after assumed an unhealthy appearance, became hard and inflamed, and presented a dusky hue, similar to that of the forearm prior to amputation. This condition subsequently extended to the adjacent soft tissues of the chest, and continued to extend to the moment of his death.
If this disease had declared itself at a much later period after admission, and if the building had been used prior to his entrance, and had not been entirely new, as it was, or if any local cause had existed to which he was immediately exposed, one might be induced to believe that it was a case of blood poisoning, superinduced by the influences surrounding him. But as the case now stands, there can be no doubt that his disease was contracted before his entrance into the ambulance; and that the wound was only an exciting cause. In confirmation of this view, Mr. Erichsen, in his work on surgery,(16) states that:---
"The constitutional condition of the patient is undoubtedly the main cause of the supervention of spreading traumatic gangrene. However severe an injury may be, and however certainly it may kill those tissues or that part of a limb which are directly and immediately exposed to the operation of the external violence, the rapidly spreading form of the disease will not supervene unless the constitution be in an unsound state; and this remark applies necessarily with especial force to its occurrence after the slighter forms of injury. The supervention of spreading traumatic gangrene will occur in circumstances similar to those which dispose to pyæmia, erysipelas, or sloughing phagedæna; and, in fact, to the low and diffuse inflammations generally. They consist of imperfect and faulty hygienic conditions, and an impure state of the blood, arising either from long-continued exposure antecedent to the injury, to such conditions, or to chronic disease of the eliminatory organs, more particularly of the kidneys. Defective depuration of the blood, consequent on chronic kidney-disease, is a most fertile cause of this as of the other forms of gangrene. Indeed, I believe that the true spreading or traumatic gangrene cannot occur unless the blood is, previously to the receipt of the injury, in a depraved and disordered state, the result of the conditions, singly or combined, above mentioned. Hospital miasmata, and exposure to faulty hygienic conditions after the receipt of the injury, do not appear to me to exercise so marked an influence on the occurrence of this form of gangrene as of the low inflammatory diseases of the erysipelatous type. In fact, the patient is rarely, if ever, exposed to these influences sufficiently long after the occurrence of the injury for them to have much effect on his constitutional condition, had that been in a sound state previously. Spreading traumatic gangrene occurs only in recent wounds, and usually manifests itself within the first three days after their occurrence, while they are still in their first stage, and before suppurative inflammation has set in . . . . I cannot, therefore, but look upon this formidable disease as a truly constitutional affection, depending more upon the state of the patient's blood at the time of the reception of the injury than upon the severity of that injury or upon the circumstances to which he has been exposed immediately after the receipt of it."
We now come to the question, whether any one treated in the ambulance had any of the sequels of blood or pus-poisoning; and if so, from what source it arose.
Up to December, as I have before stated, all the wounded remained healthy. Subsequently, the tents were not more crowded, and the same scrupulous observation of all the hygienic laws was continued with regard to the patients, tents, beds, clothing, &c.; but, as in the case of traumatic gangrene, before commented on, other cases of compound fracture resulted unsatisfactorily.
Still there was no observable specific disease; but the patients' stomachs, at the time of admission, failed to respond to food and stimulants, or were unable to digest what was taken: in short, there was no recuperative power in the system. Necrosis of the fractured shaft or joint and a low form of suppurative inflammation would ensue. The discharges became offensive, and the patient would generally sink---eating more or less to the last---but not relapsing into a typhoid condition, and except when exposed to severe cold, as occasionally happened when fuel failed, and the fires were extinguished for many hours at a time, never suffering from chills or fever.
Whence came this change? The cause was evidently not from conditions special to the ambulance, but from the morbid condition existing in the system on arrival; as in the above-mentioned case of traumatic gangrene, which was nothing more than the representative of a large family of conditions each having a specific name, depending upon the part or tissue involved, but all depending upon a depraved state of the circulating medium commonly denominated blood-poisoning.
When the blood is thus poisoned, disease is far more prevalent. In proof of this I may instance the enormous increase of mortality among those not wounded who sickened in and around Paris from pneumonia, bronchitis, pleurisy, and typhoid, after the 1st of December, 1870. In fact, all diseases had assumed a low typhoid grade, few recovering from a severe attack of any of the graver disorders. If disease, in those who were unmaimed, proved so fatal in constitutions impaired by blood loaded with effete material, should we not expect that the mortality among the severely wounded would be materially increased, particularly when suffering from the want of proper food and fuel?
There were those among our wounded, however, who were more fortunate, notwithstanding the severity of their wounds; namely, Zouaves and soldiers of the line. For example, Case 134, a compound and comminuted fracture of the thigh, received from the battle-field of Champigny, November 30th, 1870, recovered without an unfavourable symptom, and is possessed of a perfect limb with only one and one-fourth of an inch shortening. Case 166, in which the head of the humerus was crushed to atoms, and the soft parts severely lacerated and burned by an accidental shot from patient's own gun, recovered also. Other cases occurred with similar histories and results. The good results here obtained were due conjointly to good constitutions and to their having been quartered in the country, where they were enabled to obtain a greater variety and a larger supply of food, and where they were not exposed in the same degree to the obnoxious influences previously mentioned.
If any further arguments were needed to prove the position I have taken, namely, that the disease from which our patients suffered existed in the system, and only required a sufficient development, or a grave injury, to render what was once a passive condition an active disease, I would again refer to Mr. Erichsen's work, in which this matter is summed up tersely and to the point. In speaking of the necessary preparation of patients for an operation, that writer says:(17)---
"Closely allied to pyæmia, frequently co-existing with it, having the same predisposing causes, and associated with febrile disturbance of an asthenic type, are the various low and diffuse inflammations, whether assuming the form of erysipelas, of phlebitis, or of inflammation of the absorbents, which are the dread of surgeons and the scourge of hospitals. It is to pyæmia, and to these various allied erysipelatous and low inflammations, with their attendant asthenic constitutional disturbance, that at least three-fourths of the deaths after operations are due. It is in the production of these diseases that an impure blood, loaded with effete materials retained through habitual disregard of the ordinary rules of health, or through defective elimination by the kidneys and skin, acts as a potent predisposing cause, requiring but some injury or wound to call into activity a most dangerous amount of local inflammation and of constitutional disturbance. In these circumstances, it is not the extent or size of the wound that determines the dangerous results. The mere fact of a breach of surface, however trivial, is sufficient to excite these morbid processes, the materials for which have been previously stored up in the system. In such conditions of the system, the amputation of a toe may be as fatal as that of the thigh, or the removal of a small scalp-atheroma as the ablation of the breast; the only additional danger essentially connected with the greater operations being the increased risk from shock and hemorrhage."
This "low and diffuse inflammation" of the tissues surrounding compound fractures was exactly what was to be found at our ambulance during the months of December, January, and February. It was evident that its presence, which manifested itself immediately after admission, was due to the causes mentioned in the above quotation, namely, to blood loaded with effete material and retained therein, and requiring but some injury or wound to call into activity a most dangerous amount of local inflammation; and in case death were to result under such circumstances, the verdict would be death from pyæmia; and the chances are that the hospital, or the place where such persons were treated, would be considered the unfortunate executioner. Whereas Mr. Erichsen, and all other good authorities, advise deferring any surgical operation during an epidemic of erysipelas, low forms of diffuse inflammation, low forms of fever, or where any condition exists in the atmosphere which has a tendency to foul or deteriorate the blood. In these circumstances, as Mr. Erichsen states, "the amputation of a toe may be as fatal as that of the thigh." If that is true under the circumstances of which he speaks, I assume that it would be so in the case under consideration; for in addition to the exciting cause spoken of, we have to superadd the fact that after arrival these men continued to suffer more or less from insufficient and improper food and from insufficient and improper fuel, the obtainable fuel not being adapted to the furnaces. The manufactured coal emitted large volumes of sulphureous gases; at one time fuel gave out for the space of forty-eight hours; and at other times, during the most inclement part of the winter, we were compelled to drag along with a temperature so reduced as to produce great suffering. Several deaths are directly traceable to the want of fuel. Several were due, apparently, to exhaustion from cold during the night preceding and the day of the battle of Bourget, fought December 21st, 1870. Others, during the latter part of the siege, had a like history, followed by the -same melancholy result.
CANNOT, with justice to others, and with conscientious satisfaction to myself, close this Report without paying a tribute to the faithfulness, zeal, and intelligence of those who were so intimately associated with me, during the siege of Paris, in a humane work.
It affords me unwonted pleasure to state that my associate, William E. Johnston, M.D., has rendered invaluable services to the sick who, from the latter part of December to the middle of February, were in constant need of the care which he, in the most skilful and generous manner, bestowed upon them. I would refer you to his report, which will be read with much interest. By a reference to the table on page 687, it will be seen that all such cases as were not purely of a surgical character were treated by him. You will also observe that a small proportion of the medical cases had been wounded, but had either been discharged or had been sent to the convalescent hospital, where their disease was brought on by the causes previously enumerated as incident to the siege.
The gentlemen who have acted as my assistants have rendered valuable services, and were assiduous in their care and attention to the wounded. They assisted at the operations and dressings, and were charged with the especial superintendence of the wounded, each one being held responsible for the care of the patients and the cleanliness of the ward under his supervision.
The following named gentlemen were received as assistants in the order in which they here appear:-
|William J. Brewer,||V. E. Du Bouchet,|
|Emile Brewer,||Frank M. O'Connell,|
|J. B. B. Cormack,||Joseph K. Riggs,|
|Lewis Wingfield,||Louis J. Swinburne.|
Of the above-named gentlemen only three were regular students of medicine, and at the time pursuing their studies. Two had paid especial attention to chemistry and pharmacy, and performed the duties appertaining thereto. Owing to sickness and other causes, there were never more than six on active duty.
In conclusion, and in taking leave of you, I desire to express to you and to the Committee my sincere regret at parting, and to thank you for the many acts of kindness manifested to me a stranger in a strange land, and for the unbounded confidence reposed in me in the management of the surgical department of an institution of such importance in a national-representative point of view---an institution expressing the sanitary, hygienic, and surgical principles involved in the treatment of gunshot injuries as practised in the United States, and within which those principles were first to be put into operation in a foreign but friendly country.
In consideration of this expression of confidence, I am only too happy to know that the result of my labour is such as to meet with your approval. It is the only reward that I have sought.
While my connection with you and the American ambulance extends through an eventful period of over six months, I am pleased to state that the first difference of opinion, or unpleasantness in our intercourse, has yet to arise. In fact, I am happy to say that it has been the pleasantest six months of labour I have ever been called upon to perform, notwithstanding the fearful suffering we have witnessed among a proud but unfortunate people, struggling to maintain the honour of their arms and the integrity of their territory.
I say pleasant, because conscious of the good we were all striving to do in a humanitarian work, we still wished to, remind our ancient friends and allies that we had not forgotten and would not ignore the relief extended to us during our struggle for independence---that the great and good work of La Fayette and his confrères was still fresh in the memory of all true Americans. Hoping that you will convey to this warm-hearted and appreciative nation, with whom I am unable to confer in their own tongue, my fullest expressions of gratitude for their continued marks of approbation, esteem, and confidence---that if you are again called upon to act in any official capacity, you may be enabled to perform the duty as faithfully, as conscientiously, and as well as you have this, and that our relations may continue to be as pleasant in the future as they have been in the past,
Very respectfully yours,
JOHN SWINBURNE. PARIS,
July 1st, 1871.
AMERICAN AMBULANCE during the siege of Paris....
T is the first time in the history of sieges that medical men have had an opportunity of observing the influence on health of so large an agglomeration of human beings as that now present at Paris.
The ordinary sanitary condition of the city has been so much improved by the efforts of the last twenty years, that comparative safety was felt against the attacks of any of the usual forms of pestiferous disease. But no calculations had been made on a sudden addition to the population of nearly 300,000 soldiers and poor people from the outside, with their old furniture, their cattle and their swine. Much less had they taken into consideration the aggravating circumstance of the influence on the atmosphere of a large number of sick and wounded soldiers, of the want of food and fuel, and the excessive and prolonged cold weather.
It was not without the most serious apprehension, therefore, that we watched the fluctuations of the mortality bill during the progress of the siege, and the concordance in the variations of the public health with the condition of our ambulance tents. It was the first time this system of hospital had been tried in France on a large scale, and the first time it had ever been tried in a besieged city of such a size.
We not only watched with deep interest the effects of these various pernicious influences on our patients, but we were naturally anxious to seize upon some testimony bearing upon the difficult question of the comparative healthfulness of the climates of the two hemispheres, and of the power of resistance and of recuperation of the two races.
Much light was thrown, we think, upon some of these points by the results obtained.
Thus, it may be said that, from the moment of installation in the month of September till the middle of the month of December, that is to say, while it was still possible to obtain regular supplies of food and fuel, and while the men who came in were not too much prostrated by the privations of the siege, there was an almost complete exemption from disease in the 157 wounded men received up to that time. A few cases of ephemeral fever from gastric derangements; a few cases of diarrhoea of a mild type; and one case of light variola----in fine, hardly more disturbance of the system than would have been observed in the same number of men in active duty in the field; the gravity of the wounds, moreover, apparently bearing no relation to the nature or the force of the malady. These were the only manifestations of disease we were called on to observe.
While bronchitis, pneumonia, typhoid fever and small-pox were on the increase in the barracks, and among the civil population; while the bill of mortality in the city was rising from 981 a week to the enormous figure of 4,671--- figure which would have carried off one-eighth of the entire population in a year, and which killed from six to eight times more people than the war---the inmates of our tents, notwithstanding their apparently crowded state, continued to enjoy a perfect immunity from any grave form of disease.
Up to this point in the history of the ambulance, that is to say, till about the middle of December, there had been no great difficulty in obtaining a sufficiency of food and fuel; and the results, as will be seen by this and the surgeon's report, were in the highest degree satisfactory. But after this period several seriously wounded men died whose symptoms were clearly traceable to the effects of cold or a want of proper nourishment; and toward the middle of January it was evident that a certain typhoid condition had invaded the tents, and, in an insidious way, was furnishing a slight increase to our mortality ratio.
Thus, in the second fortnight of January, a man with a contused wound of no special gravity died after a week's illness from typhoid symptoms of a well-marked form.
Another man with a flesh wound of the shoulder was attacked with a pleuro-pneumonia in an insidious way, and died at the end of four days. He had a slight cough, with a light mucous crepitation for a few days, without fever, and was not considered in any danger, when all his symptoms suddenly grew worse, both lungs filled up rapidly, the expectoration changed to orange colour, there was tympanitis, sordes in the mouth, and delirium. He was treated with an expectorant mixture, brandy, blisters, and abundant nourishment.
Another man attacked about the same time, and in the same way, with pleuro-pneumonia, and who had also a flesh wound of the chest, died even more rapidly than the preceding one. His disease had also lain latent for several days.
Eight other cases of pneumonia and two of bronchitis were treated in the period between the middle of January and the middle of February, three only of which were wounded men.
All of these cases recovered but one---a man who was brought in from without the walls in a hopeless condition with bronchitis.
The treatment of these cases consisted generally in Todd's ,brandy mixture, blisters, poultices, nourishing diet, and sometimes, when the cough was too violent, an expectorant mixture.
A very young man who came in with a flesh wound of the thigh had several epileptic fits after his entrance, and was finally seized with scarlet fever, although it was the only example of this disease in the ambulance, and died.
Another man with a contused wound of the back was seized five days after his entry with confluent small-pox, and got well. He was isolated at once, but communicated the disease in a lighter form to the aid-surgeon charged with his nursing.
The other attacks of disease in the ambulance, independent of purely surgical conditions, were of the most ordinary and accidental kind, without special bearing upon miasmatic or atmospheric influences.
The foregoing is in brief the medical history of the ambulance; and we think we are authorized in drawing from it the following conclusions :---
1. That so long as the exterior conditions were normal, that is to say, for a period of three months, the sanitary condition of the ambulance was most remarkable.
2. That, after this period, several deaths and several attacks of disease were directly traceable to the influence of cold and the want of food, at a moment when the supplies of food and fuel were irregular and insufficient.
3. That the condition of the men on entering was, after a certain period, generally bad, from insufficient nourishment and the fatigues of the siege.
4. That the soldiers of the line, who most frequently occupied the outposts and had fresh vegetables to eat, resisted the fatal effects of wounds better than those fed on a less healthful diet.
5. That the scorbutic or typhoid condition, which manifested itself in the ambulance towards the close, depended on the condition of the men on entering, and on the bad medical constitution of the city at the time.
6. That notwithstanding these pernicious exterior influences, which operated equally on all, the number of deaths in this ambulance, as the statistics will show, did not reach the ratio of mortality, depending upon the same influences, elsewhere.
7. That as regards the comparative healthfulness of the two climates and the two races, the experiment was too limited to admit of a positive indication; but that to the medical men who had been in the habit of treating the same accidents in the Western hemisphere, the general physiognomy of the ambulance was most striking, and left the conviction that, whatever the cause or causes, the power of resistance and of recuperation was inferior to that which they had been in the habit of observing.
W. E. JOHNSTON, M. D.,
Physician to the Ambulance.
March 1, 1871.
|TABLE showing the name, corps, rank, disease, and the date of admission, discharge, or death, of each case treated medically at the American Ambulance during the siege of Paris, 1870-71.|
Physician---William E. Johnston.
Surgeon's Aids---Emile Brewer, Gilead Peet, M V du Bouchet, Mr. Frank O'Connell, William Brewer, Joseph K. Riggs, J. B. B. Cormack, Louis Wingfield.
Aids Volunteer---Transport Corps---Captains of Squad---William B. Bowles, Joseph K. Riggs.
Corps Members ---Messrs. E. H. May, Gratiot Washburne, Charles J. Rilliet, William C. Dreyer, C. B. Gunther, E. B. Beylard, Auguste Meslier, Victor Meslier, W. A. S. Dick, Jules Dupré, G. W. Kidder, M. Whittaker, Thomas O'Flinn, E. Malherbe, Oswald Murray, M. Pollock, M. Ablet, C. Hansen, Frank Riggs, Geo. B. M'Farland, Major Hutton, Lewis Swinburne, M. Ranzi.
Secretary of the Aid Volunteer Corps---Albert Piperno.
Lady Volunteers---(Nurses)---Mrs. George B. M'Farland, Mrs. William B. Bowles, Mrs. Koch, Mrs. Demming, Mrs. Ward, Mrs. Howland, Mrs. Moulton, Mrs. Meslier, Mrs. Huggard, Mrs. Ricker, The Marquise de Bethisy, Miss K. Cammeron, Miss Maas, Miss Wissembourg, Miss Jenny Castri, Miss Bewick, Miss Chandor.
Director of the Linen Department, &c. &c.---Mrs. Conkling.
Superintendent of the Kitchen and Special Diet Department---Miss Rachel Castri.
Superintendent of the Grounds---Mr. Benjamin Meakes.
a a, gates.
|15.||Dirty Linen Room.|
a, post-mortem table.
|3.||A, reception bureau.
B, committee room.
|17.||Pavilion, No. 7.
A, store room.
B, knapsack and gun room.
C, salon of the aids volunteer.
|4.||Tent-Pavilion, No. 3.
a a, portals.
b b b b b b, tent-poles.
c stove pipe.
d d d, registers.
e e e, dressers.
g g g g g g g, beds.
h h h h, tent walls.
i i i i, border of fly.
k k k k k k k k, cords and tent pins.
I, roof for furnace.
|18.||Pavilion, No. 8.
A, stable (horse).
a a a a, stalls.
B, stable (cow).
a a a, stalls.
C, carriage shed.
a a a a, ambulance waggons.
|5.||Hose-room.---Fire Department.||19.||Nurses' dormitory.
a a a a a a a a a, beds.
|20.||Tent for the watch and chief of
|7.||Pavilion, No. 4.
A, operating room.
b, operating table.
f f f f f f, beds.
G, wine room.
H, bottle room.
i i, portals.
b b b b b b, beds.
d d, dressers.
|8.||Pavilion, No. 6.
A, servants' dining-room.
C, officers' dining-room.
D, surgeons' salon. E, pharmacy.
F, coal bin.
a a a a a a a, tables.
b b b, stoves.
c c, ranges.
d d, soup cauldrons.
e e e e e, shelves.
f, alcove and bed.
|22 22 22.||Reserved lots.
x x x x, railings.
y y y y y y y y y y, trees.
s s, sinks.
|9.||Covered passage way.||23.||Washing Apparatus.|
|10.||Pavilion, No. 5.
A, linen room.
B, office of the superintendent.
C, provision room.
a a a a, tables.
b b b, stoves.
c c c, shelves.
d d d, sofa and fauteuils.
e e, ventilators.
f f, air pipes.
g g g g, beds.
a a a a a a, cabinets.
b b b b b b, screens.
|25.||Flagstaff. (Red Cross.)|
|13.||Coal yard.||27.||Coffee Waggon.|
|14.||Tent-Pavilion, No. 1.
(See detail under No. 4.)
|28. 29.||Ambulance Waggons.
z z z z z z, plank walks.